What is the recommended dosage of Sugammadex (Bridion) for reversal of neuromuscular blockade?

Sugammadex Dosing for Reversal of Neuromuscular Blockade

Sugammadex dosing must be determined by quantitative neuromuscular monitoring, with doses ranging from 2 mg/kg for moderate blockade to 16 mg/kg for immediate reversal, based on the depth of blockade at the time of administration. 1

Dosing Algorithm Based on Depth of Blockade

The dose of sugammadex is entirely dependent on the degree of neuromuscular blockade present at the time of reversal, making quantitative monitoring essential 2, 3, 4:

For Rocuronium or Vecuronium-Induced Blockade:

Moderate Blockade (TOF count = 2):

• Administer 2 mg/kg sugammadex when the second twitch (T2) has reappeared on train-of-four (TOF) stimulation 1, 2
• Recovery to TOF ratio ≥0.9 occurs in approximately 1.3-2.0 minutes 2, 5
• This dose is 10.22 minutes (6.6 times) faster than neostigmine 0.05 mg/kg for achieving complete reversal 6

Deep Blockade (PTC = 1-2, no TOF responses):

• Administer 4 mg/kg sugammadex when post-tetanic count (PTC) shows 1-2 responses with no visible TOF responses 1, 2
• Recovery to TOF ratio ≥0.9 occurs in 2-5 minutes 2, 3
• This dose is 45.78 minutes (16.8 times) faster than neostigmine 0.07 mg/kg 6

For Rocuronium Only:

Immediate Reversal (Very Deep Blockade):

• Administer 16 mg/kg sugammadex when clinical need exists to reverse blockade approximately 3 minutes after administration of rocuronium 1.2 mg/kg 1, 2
• Recovery to TOF ratio ≥0.9 occurs in 1.5-2.0 minutes 5
• This indication has NOT been studied for vecuronium and should only be used with rocuronium 1

Very Moderate Blockade (TOF ratio = 0.5):

• A dose as low as 0.22 mg/kg can achieve TOF ratio >0.9 in less than 5 minutes in 95% of patients, though this is not a standard FDA-approved dosing regimen 2

Critical Monitoring Requirements

Quantitative neuromuscular monitoring is mandatory for appropriate sugammadex dosing and to detect potential recurarization 2, 4:

• Use objective adductor pollicis monitoring with TOF and PTC stimulation to determine the depth of blockade before administering sugammadex 4
• Continue monitoring after sugammadex administration until complete recovery is confirmed (TOF ratio ≥0.9) 2, 4
• Clinical tests alone are insufficient to detect residual neuromuscular blockade 4

Administration Guidelines

Sugammadex should be given as a single intravenous bolus injection 1:

• May be administered over 10 seconds into an existing IV line 1
• Dosing is based on actual body weight, not ideal body weight 1
• Flush the IV line adequately (with 0.9% sodium chloride) between sugammadex and other drugs 1

Special Population Considerations

Elderly Patients:

• Efficacy of sugammadex is decreased in elderly patients, though specific dose adjustments are not provided in guidelines 2, 3

Severe Renal Impairment (CrCl <30 mL/min):

• Efficacy is significantly decreased, particularly for reversal of deep blockade 2, 3
• Exercise caution and ensure prolonged monitoring in this population 2

Pediatric Patients (<2 years old):

• 2 mg/kg for moderate blockade and 4 mg/kg for deep blockade are effective and well-tolerated in neonates and infants 7
• No dose adjustments based on age are necessary 7

Critical Pitfalls to Avoid

Inadequate dosing is the primary cause of recurarization 2, 3:

• Never administer sugammadex without first determining the depth of blockade through quantitative monitoring 4
• Doses lower than 1 mg/kg may lead to rebound of rocuronium's effect 8
• Do not discontinue monitoring after reversal agent administration, as recurarization can occur 2, 4
• Sugammadex is physically incompatible with verapamil, ondansetron, and ranitidine—flush lines adequately 1

Comparative Efficacy

Sugammadex demonstrates superior reversal speed compared to neostigmine across all depths of blockade 6:

• For moderate blockade: median recovery time 1.9 minutes vs 10.6 minutes with neostigmine 5
• For deep blockade: median recovery time 2.9 minutes vs 19.0 minutes with neostigmine 5
• Number needed to treat to avoid one adverse event compared to neostigmine: 8 patients 6
• Significantly reduced risk of bradycardia (RR 0.16), PONV (RR 0.52), and residual paralysis (RR 0.40) compared to neostigmine 6