UMEM Educational Pearls - By Meghin Moynihan

Sugammadex works by chelating non-depolarizing neuromuscular blocking agents (NMBA) such as rocuronium and vecuronium to reverse the effects of paralysis.  Dosing per package insert varies based on time from administration of the NMBA, and side effects, although rare, include severe bradycardia, hypotension, and asystole. While sugammadex is routinely used by our anesthesia colleagues, it is rarely utilized in the emergency department (ED) or intensive care unit (ICU) setting. 

A recent single-center study assessed 11 patients with either a traumatic brain injury (TBI) or intracranial hemorrhage (ICH) who received sugammadex for neurologic assessment in the ED or ICU.  The median dose was 240mg and the median time since last NMBA administration was 101 minutes.

In 6/11 patients, the neurosurgical plan changed and it affirmed a poor prognosis in 3/11 patients. In the ICU patients, sugammadex was associated with reduction in unnecessary tests.

All patients had a GCS of 3T prior to administration and 67% responded to sugammadex with a median increase to 8T (P=0.0156).  MAP reductions were common with a median of -8 mmHg.

Bottom Line:  Sugammadex can assist in determining a neurosurgical or clinical prognosis plan in patients with TBI and ICH.  Larger studies are needed in this patient population and caution should be used inpatients who are already hypotensive or bradycardic.  A reasonable dose, especially when given >1h from intubation would be 200mg.  The team should be available at administration to note changes in GCS.


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