To the Editor, Patients occasionally may require reoperation in the immediate postoperative period. We present a case where rocuronium-induced neuromuscular block (NMB) was achieved more than 2 h after sugammadex had been given. Written consent for publication of the manuscript was granted by the patient. A 65-year-old man (American Society of Anesthesiologists physical status III, weight 95 kg, body mass index 29.3 kg m) with a history of hypertension, dyslipidemia, and symptoms suggesting carotid vascular disease was scheduled for left carotid endarterectomy. Laboratory values were within normal limits. Two hours after the procedure while the patient was in the postanesthesia care unit, he developed an expanding neck hematoma without airway compromise and was brought back to the operating room for hematoma evacuation. Following preoxygenation, anesthesia was induced slowly with fentanyl 100 lg, etomidate 15 mg, and rocuronium 50 mg (0.53 mg kg). Once the patient was unconscious, gentle manual ventilation was applied, and neuromuscular function was monitored with acceleromyography using train-of-four (TOF) stimulation of the ulnar nerve (TOF-Watch SX, Organon Ireland Ltd, a division of MSD, Swords, Co. Dublin, Ireland). Calibration was performed at the left adductor pollicis (AP) before rocuronium administration. Neuromuscular data were collected via the TOF-Watch SX monitoring program. The onset time from the injection of rocuronium until maximum NMB was 4 min 56 s; the maximum first twitch depression (T1 block) attained at the AP was 86%. An additional 10 mg of rocuronium was administered, achieving a maximum T1 block of 90%. Tracheal intubation was accomplished with ease 5 min after rocuronium administration, and anesthesia was maintained with propofol and remifentanil. Accelerometer calibration was lost because it was impossible to access the patient’s arm during surgery. At the end of the procedure 60 min later, the TOF-Watch monitor was set in the TOF mode with the initial calibration parameters. At that time, the TOF ratio was 0.12. Sugammadex 160 mg (1.7 mg kg) was injected, and within 1 min, the TOF ratio reached the value of 0.9. The patient’s trachea was then extubated. Subsequently, we learned from the previous anesthesia team that sugammadex 400 mg (4.2 mg kg) had been given to antagonize rocuronium-induced NMB, but this was not recorded in the patient’s chart. No neuromuscular monitoring had been used for the first procedure. The time interval between the previous dose of sugammadex and the second intubating dose of rocuronium was 143 min. It is recommended to wait 24 h following the initial reversal of NMB with sugammadex before re-administering rocuronium. This waiting time is based on a mean clearance of 95 ml min for sugammadex. In our case, sugammadex 4.2 mg kg was administered only 143 min before another dose of rocuronium was given. Unnecessarily large doses of sugammadex have a potential downside, as patients occasionally may require re-operation in the immediate postoperative period. It is important to use