Anaes · Neuromuscular blockade & reversal

Sugammadex reversal and residual neuromuscular blockade

Also known as Modified gamma-cyclodextrin · Selective relaxant binding agent · Encapsulation reversal of rocuronium/vecuronium · Sugammadex depth-based dosing

Sugammadex is a modified gamma-cyclodextrin — a selective relaxant binding agent — that reverses the aminosteroid neuromuscular blockers by ENCAPSULATION: it forms a tight 1 to 1 host-guest inclusion complex with rocuronium (highest affinity) and vecuronium in plasma, lowering their free plasma concentration so the blocker diffuses off the nicotinic receptor and transmission is restored, acting in plasma rather than at the receptor or at acetylcholinesterase (Lawson 2026; Kronauer 2026). It is transformative because it reverses even a profound, deep block, with depth-based dosing — 2 mg per kg at a train-of-four count of 1 to 2, 4 mg per kg for a deep block (post-tetanic count 1 to 2), and 16 mg per kg for immediate reversal of a 1.2 mg per kg rocuronium intubating dose within about 3 minutes (Lawson 2026; Kronauer 2026). It needs no anticholinergic — it does not raise acetylcholine — and it is excreted unchanged in the urine, so it is contraindicated in severe renal impairment (Kronauer 2026). It markedly reduces residual neuromuscular blockade and postoperative pulmonary complications versus neostigmine (Leslie 2026; Tsai 2026). The principal hazards are anaphylaxis, sometimes severe (Lee 2026), recurarisation if the dose is inadequate (Felix 2026), delayed airway oedema (Habib 2026), and a reduction in hormonal-contraceptive efficacy through progesterone binding so that women of childbearing potential need additional contraception for 7 days (Akca 2025).