Rocuronium Bromide and Sugammadex Dosing and Reversal Protocol
Rocuronium Dosing
For rapid sequence intubation and tracheal intubation, administer rocuronium 0.9 to 1.2 mg/kg to achieve excellent intubating conditions within 60-90 seconds. 1
- Standard intubating dose: 0.6 mg/kg (2 x ED95) provides good to excellent intubating conditions within 60-90 seconds 1
- Rapid sequence induction: 0.9 to 1.2 mg/kg is recommended for rapid sequence settings, though this results in longer duration of action 1
- Maintenance dosing: Rocuronium is dosed based on actual body weight 2
- Onset time: Rocuronium is the fastest-acting non-depolarizing muscle relaxant, though suxamethonium still provides slightly superior intubating conditions at lower rocuronium doses 1
Clinical Context
- Rocuronium reduces pharyngeal and laryngeal injury rates from 22.6% without muscle relaxant to 9.7% with muscle relaxant use 1
- The use of muscle relaxants facilitates tracheal intubation, reducing poor intubating conditions from 24.6% to 4.1% 1
Sugammadex Reversal Protocol
The dose of sugammadex must be determined by the depth of neuromuscular blockade at the time of reversal, with quantitative train-of-four (TOF) monitoring essential to guide dosing and confirm adequate reversal. 1, 2
Dosing Based on Depth of Blockade
For moderate blockade (TOF count ≥2):
- Sugammadex 2.0 mg/kg achieves TOF ratio ≥0.9 within 3-5 minutes 1, 2, 3
- Geometric mean recovery time: 1.9 minutes after rocuronium 3
For deep blockade (1-2 post-tetanic counts, TOF count = 0):
- Sugammadex 4.0 mg/kg achieves TOF ratio ≥0.9 within 3-5 minutes 1, 2, 3
- Geometric mean recovery time: 2.2 minutes after rocuronium 3
For immediate reversal (3 minutes after rocuronium 1.2 mg/kg):
- Sugammadex 16.0 mg/kg (rocuronium only) achieves reversal within approximately 3 minutes 1, 2
- Mean recovery time: 1.7 minutes 3
- This dose has not been studied for vecuronium reversal 2
For very light blockade (TOF ratio 0.5):
- Sugammadex 0.22 mg/kg provides TOF ratio >0.9 in less than 5 minutes in 95% of patients 1
Administration Technique
- Administer as a single intravenous bolus over 10 seconds into an existing IV line 2
- Dosing is based on actual body weight 2
- Flush the IV line adequately (with 0.9% sodium chloride) between sugammadex and other drugs 2
Monitoring Requirements
Quantitative neuromuscular monitoring is mandatory both during reversal and in the postoperative period to ensure adequate recovery and detect potential recurarization. 1, 4, 5
Key Monitoring Points
- Continue monitoring from sugammadex administration until complete recovery of neuromuscular function 2
- Assess adequacy through skeletal muscle tone, respiratory measurements, and peripheral nerve stimulation response 2
- Post-reversal monitoring should continue in the recovery area or ICU, as recurarization can occur 1, 5
- In a cardiac surgery study, 2 of 97 patients (2%) experienced recurrent paralysis requiring additional sugammadex 5
Special Populations and Dose Adjustments
Elderly Patients
- Efficacy is decreased in elderly patients; consider higher end of dose range or additional monitoring 1, 4
Severe Renal Impairment (CrCl <30 mL/min)
- Efficacy is decreased, especially for deep blockade reversal 1, 4
- Use with caution and ensure adequate monitoring 4
Obese Patients
- Dose sugammadex based on actual body weight 2
- Rocuronium should be dosed based on lean body weight in most patients 4
Drug Compatibility and Incompatibilities
Sugammadex is physically incompatible with verapamil, ondansetron, and ranitidine. 2
Compatible IV Solutions
- 0.9% sodium chloride 2
- 5% dextrose 2
- 0.45% sodium chloride with 2.5% dextrose 2
- 5% dextrose in 0.9% sodium chloride 2
- Ringer's lactate and Ringer's solution 2
Critical Pitfalls to Avoid
Inadequate sugammadex dosing is the primary cause of reversal failure and recurarization. 1, 5
Common Errors
- Administering fixed doses without TOF monitoring: The dose required varies from 0.43 to 5.6 mg/kg depending on blockade depth; 87% of patients required less than recommended doses, but 13% required more 5
- Assuming reversal is complete without objective monitoring: Subjective assessment is unreliable 1, 2
- Discontinuing monitoring after initial reversal: Recurarization can occur and requires continued surveillance 1, 5
- Using inadequate doses for deep blockade: Insufficient dosing may lead to situations requiring emergency airway access 1
Non-Operating Room Use
- When TOF monitoring is unavailable in the ED or ICU setting, sugammadex 3-4 mg/kg administered 1-2 hours after rocuronium for rapid sequence intubation has demonstrated safe and effective reversal 6
- However, this approach should only be used when quantitative monitoring is truly unavailable, as dose requirements vary significantly 6, 5
Hypersensitivity Risk
Clinicians must be prepared for potential anaphylaxis, which occurs in approximately 0.3% of patients, even without prior exposure to sugammadex. 2