Sugammadex

Aka: Sugammadex, Bridion

1. Indications
   1. Rapid reversal of Rocuronium and Vecuronium (Non-depolarizing Neuromuscular Blocking Agents)
   2. FDA approved for reversal in adult surgery cases, to speed recovery after case completion
   3. Follow neurologic status in neurologic catastrophe (e.g. Intracranial Hemorrhage) or Status Epilepticus
   4. Emergency paralytic reversal is off-label use and may not be ideal
      1. A patient who requires emergent Endotracheal Intubation still needs an airway
      2. Reversal agents render further Non-depolarizing Neuromuscular Blocking Agent use ineffective
      3. Can't Intubate but CAN ventilate scenarios may be treated with temporarily with BVM or LMA
      4. Can't Intubate, Can't Ventilate scenarios require emergency Cricothyrotomy
         1. Paralysis reversal may worsen this situation and delay definitive management
      5. References
         1. Strayer in Herbert (2019) EM:RAP 19(11):4-6
2. Background
   1. Approved in Europe in 2008
   2. FDA approved in U.S. in 2016 (initially rejected due to Anaphylaxis risk)
3. Mechanism
   1. Sugammadex tightly binds Rocuronium and Vecuronium
   2. Prevents paralytic binding to acetylcholine receptors
4. Pharmacokinetics
   1. Reverses paralysis within 3-4 minutes
5. Dosing
   1. Typical dose: 4 mg/kg total body weight
   2. Rapid reversal dose: 16 mg/kg total body weight
6. Adverse Effects
   1. Anaphylaxis in 0.3% of patients
   2. Bradycardia
7. References
   1. Braude and Hayes in Herbert (2016) EM:Rap 16(11): 7