What is the recommended dose and use of Sugammadex (cyclohexanol) for reversing neuromuscular blockade after surgery?

Sugammadex Dosing for Reversal of Neuromuscular Blockade

Dose sugammadex based on quantitative neuromuscular monitoring: 2 mg/kg for moderate blockade (reappearance of T2 on TOF), 4 mg/kg for deep blockade (1-2 post-tetanic counts), or 16 mg/kg for immediate reversal within 3 minutes of rocuronium 1.2 mg/kg. 1

Dosing Algorithm Based on Depth of Blockade

The dose of sugammadex must be determined by quantitative monitoring of neuromuscular blockade, as the deeper the blockade, the greater the amount of sugammadex required 2, 3:

Moderate Blockade

• 2 mg/kg when the second twitch (T2) has reappeared on TOF stimulation 1
• Recovery to TOF ratio ≥0.9 occurs in approximately 1.3-2.0 minutes 3
• This dose is effective for both rocuronium and vecuronium 1

Deep Blockade

• 4 mg/kg when 1-2 post-tetanic counts (PTC) are present with no TOF responses 1
• Recovery to TOF ratio ≥0.9 occurs in 2-5 minutes 3, 4
• This dose is effective for both rocuronium and vecuronium 1

Immediate Reversal (Rocuronium Only)

• 16 mg/kg when reversal is needed approximately 3 minutes after rocuronium 1.2 mg/kg 1
• Recovery to TOF ratio ≥0.9 occurs in 3-5 minutes 4
• This dose has not been studied for vecuronium 1

Very Moderate Blockade (Off-Label)

• 0.22 mg/kg can achieve TOF ratio >0.9 in less than 5 minutes in 95% of patients when TOF ratio is already 0.5 2, 4
• This is not an FDA-approved dosing regimen 3

Administration Technique

Administer sugammadex as a single intravenous bolus injection over 10 seconds into an existing IV line. 1

Compatible IV solutions include 1:

• 0.9% sodium chloride
• 5% dextrose
• 0.45% sodium chloride with 2.5% dextrose
• Ringer's lactate
• Ringer's solution

Flush the IV line adequately between sugammadex and other drugs, as sugammadex is physically incompatible with verapamil, ondansetron, and ranitidine. 1

Critical Monitoring Requirements

Continue quantitative neuromuscular monitoring after sugammadex administration until TOF ratio ≥0.9 is confirmed to detect potential recurarization. 2, 3

• Quantitative adductor pollicis monitoring is mandatory for appropriate dosing 3
• Clinical tests alone are insufficient to detect residual neuromuscular blockade 3
• Monitor the patient to ensure adequate ventilation and patent airway from the time of administration until complete recovery 1
• Assess skeletal muscle tone, respiratory measurements, and peripheral nerve stimulation responses 1

Special Population Considerations

Renal Impairment

Exercise caution in patients with severe renal failure (creatinine clearance <30 mL/min), as sugammadex efficacy is significantly decreased, particularly for deep blockade. 3, 4

• Ensure prolonged monitoring in this population 3

Elderly Patients

Sugammadex efficacy is decreased in elderly patients, though specific dose adjustments are not provided. 3, 4

• Use standard dosing based on actual body weight 1

Dosing Based on Body Weight

Calculate all sugammadex doses using actual body weight, not ideal body weight. 1

• This differs from neostigmine, which should be dosed based on ideal body weight 2

Common Pitfalls to Avoid

• Underdosing sugammadex for the depth of blockade present leads to inadequate reversal and potential recurarization 3, 4
• Discontinuing monitoring after reversal agent administration may miss recurarization 3
• Failing to use quantitative monitoring results in inappropriate dosing decisions 3
• Assuming sugammadex works for all neuromuscular blocking agents when it is only effective for rocuronium and vecuronium 1

Comparison with Neostigmine

Sugammadex provides significantly faster reversal than neostigmine 5:

• At moderate blockade (T2): sugammadex 1.9 minutes vs neostigmine 10.6 minutes after rocuronium 5
• At deep blockade (1-2 PTC): sugammadex 2.2 minutes vs neostigmine 19.0 minutes after rocuronium 5
• Sugammadex does not require co-administration of muscarinic antagonists like atropine 6