II. Indications
- Rapid reversal of Rocuronium and Vecuronium (Non-depolarizing Neuromuscular Blocking Agents)
- FDA approved for reversal in adult surgery cases, to speed recovery after case completion
- Follow neurologic status in neurologic catastrophe (e.g. Intracranial Hemorrhage) or Status Epilepticus
III. Contraindications
- Chronic Kidney Disease Stage 4-5 (GFR <30 ml/min)
IV. Precautions: Emergency Paralytic Reversal
- Emergency paralytic reversal is off-label use and may not be ideal
- A patient who requires emergent Endotracheal Intubation still needs an airway
- Reversal agents render further Non-depolarizing Neuromuscular Blocking Agent use ineffective
- Can't Intubate but CAN ventilate scenarios may be treated with temporarily with BVM or LMA
- Can't Intubate, Can't Ventilate scenarios require emergency Cricothyrotomy
- Paralysis reversal may worsen this situation and delay definitive management
- References
- Strayer in Herbert (2019) EM:RAP 19(11):4-6
V. Background
- Approved in Europe in 2008
- FDA approved in U.S. in 2016 (initially rejected due to Anaphylaxis risk)
VI. Mechanism
- Sugammadex is a modified gamma cyclodextrin that tightly binds Rocuronium and Vecuronium
- Reduces available Rocuronium and Vecuronium to bind Nicotinic Acetylcholine Receptors at Neuromuscular Junction
VII. Pharmacokinetics
- Reverses paralysis within 3-5 minutes
- Not metabolized
- Up to 95% if excreted unchanged in the urine
-
Half-Life
- Normal Renal Function: 2 hours
- Mild renal Impairment: 4 hours
- Moderate renal Impairment: 6 hours
- Severe renal Impairment: 19 hours
- Continues to block Neuromuscular Blockade until cleared (based on weight and Renal Function)
- Requires delay if another Neuromuscular Blocker needs to be given
- Consider nonsteroidal Neuromuscular Blocker if another paralytic is needed
VIII. Dosing
- Train-Of-Four Testing
- Consider to determine level of residual sedation and appropriate Sugammadex dose
- Nerve stimulator applied to Ulnar Nerve and estimates degree of paralysis
- Finger twitching
- Deep remaining paralysis = 0-1 twitches
- Moderate remaining paralysis = 2-3 twitches
- No residual paralysis >=4 twitches (no need for Sugammadex)
- Reversal of moderate Neuromuscular Blockade
- Dose: 2 mg/kg total body weight
- Reversal of deep Neuromuscular Blockade (typical dose)
- Dose: 4 mg/kg total body weight
- Rapid reversal dose (difficult intubation and ventilation, onset within 3 min)
- Dose: 16 mg/kg total body weight
- Minimum wait times to re-dose neuromuscular blocking agent (NMBA)
- Indications to wait >5 minutes
- Standard dosing with normal Renal Function
- However if NMBA given within 30 minutes of Sugammadex expect modified Pharmacokinetics
- Onset delayed up to 4 minutes from time of administration
- Duration of action may be decreased to as short as 15 minutes
- Indications to wait 24 hours
- High dose Sugammadex given (16 mg/kg)
- Renal Impairment
- Indications to wait >5 minutes
IX. Adverse Effects
- Recurrent Neuromuscular Blockade
- Drug Interactions may displace Sugammadex from binding NMBA, resulting in recurrent Neuromuscular Blockade
- Severe Bradycardia (1 to 5%)
- Onset within minutes of administration
- May require Atropine
- Cardiac Arrest has occurred in some cases
- Prolonged QT Interval (6%)
- Hypotension (4 o 13%)
-
Anaphylaxis or anaphylactoid reactions (0.3% to 1%)
- Dose dependent risk (higher doses are higher risk for Anaphylaxis)
- Occurs within 5-10 minutes of administration
- Treat with Anaphylaxis protocol (esp. Epinephrine)
- Other adverse effects
X. Drug Interactions
-
Coagulation Factor assays
- Falsely elevates Coagulation Factors (without causing a Coagulopathy)
XI. Resources
XII. References
- Braude and Hayes in Herbert (2016) EM:Rap 16(11): 7
- Nordt amd Rech (2024) Sugammadex, EM:Rap 5/20/24
- Whiting and LoVecchio (2018) Crit Dec Emerg Med 32(11): 28
- Mishler and LoVecchio (2017) Crit Dec Emerg Med 31(5): 24