sugammadex

Sugammadex is a selective neuromuscular blockade reversal agent used to reverse the effects of certain aminosteroid nondepolarizing agents, most commonly rocuronium and, to a lesser extent, vecuronium. It does not reverse benzylisoquinolinium blockers such as atracurium or cisatracurium. Sugammadex is a gamma-cyclodextrin that binds these neuromuscular blockers in the plasma to form stable 1:1 complexes, thereby rapidly reducing active drug at the nicotinic receptors and allowing recovery of muscle function. The complex is primarily eliminated by the kidneys.

Dosing and use are guided by the depth of neuromuscular blockade and monitoring. In adults, about 2 mg/kg reverses moderate blockade with two twitches on train-of-four testing. For deeper blockade with no twitches but a post-tetanic count of 1–2, 4 mg/kg is recommended. For immediate reversal after rocuronium-induced apnea, 16 mg/kg may be used. Pediatric dosing is weight-based and similar principles apply. Reversal should be guided by quantitative neuromuscular monitoring, and maintenance of airway and respiration is essential during emergence.

Safety and adverse effects are generally favorable, but potential reactions include bradycardia, hypotension, nausea, and rare hypersensitivity or anaphylaxis. Since sugammadex and its complexes are cleared renally, impaired kidney function can prolong reversal time and reduce clearance; patients with severe renal impairment require careful assessment and monitoring. Sugammadex does not interact with acetylcholinesterase inhibitors and offers a distinct pharmacologic alternative to traditional reversal strategies.