Makindo Medical Notes

💊 About

Always check the BNF entry for Sugammadex here for the latest dosing and safety updates. It is a revolutionary agent in anaesthetic pharmacology, offering rapid and reliable reversal of neuromuscular blockade caused by aminosteroid relaxants.

⚙️ Mode of Action

• 🧬 Sugammadex is a modified γ-cyclodextrin that encapsulates aminosteroid neuromuscular blockers such as rocuronium and vecuronium.
• 🔒 It forms a tight 1:1 complex with the drug molecule, chelating the free rocuronium/vecuronium in plasma.
• ⬇️ This creates a concentration gradient — the drug diffuses from the neuromuscular junction back into plasma, reducing receptor blockade and restoring muscle tone.
• ⚡ The complex has a very high affinity and very low dissociation rate, so the captured aminosteroid is not released back into circulation.
• 🚽 Excreted unchanged in urine — hence caution in renal impairment.

📦 Indications & Doses

• 👶 Children (2–17 years): 2 mg/kg for routine reversal of rocuronium-induced block.
• 👩‍⚕️ Adults:
  • 💨 Immediate reversal (after large rocuronium dose): 16 mg/kg.
  • ⬇️ Deep block: 4 mg/kg for rocuronium or vecuronium.
  • 💪 Moderate block: 2 mg/kg for rocuronium or vecuronium.
  • 🔁 Repeat 4 mg/kg if re-paralysis occurs.

⚠️ Interactions

• 💊 Oral contraceptives: Sugammadex binds steroid molecules and can reduce contraceptive efficacy. Patients should follow the “missed pill” protocol for their specific preparation or use backup contraception for 7 days.

🩺 Cautions

• ⏳ Delayed recovery possible in elderly or those with cardiovascular disease.
• 🚫 Re-use of rocuronium should be avoided for 24 hours post-sugammadex (drug remains bound and inactive).
• 🩸 May slightly increase risk of post-operative bleeding — mechanism thought to involve mild coagulation changes.

❌ Contraindications

• ⚕️ Severe renal impairment: avoid if creatinine clearance < 30 mL/min (due to reliance on renal excretion).

💢 Side Effects

• 🤢 Common: vomiting, dry mouth, dizziness, tachycardia.
• 🚨 Serious (rare): hypersensitivity, anaphylaxis, or bronchospasm.

📚 References

• Nag K, Singh DR, Shetti AN, Kumar H, Sivashanmugam T, Parthasarathy S. Sugammadex: A revolutionary drug in neuromuscular pharmacology. Anesthesia, Essays and Researches (2013) 7(3):302–306. DOI:10.4103/0259-1162.123211
• Chang HW, Lee IO, Kang H, Won YJ, Lim YS. Coagulation Effect of Sugammadex as Determined by Thromboelastography. Int J Med Sci (2021) 18(6):1318–1324. DOI:10.7150/ijms.42563

💡 Teaching tip: Sugammadex offers rapid, predictable reversal — far faster than neostigmine and without muscarinic side effects. However, its cost, renal dependence, and steroid interactions make BNF consultation essential before use.