Sugammadex
Bridion
Modified γ-cyclodextrin selective relaxant binding agent
Encapsulates rocuronium > vecuronium > pancuronium in 1:1 complex. No effect on cisatracurium, atracurium, sux.
Indications
- •Reversal of rocuronium / vecuronium NMB
- •Emergency reversal of failed RSI
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| Routine reversal (TOF 2+) | 2 mg/kg IV | 2 mg/kg IV (FDA labeled for ages 2+ as of Dec 2021) |
| Deep block (PTC ≥ 1, no TOF) | 4 mg/kg IV | 4 mg/kg IV (off-label peds; widely used per APA/Coté) |
| Immediate emergency reversal | 16 mg/kg IV | 16 mg/kg IV (off-label peds; used in cannot-intubate-cannot-ventilate after roc) |
Pharmacokinetics
Onset 1–3 min. Renally excreted; ESRD prolonged clearance (still effective).
Side effects
- !Anaphylaxis (~1:2,500 to 1:20,000)
- !Bradycardia/asystole (rare)
- !Hormonal contraceptive interaction — counsel 7 days alternative contraception
- !Coagulation prolongation (small ↑ in PT/aPTT, no clinical bleeding)
Contraindications
- ×Known sugammadex allergy
Clinical pearls
- ★Re-paralysis with roc/vec ineffective for 24 h post-sugammadex; use cis or non-aminosteroid.
- ★ESRD: works fine; sugammadex-roc complex slowly excreted but no toxicity.
- ★Quantitative TOF should still be confirmed even after 4 mg/kg deep dose.
Other drugs in Muscle Relaxants & Reversals
- Succinylcholine
Acetylcholine receptor agonist at the NMJ; sustained depolarization → fasciculations → flaccid paralysis. Hydrolyzed by plasma cholinesterase.
- Rocuronium
Competitive antagonist at the NMJ nicotinic receptor.
- Cisatracurium
Competitive antagonist at the post-synaptic nicotinic ACh receptor at the neuromuscular junction. Single cis-cis isomer of atracurium (4× more potent, lower laudanosine production).
- Vecuronium
Competitive nicotinic ACh-receptor antagonist at the NMJ. Aminosteroid → reversible by sugammadex.
- Atracurium
Competitive nicotinic antagonist. Eliminated by HOFMANN elimination (spontaneous, temp/pH-dependent) + ester hydrolysis → organ-independent clearance.
- Pancuronium
Competitive nicotinic antagonist. Also blocks cardiac muscarinic receptors (vagolytic) → tachycardia.
- Mivacurium
Competitive nicotinic antagonist. UNIQUE among non-depolarizers: metabolized by PLASMA CHOLINESTERASE (like succinylcholine) → shortest-acting NDMR.
Suggested reading
- •Miller's Anesthesia, 9e
- •Coté, A Practice of Anesthesia for Infants and Children, 7e
- •FDA package insert
