Neuromuscular blockers and their reversal: have we finally found the on-off switches?

Background: A nondepolarizing neuromuscular blocking agent (NMBA) with a succinylcholine-like quick onset and offset has been the holy grail of the science of neuromuscular blockade. Although this drug is still elusive, the advent of promising new drug combinations like rocuronium-sugammadex and gantacurium-L-cysteine may achieve the same end result. The type of NMBA; the type, timing, and dose of their reversal drugs; the means of monitoring NMB; and the site of monitoring are potentially on the verge of a paradigm shift. Main text A comprehensive search using PubMed and Google Scholar and Medline search was made by using keywords gantacurium, L-cysteine, calabadion, and newer neuromuscular blocking agents for peer-reviewed English language manuscripts published before December 2019. Out of the 97 articles screened, 16 were found to be eligible (original articles) and included in this review. Conclusion: Quantitative, objective neuromuscular monitoring should be included in the minimum monitoring standards. Gantacurium is a new promising nondepolarizing NMBA with desirable succinylcholine-like onset and duration of action without its side effects. A broad-spectrum reversal agent (calabadion) can be used for both depolarizing and nondepolarizing NMB as well as general anesthetics (etomidate and ketamine). A novel drug (WP [6]) can block the side effects of succinylcholine; all are staring at us from the horizon.