II. 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

III. Background

  1. Approved in Europe in 2008
  2. FDA approved in U.S. in 2016 (initially rejected due to Anaphylaxis risk)

IV. Mechanism

  1. Sugammadex is a modified gamma cyclodextrin that tightly binds Rocuronium and Vecuronium
  2. Reduces available Rocuronium and Vecuronium to bind nicotinic acetylcholine receptors at neuromuscular junction

V. Pharmacokinetics

  1. Reverses paralysis within 3-5 minutes
  2. Continues to block Neuromuscular Blockade until cleared (based on weight and Renal Function)
    1. Requires delay if another neuromuscular blocker needs to be given
    2. Consider nonsteroidal neuromuscular blocker if another paralytic is needed

VI. Dosing

  1. Reversal of moderate Neuromuscular Blockade
    1. Dose: 2 mg/kg total body weight
  2. Reversal of deep Neuromuscular Blockade (typical dose)
    1. Dose: 4 mg/kg total body weight
  3. Rapid reversal dose (difficult intubation and ventilation)
    1. Dose: 16 mg/kg total body weight

VII. Adverse Effects

  1. Severe Bradycardia
    1. Onset within minutes of administration
    2. May require Atropine
  2. Anaphylaxis in 0.3% of patients
    1. Dose dependent risk (higher doses are higher risk for Anaphylaxis)
  3. Other adverse effects
    1. Nausea or Vomiting
    2. Pain
    3. Hypotension
    4. Headache

VIII. References

  1. Braude and Hayes in Herbert (2016) EM:Rap 16(11): 7
  2. Whiting and LoVecchio (2018) Crit Dec Emerg Med 32(11): 28

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Ontology: Sugammadex (C1700695)

Concepts Pharmacologic Substance (T121) , Carbohydrate (T118)
MSH C453980
SnomedCT 442379000, 442340006
English Sugammadex (product), Sugammadex (substance), Sugammadex, sugammadex, SUGAMMADEX
Spanish sugammadex, sugammadex (sustancia), sugammadex (producto)

Ontology: Bridion (C2699711)

Concepts Pharmacologic Substance (T121)
English Bridion