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Selective Neuromuscular Blockade Reversal Agent Pregnancy: Compatible — no teratogenicity data in humans; use when clinically indicated

Sugammadex

Brand names: Bridion

Adult dose

Dose: Routine reversal (moderate block, TOF count ≥2): 2 mg/kg IV. Deep block (post-tetanic count 1–2): 4 mg/kg IV. Immediate reversal (after 1.2 mg/kg rocuronium): 16 mg/kg IV.
Route: IV bolus
Frequency: Single dose
Max: 16 mg/kg (emergency reversal)
Selective reversal of rocuronium and vecuronium ONLY (encapsulates steroidal NMBAs). Not effective for suxamethonium, atracurium, or cisatracurium. At 16 mg/kg reverses 1.2 mg/kg rocuronium within 3 min — used as alternative to succinylcholine for 'can't intubate, can't oxygenate' scenario.

Paediatric dose

Dose: 2 mg/kg
Route: IV
Frequency: Single dose
Max: 16 mg/kg
Concentration: 200 mg/2 mL mg/ml
BNFc child ≥2 years: routine reversal (TOF count ≥2) 2 mg/kg; deep block (post-tetanic count 1–2) 4 mg/kg; immediate reversal after 1.2 mg/kg rocuronium 16 mg/kg. Same doses as adults by weight. Data limited in neonates.

Dose adjustments

Renal

Avoid if eGFR <30 — sugammadex–rocuronium complex accumulates; rebound blockade possible

Hepatic

No dose adjustment required

Paediatric weight-based calculator

BNFc child ≥2 years: routine reversal (TOF count ≥2) 2 mg/kg; deep block (post-tetanic count 1–2) 4 mg/kg; immediate reversal after 1.2 mg/kg rocuronium 16 mg/kg. Same doses as adults by weight. Data limited in neonates.

Clinical pearls

  • Game-changer for RSI: using rocuronium 1.2 mg/kg + sugammadex 16 mg/kg can provide intubating conditions similar to suxamethonium and be fully reversed within 3 min
  • Contraceptive warning: 16 mg/kg dose may bind and displace progesterone in combined OCP — advise barrier contraception for 7 days post-dose
  • Anaphylaxis rates 0.3% — have resuscitation available; allergy testing available pre-operatively if concern
  • Unlike neostigmine: reverses deep NMB (PTC 1–2) rapidly and reliably — no re-curarisation

Contraindications

  • Allergy to sugammadex
  • Use for reversal of non-steroidal NMBAs (atracurium, cisatracurium, suxamethonium — ineffective)

Side effects

  • Anaphylaxis/hypersensitivity (0.3%)
  • Taste disturbance
  • Cough or movement on reversal
  • Bradycardia (rare)
  • QT prolongation (rare)

Interactions

  • Toremifene (oestrogen receptor modulator) — may displace sugammadex–rocuronium complex; may need additional sugammadex
  • Hormonal contraceptives — one-time displacement; patients should use alternative contraception for 7 days after high-dose sugammadex
  • Flucloxacillin and fusidic acid — may compete for cyclodextrin complex (theoretical)

Monitoring

  • TOF ratio after reversal (must achieve >0.9 before extubation)
  • Clinical signs of residual NMB (5-second head lift, grip strength)
  • Vital signs during administration
  • Signs of anaphylaxis

Reference: BNFc; BNF; Bridion SPC; RCoA; NICE TA Bridion 2015. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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