Sugammadex (Bridion) | Medication Reference

Bedside Snapshot

Modified γ-cyclodextrin that encapsulates and inactivates aminosteroid neuromuscular blocking agents, primarily rocuronium and vecuronium
Provides rapid, reliable reversal of even deep neuromuscular blockade with a more predictable profile than neostigmine and without muscarinic side effects
Dosed by actual body weight and depth of block: 2 mg/kg (moderate block with TOF ≥2 twitches), 4 mg/kg (deep block with TOF 0), or 16 mg/kg (immediate reversal after RSI-dose rocuronium in airway emergencies)
Eliminated renally as sugammadex–NMB complexes; use is generally not recommended in severe renal impairment (CrCl <30 mL/min) due to prolonged complex persistence
Has been associated with rare but serious anaphylaxis and bradycardia/asystole; monitoring after dosing is essential with atropine and resuscitation equipment immediately available
Does not reverse succinylcholine or benzylisoquinoline NMBs (cisatracurium, atracurium); neostigmine is still needed for those agents

Brand & Generic Names

Generic Name: Sugammadex
Brand Names: Bridion

Medication Class

Selective relaxant binding agent (SRBA); reverses aminosteroid neuromuscular blockers (rocuronium, vecuronium)

Pharmacology

Mechanism of Action:

Sugammadex is a ring-shaped cyclodextrin with a hydrophobic core and hydrophilic exterior that forms tight 1:1 inclusion complexes with aminosteroid NMBs (rocuronium > vecuronium >> pancuronium)
Encapsulation of free NMB molecules in plasma reduces their free concentration, creating a gradient that pulls drug away from the neuromuscular junction back into the plasma
As NMB molecules are sequestered, fewer are available to bind nicotinic receptors, allowing rapid restoration of neuromuscular transmission
Because reversal is based on binding the NMB, acetylcholinesterase is not affected, and sugammadex does not cause muscarinic side effects like bradycardia, bronchospasm, or increased secretions seen with neostigmine

Pharmacokinetics:

Onset of reversal: Typically 2–3 minutes for moderate block with 2 mg/kg, slightly longer for deep block with 4 mg/kg; 16 mg/kg can reverse profound block within ~3 minutes
Distribution: Confined largely to extracellular fluid; does not cross the blood–brain barrier
Elimination: Primarily renal excretion of unchanged sugammadex–NMB complexes; elimination half-life ~2 hours in normal renal function
Renal impairment: In severe renal impairment, clearance is significantly reduced and complexes may persist, raising concerns about prolonged exposure and uncertain safety

Dosing & Administration

Available Forms:

Vials of 100 mg/mL solution (e.g., 200 mg/2 mL or 500 mg/5 mL)
Administered as a single IV bolus over 10 seconds based on actual body weight and depth of block

Dosing – Sugammadex (Adult):

Always follow local protocols and consult current drug references

Depth of Block / Scenario	Dose	Route	Notes
Routine reversal – moderate block (TOF ≥2 twitches)	2 mg/kg	IV bolus over 10 s	Most common dosing; expect TOF ratio ≥0.9 within ~2–3 min
Deep block (post-tetanic count 1–2; TOF 0)	4 mg/kg	IV bolus	Used when block is deeper; recovery slightly slower than 2 mg/kg at moderate block
Immediate reversal after RSI-dose rocuronium (≈1.2 mg/kg)	16 mg/kg	IV bolus	Rescue dose in rare airway emergencies; very high cost; not a substitute for airway rescue maneuvers
Pediatric patients ≥2 years (outline)	2–4 mg/kg	IV bolus	Similar indications as adults; follow pediatric anesthesia guidelines
Renal impairment (CrCl <30 mL/min)	Use generally not recommended	—	Sugammadex–NMB complexes persist; limited safety data
Re-dosing after recurrence (rare)	2–4 mg/kg	IV bolus	Recurarization is rare if initial dose and indication are appropriate; consult anesthesia/pharmacy
Maximum practical dose	16 mg/kg	IV	Higher doses almost never needed; consider cost/resource issues

Contraindications

Known serious hypersensitivity to sugammadex or any component of the formulation

Adverse Effects

Common:

Dysgeusia (metallic or bitter taste)
Nausea, vomiting
Cough, mild hypotension
Headache

Serious:

Anaphylaxis and severe hypersensitivity reactions
Marked bradycardia and rare cardiac arrest
Potential recurarization if under-dosed or in unusual pharmacokinetic circumstances

Indications / Clinical Uses (OR/ICU Focus)

Routine reversal of rocuronium- or vecuronium-induced neuromuscular blockade at the end of surgical or procedural anesthesia
Rapid or immediate reversal of rocuronium in unanticipated difficult airway or 'can't intubate/can't ventilate' scenarios, in conjunction with full airway rescue maneuvers
Occasional ICU use to rapidly discontinue neuromuscular blockade in deeply paralyzed patients (e.g., ARDS) when quick recovery of neuromuscular function is desired
Operating room cases using rocuronium or vecuronium as the primary neuromuscular blocker
Rapid sequence induction with rocuronium where quick reversal could be required

Major Precautions

Severe renal impairment (CrCl <30 mL/min): Sugammadex–NMB complexes are cleared slowly; routine use is generally not recommended
Hypersensitivity and anaphylaxis: Rare but serious; can occur on first exposure; monitor for rash, bronchospasm, hypotension, or angioedema
Bradycardia/asystole: Sometimes severe and rarely progressing to asystole, has been reported shortly after administration; have atropine and resuscitation equipment immediately available
Hormonal contraceptives interaction: Sugammadex can transiently lower progestin levels, effectively similar to missing one contraceptive pill; advise backup contraception for 7 days
Coagulation effects: Mild, transient prolongation of PT/INR and aPTT has been seen; usually not clinically significant but may interact additively with anticoagulants

Monitoring Parameters (OR/ICU)

Neuromuscular function: TOF ratio (goal ≥0.9) and clinical assessment of airway protection, respiratory effort, and strength
ECG and blood pressure monitoring after administration to detect bradycardia or hypotension
Observation for at least several minutes post-dose for signs of hypersensitivity or recurrence of weakness

Clinical Pearls

Deep block management: Sugammadex allows safe use of deep rocuronium block (e.g., for difficult surgical conditions) with rapid reversal at case end, providing more predictable recovery than neostigmine.

Selective for aminosteroids: It does not reverse succinylcholine or benzylisoquinoline NMBs (cisatracurium, atracurium); neostigmine is still needed for those agents.

Airway emergencies: In 'can't intubate/can't ventilate' scenarios after rocuronium, sugammadex is a powerful adjunct but must be used alongside established airway rescue algorithms—don't delay front-of-neck access while waiting for it to work.

No anticholinergic needed: No anticholinergic co-administration is required, reducing bradycardia and secretory side effects seen with neostigmine/glycopyrrolate combination.

Contraceptive interaction: Ensure counseling and documentation about the interaction with hormonal contraceptives, especially in day-surgery patients. Advise backup contraception for 7 days post-administration.

References

Lexicomp. (2024). Sugammadex: Drug information. Wolters Kluwer.
Brueckmann, B., Sasaki, N., Grobara, P., et al. (2015). Effects of sugammadex on incidence of postoperative residual neuromuscular blockade. Anesthesiology, 123(3), 717–728.