Sugammadex

Rapid reversal of Rocuronium and Vecuronium (Non-depolarizing Neuromuscular Blocking Agents)
FDA approved for reversal in adult surgery cases, to speed recovery after case completion
Follow neurologic status in neurologic catastrophe (e.g. Intracranial Hemorrhage) or Status Epilepticus

Emergency paralytic reversal is off-label use and may not be ideal
1. A patient who requires emergent Endotracheal Intubation still needs an airway
2. Reversal agents render further Non-depolarizing Neuromuscular Blocking Agent use ineffective
Can't Intubate but CAN ventilate scenarios may be treated with temporarily with BVM or LMA
Can't Intubate, Can't Ventilate scenarios require emergency Cricothyrotomy
1. Paralysis reversal may worsen this situation and delay definitive management
References
1. Strayer in Herbert (2019) EM:RAP 19(11):4-6

Sugammadex is a modified gamma cyclodextrin that tightly binds Rocuronium and Vecuronium
Reduces available Rocuronium and Vecuronium to bind Nicotinic Acetylcholine Receptors at Neuromuscular Junction

Reverses paralysis within 3-5 minutes
Not metabolized
1. Up to 95% if excreted unchanged in the urine
Half-Life
1. Normal Renal Function: 2 hours
2. Mild renal Impairment: 4 hours
3. Moderate renal Impairment: 6 hours
4. Severe renal Impairment: 19 hours
Continues to block Neuromuscular Blockade until cleared (based on weight and Renal Function)
1. Requires delay if another Neuromuscular Blocker needs to be given
2. Consider nonsteroidal Neuromuscular Blocker if another paralytic is needed

Train-Of-Four Testing
1. Consider to determine level of residual sedation and appropriate Sugammadex dose
2. Nerve stimulator applied to Ulnar Nerve and estimates degree of paralysis
3. Finger twitching
  1. Deep remaining paralysis = 0-1 twitches
  2. Moderate remaining paralysis = 2-3 twitches
  3. No residual paralysis >=4 twitches (no need for Sugammadex)
Reversal of moderate Neuromuscular Blockade
1. Dose: 2 mg/kg total body weight
Reversal of deep Neuromuscular Blockade (typical dose)
1. Dose: 4 mg/kg total body weight
Rapid reversal dose (difficult intubation and ventilation, onset within 3 min)
1. Dose: 16 mg/kg total body weight
Minimum wait times to re-dose neuromuscular blocking agent (NMBA)
1. Indications to wait >5 minutes
  1. Standard dosing with normal Renal Function
  2. However if NMBA given within 30 minutes of Sugammadex expect modified Pharmacokinetics
    1. Onset delayed up to 4 minutes from time of administration
    2. Duration of action may be decreased to as short as 15 minutes
2. Indications to wait 24 hours
  1. High dose Sugammadex given (16 mg/kg)
  2. Renal Impairment

Recurrent Neuromuscular Blockade
1. Drug Interactions may displace Sugammadex from binding NMBA, resulting in recurrent Neuromuscular Blockade
Severe Bradycardia (1 to 5%)
1. Onset within minutes of administration
2. May require Atropine
3. Cardiac Arrest has occurred in some cases
Prolonged QT Interval (6%)
Hypotension (4 o 13%)
Anaphylaxis or anaphylactoid reactions (0.3% to 1%)
1. Dose dependent risk (higher doses are higher risk for Anaphylaxis)
2. Occurs within 5-10 minutes of administration
3. Treat with Anaphylaxis protocol (esp. Epinephrine)
Other adverse effects
1. Nausea or Vomiting
2. Pain
3. Headache