Sugammadex (Bridion)

Anesthesia Implications

Classification: Rocuronium and Vecuronium antagonist, modified gamma-cyclodextrin
Therapeutic Effects: non-depolarizing neuromuscular blockade reversal

Time to Peak: 3 minutes

Primary Considerations

Rocuronium and Vecuronium – Sugammadex works to reverse aminosteroid non-depolarizing neuromuscular blockade – specifically Rocuronium and Vecuronium. The effectiveness of sugammadex on these drugs is equal.

Succinylcholine or benzylisoquinoline neuromuscular blocking drugs – This drug will NOT reverse succinylcholine or benzylisoquinoline NDNMB agents (eg. mivacurium, atracurium, cisatracurium).

Rapid NDNMB reversal – Sugammadex will reverse neuromuscular blockade much faster than using neostigmine. In fact, Sugammadex will reverse deep blockade faster than neostigmine can reverse a moderate blockade.

Non-reversible – Once Sugammadex has bound to the NDNMB agent, it cannot be reversed.

Incompatable Drugs – Ondansetron, ranitidine, and verapamil are all incompatible with Sugammadex. Make sure to keep these drugs separate if administering through the same IV line.

Reinitiating Neuromuscular Blockade AFTER Sugammadex – The recommendation is 1.2 mg/kg of Rocuronium 5 minutes after administering a sugammadex reversal. However, receiving a dose of Rocuronium this early will result in a delayed onset and shortened duration. Alternatively, the recommendation is 0.6 mg/kg (or 0.1 mg/kg of Vecuronium) after a minimum waiting period of 4 hours after sugammadex reversal. If a 16mg/kg dose was administered, a minimum wait time of 24 hours is most likely needed.

cisatracurium (Nimbex) – Neuromuscular blockade using Nimbex will have a faster onset and deeper level of blockade when administered after a sugammadex reversal.

Neostigmine – Sugammadex does NOT inhibit neostigmine.

Actual Body Weight – Sugammadex should be dosed by ACTUAL body weight. If dosed according to ideal body weight, the dose will not likely be enough for the obese.

Hormonal Contraceptives – Sugammadex may interfere with hormonal contraceptives such as the pill, vaginal ring, implants, and intrauterine devices (IUDs). This is thought to be the equivalent of missing a single oral contraceptive pill. The patient should be counseled to use ADDITIONAL non-hormone contraceptives for 7 days after surgery (eg. condoms).

IV push dose

2 mg/kg – 16 mg/kg ACTUAL body weight.

2mg/kg for moderate blockade (two twitches TOF)
4 mg/kg for deep blockade (1-2 post-tetanic counts after a 5 second 50-hertz tetany)
16 mg/kg for immediate reversal of an intubating dose of rocuronium or vecuronium

Method of Action

Sugammadex is a modified gamma-cyclodextrin that selectively encapsulates rocuronium and vecuronium. This encapsulation prevents binding at the nicotinic acetylcholine receptor, which effectively renders these drugs ineffective.

Elimination

Renal

Nag. Sugammadex: A revolutionary drug in neuromuscular pharmacology. 2013.
Ezri. Sugammadex: An Update. 2016.
Swerdlow. Sugammadex: Pharmacometrics, clinical utility, and adverse effects. 2022.