Residual neuromuscular blockade has been identified as a significant risk factor for adverse postoperative patient outcomes

Sugammadex (Bridion®) is a selective relaxant-binding agent designed to encapsulate rocuronium and chemically similar steroidal muscle relaxants such as vecuronium

The main advantages of sugammadex are much faster reversal and the unique ability to reverse deep levels of neuromuscular blockade rapidly and efficiently

However, sugammadex is a relatively high-cost medication that impacts drug expenditure and its use should be carefully considered

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Abbreviations

(For obese patients, dose according to ACTUAL BODY WEIGHT)

Give as IV a single bolus injection rapidly within 10 seconds.

1. Emergency reversal 3 mins after rocuronium 1.2 mg/kg: sugammadex 16 mg/kg.

2. Shallow reversal sugammadex 2 mg/kg (two twitches of ToF).

3. Deep reversal sugammadex 4 mg/kg (post tetanic count of two twitches).

Storage

Each vial contains 200mg in 2 ml (100mg/ml). Pack size 10 vials

• FPH: Drug cupboard in Theatre 7 anaesthetic room, DSU 1 (theatre 17), DSU 2 (theatre 13), Emergency Pharmacy cupboard, ED and ICU.

• WP: Main theatre pharmacy cupboard; Theatre 4 anaesthetic room drug cupboard, Labour Ward theatre drug cupboard, ED, ICU and Ward 24.

• HWD: Main corridor cupboard.

N.B.

• Peripheral nerve stimulation should always be used (and documented) to guide reversal of neuromuscular (NM) blockade.

• Sugammadex can be considered for the reversal of neuromuscular blockade included by rocuronium or vecuronium, as an alternative to neostigmine/glycopyrrolate.

It’s use is accepted when the generic, unbranded product is available. At times supply, and hence usage, may be restricted to the following indications:

• Rare but life-threatening “can’t intubate, can’t oxygenate” situation when rocuronium was used.

• In intubated or extubated patients not adequately reversed with neostigmine despite ToF monitoring.

• In patients with contraindications to other reversal agents (neostigmine), e.g., muscular disorders.

• Myasthenia Gravis.

No reversal required when T4:T1 ratio > 0.9 Post Tetanic Count

Tracheal re-intubation after sugammadex should be facilitated by a non-aminosteroid NM blocking drug.

• The time to reversal with high dose sugammadex is a minimum of 1.4 minutes – excluding time to decision, accessing, drawing up and administering.

• Repeat use of rocuronium: Allow 24 hours before repeat use of rocuronium after 16mg/kg sugammadex.

• Women taking hormonal contraceptives should use additional contraception for at least seven days.

• Report all suspected adverse reactions to the MHRA.

• Injection solution is stable for 24 hours after opening at 2-8°C

• Cases of marked bradycardia have been observed within minutes administration of sugammadex. Treat with anticholinergic agents if clinically significant.

• Should you anticipate needing sugammadex in a remote area (Cath lab, A&E), please ensure you have sufficient sugammadex immediately available before anaesthetising your patient.

• Mild to mod renal impairment: No dose adjustment (CrCl 30-80 ml/min).

• Not recommended in severe renal impairment, including those requiring dialysis.

• Not recommended for treatment of patients with severe hepatic impairment.

• There may be a bleeding risk with coagulopathic patients, particularly when using 16mg/kg of sugammadex.

• Caution in pregnancy - although safe in breastfeeding.

1. Merck Sharp and Dohme (UK) (2025) Bridion 100 mg/ml solution for injection. London: Royal Pharmaceutical Society. Available from: https://www.medicines.org.uk/emc/product/6409/smpc#gref (Accessed: 14 March 2025).

For obese patients, dose according to ACTUAL BODY WEIGHT

All volumes given have been rounded to nearest practical volume.

Dosing Reference Guide