Title of Guideline (must include the word “Guideline” (not protocol, policy,
procedure etc)
Revised guidelines for the administration of
Sugammadex
Author: Contact Name and Job Title
Dr DM Levy, Consultant Anaesthetist
Directorate & Speciality
Specialist Support: Anaesthetics
Date of submission
May 2014
Explicit definition of patient group to which it applies (e.g. inclusion and
exclusion criteria, diagnosis)
Patients undergoing general anaesthesia
with neuromuscular blockade
Version
3a
Key Words:(A few words that may make it easier for users to locate this
guideline using an intranet search)
Sugammadex, reversal, neuromuscular
blockade
If this version supersedes another clinical guideline please be explicit
about which guideline it replaces including version number.
V.1
Statement of the evidence base of the guideline – has the guideline been
peer reviewed by colleagues?
Evidence base encompasses an HTA
assessment. Peer-reviewed by consultant
anaesthetists (NUH); amended following
examination by the Drugs & Therapeutics
Committee (DTC).
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN (please state which source)
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without randomisation
3b
at least one other type of well-designed quasi-experimental study
4
well –designed non-experimental descriptive studies (ie comparative / correlation and
case studies)
5
expert committee reports or opinions and / or clinical experiences of respected
authorities
6
recommended best practise based on the clinical experience of the guideline
developer
Consultation Process
Within-directorate and formal DTC
application.
Ratified by:
Anaesthetics directorate: 8 Jan ‘14
Date:
DTC: 19 March 2014
Target audience
Anaesthetists (only).
Review Date: (to be applied by the Integrated Governance Team)
May 2019
A review date of 5 years will be applied by the Trust. Directorates can
choose to apply a shorter review date, however this must be managed
through Directorate Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in
doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
1 NUH Anaes
sthetics Departmen
D
ts
R
Revised guidelines for th
he admin
nistration
n of Suga
ammadex
x
Dosse regimenss: 1. Emergeency reversaal 3 min afte
er rocuroni um 1.2 mg//kg: Sugamm
madex 16 m
mg/kg 2. Reversaal of ‘shallow
w’ block (de
efined as tw
wo twitchess of a train o
of four): Sugamm
madex 2 mgg/kg 3. Reversaal of ‘deep’ block (defin
ned as a posst‐tetanic count of two
o twitches):: Sugamm
madex 4 mgg/kg 
Peripheeral nerve sstimulation should alw
ways be used to guide reversal of neuromusccular blockaade. The drug will be stored in Recovery u
units. Grey emergenccy boxes comprising 3  500 mg vvials will rem
main as prevviously. nufacturer’ss boxes of 2
200 mg vials will now bbe available
e. Man
Indications: 1. Reversaal with sugaammadex is permitted in any patie
ent in whom
m suxamethhonium is co
ontra‐indicaated and roccuronium haas become tthe neurom
muscular blo
ocking drug of choice: ee.g. MH, anaphylaxis to
o suxameethonium, aatypical plassma cholineesterase, de
enervation injury, criticcal illness neuropathy/myopathy, burnss. bation of an
ny patient inn whom inttubation wa
as difficult (aand rocuron
nium was 2. Safe traacheal extub
used). U
Use of sugammadex will allow supperior recovvery of neurromuscular function co
ompared to
o neostigmine, when
n significantt residual reeceptor blockade might threaten m
maintenancce of airwayy patencyy after extubation. 3. Reversaal of neurom
muscular blo
ockade for any patientt for whom postoperattive critical ccare ventilattory supporrt is an optio
on, but ‘Pla n A’ is a triaal of extubation. 4. Any pattient with p
poor respiratory reservee (e.g. post‐oesophage
ectomy or luung resectio
on) or sepsiis, who might derive aa material b
benefit from
m optimal re
ecovery of rrespiratory muscle function in thee n immediiate postoperative period: e.g. pattients with compromissed respirattory muscle innervation
(e.g. cervical lamin
nectomy) orr impaired rrespiratory muscle mecchanics (anyy ‘sick’ laparotomy). 5. Bariatric (weight lo
oss) surgeryy. a. Any morbid
dly obese paatient undeergoing incid
dental surge
ery, includinng Caesareaan section.
6. Any pattient with m
myasthenia gravis. 2 7. Any patient with obstructive sleep apnoea. 8. Procedures for which deep neuromuscular blockade is critical (e.g. trans‐sphenoidal pituitary surgery and interventional neuroradiology) and which are concluded abruptly. Sugammadex reconciles provision of deep neuromuscular block with facilitation of rapid and safe neuromuscular reversal. 9. Patients exhibiting postoperative residual curarisation: {a} in theatre, after neostigmine or {b} in the post‐anaesthesia care (Recovery) unit – if there are clinical signs of incomplete reversal of rocuronium/vecuronium/pancuronium. Anaesthetists must be mindful that [1] sugammadex does not antagonise succinylcholine or neuromuscular blockade by benzylisoquinolinium drugs; [2] tracheal reintubation after sugammadex should be facilitated by a non‐aminosteroid neuromuscular blocking drug. 


Application to the Trust Drugs & Therapeutics Committee (DTC) was supported at the Anaesthetics Directorate meeting on 16th October 2013 and approved on 8th January 2014. The DTC has stipulated on‐going audit of use. A data capture form (see below) should continue to be completed for all cases in which sugammadex is used, and deposited in the grey emergency box. Data will be assimilated by Drs Michael WR Bennett (Clinical Lead, QMC) and Sumera K Hussain (Clinical Lead, City). Data needs to be reviewed and fed back to DTC on a 3‐monthly basis. Dr DM Levy, 30th Apr 2014 3 NUH Anaes
sthetics Departmen
D
ts
Data capture : use of Sugamm
S
madex
Pattient’s NHS
S or hosp
pital number:______
_________
_________
__
Surrgical proc
cedure:__
_________
_________
_________
__________
_
The
eatre (& ca
ampus):__
_________
_________
_________
_________
_
Nam
me & grad
de of anae
esthetist:_
__________
__________
_________
_
1. Was use o
of sugamm
madex pla
anned at th
he start off the case
e?
Yes
No


2. What was
s the indic
cation for use?
u
cy reversa
al

Emergenc
Reversal of ‘deep’ block
b

Reversal of ‘shallow
w’ block 
s the (inten
nded) surg
gical proc
cedure?
3. What was
_________
_________
_________
_________
_________
__
4. Specific in
ndication (accordin
ng to NUH guideline
e)
Conta-ind
dication to
o succinylcholine

Difficult a
airway

Trial of ex
xtubation, critical ca
are a poss
sibility

Poor pre-operative respiratory reserve
e

besity
Morbid ob

Myasthen
nia Gravis

Obstructiv
ve Sleep Apnoea
A

Indication
n for deep neuromuscular blo
ock

Postopera
ative resid
dual curarrisation

4 5. What dose did you use?_____________ mg
Patient’s (approx.) body mass? _______kg
Sugammadex 16 mg/kg

Sugammadex 4 mg/kg

Sugammadex 2 mg/kg

Briefly, what was the outcome?
Admission to critical care averted 
Shortened time in theatre/recovery
Other: please summarise concisely:
________________________________________________________________
Please return to the grey plastic box for collection by a pharmacy technician
Stock levels:
City Quantity of 500mg in grey box Quantity of 200mg QMC Quantity of 500mg in grey box Quantity of 200mg Urology 3 vials 4 vials ENT 3 vials 10 vials Main theatres back up cupboard 10 vials not in grey box 10 vials Obstetrics 3 vials 10 vials Cardiac 3 vials 10 vials Main theatres 6 vials 10 vials Obstetrics 3 vials 10 vials B floor None none Short stay Unit 3 vials 4 Vials Emergency cupboard 6 vials 10 vials Day surgery 3 vials 4 vials Burns 1 vials 2 vials Vanguard 3 vials 4 vials Pharmacy min stock 10 vials 10vials Pharmacy min stock 10 vials 10 vials 5