Sugammadex (Bridion)

ED / ICU / Transport

• Immediate reversal after an RSI dose of rocuronium: the block has to end about 3 min after rocuronium 1.2 mg/kg. Picture a failed intubation. FDA-labeled in adults. Run it alongside the difficult-airway algorithm, never instead of it (see RSI)
• Reversal for a neurologic exam after ED intubation with rocuronium: traumatic brain injury is the example, once sedation is planned. Off-label, on retrospective data. Soon after RSI the block can be profound (PTC 0). Wait for PTC 1 or more, then give 4 mg/kg. Lower doses risk recurrence.
• Reversal in the ICU: the same twitch-guided doses. Off-label, since the label has not studied it.

Other Uses

• Routine reversal of rocuronium or vecuronium block after surgery: this is the FDA-labeled use, in adults and children. The 2023 American Society of Anesthesiologists (ASA) guideline prefers it over neostigmine outside minimal block. The 2023 European Society of Anaesthesiology and Intensive Care (ESAIC) guideline recommends it for deep, moderate and shallow block.
• Minimal-depth block (train-of-four (TOF) ratio 0.4 to <0.9): both sugammadex and neostigmine are options. ASA 2023 limits neostigmine to this range and sends deeper block to sugammadex. ESAIC 2023 advises neostigmine only once spontaneous TOF ratio exceeds 0.2. Monitor quantitatively until TOF ratio >0.9.

Available Forms

• Single-dose vials: 100 mg/mL in 2 mL (200 mg) and 5 mL (500 mg); preservative-free, discard any unused portion
• Products: Bridion, plus multiple generics since 2026 at the same concentration. Some come only as 200 mg/2 mL vials or prefilled syringes.
• Pediatric labeling: the Bridion label covers children from birth, with the same 2 and 4 mg/kg doses. Generic labels start at 2 yr, so generic use under 2 yr is off-label.
• Pediatric dilution: 10 mg/mL (one 200 mg/2 mL vial in 18 mL NS); use immediately

Adult Dosing

Pediatric Dosing

Preparation & Administration

• Grade the block first: nerve stimulator, ideally quantitative TOF at the adductor pollicis, to choose 2 or 4 mg/kg; labeled doses do not apply to eye-muscle monitoring.
• Push and flush: single IV bolus over 10 seconds into an existing line; flush between drugs.
• Inspect: do not use if particles are present.

Contraindications

• Known hypersensitivity to sugammadex or any component. Reactions have happened on the first exposure.

Precautions

• Wrong blocker: it does nothing to succinylcholine, cisatracurium or atracurium. Not for pancuronium or other steroidal blockers.
• CrCl <30 mL/min or dialysis: not recommended.
• Coagulopathy or anticoagulation: expect a transient rise in aPTT and PT/INR. Monitor coagulation tests.
• Pulmonary history: bronchospasm has been reported.

Hold / Reassess If

• No twitch assessment yet, and a 2 or 4 mg/kg dose is next? Get a nerve stimulator first. The exception is 16 mg/kg about 3 min after rocuronium 1.2 mg/kg, which you choose by timing.
• TOF ratio already ≥0.9 on quantitative monitoring: no reversal needed, per ASA 2023
• Sedation inadequate in a patient who stays intubated: sedate first
• CrCl <30 mL/min: plan with anesthesia (ventilate until spontaneous recovery)

Common

• Nausea and vomiting: most common (nausea 23–26%, vomiting 11–15%), close to placebo after surgery; procedural pain and headache
• Hypotension: 4–5% at 2–4 mg/kg, 13% at 16 mg/kg (placebo 4%)
• Cough and airway complications of anesthesia: 8–9% at 16 mg/kg
• Hypersensitivity symptoms (nausea, pruritus, urticaria): dose-related
• Bradycardia: adults 1% at 2–4 mg/kg, 5% at 16 mg/kg; children 2 to <17 yr 10% at 2 mg/kg and 7% at 4 mg/kg; under 2 yr cardiac disorders (all types) 6.8% at 2 mg/kg (label section 6.1). Reviews report 1–7% depending on the definition. Most of it is inconsequential

Serious / Life-Threatening

Overdose & Toxicity Management

• Overdose: in trials, one accidental 40 mg/kg dose caused no significant effects. Treat supportively.
• Extracorporeal removal: high-flux hemodialysis drops plasma levels about 70% over 3–6 hr. Low-flux filters do not.
• The antidote's own trap: it keeps grabbing any rocuronium or vecuronium you give afterward. See re-paralysis timing in Interactions.

Clinically Significant Interactions

IV Compatibility

• Running infusions: you can inject it into a line running NS, D5W, 0.45% NaCl with 2.5% dextrose, D5NS, Isolyte P with D5W, lactated Ringer's or Ringer's solution.
• Incompatible: verapamil, ondansetron and ranitidine are physically incompatible with it. Don't mix it with any other product.
• Check an institutional compatibility resource.

• Pediatrics: the Bridion label starts at birth. Generic labels start at 2 yr. Bradycardia runs higher than in adults: 10% at 2 mg/kg and 7% at 4 mg/kg in ages 2 to <17 yr. Under 2 yr, cardiac disorders hit 6.8% at 2 mg/kg (label section 6.1). Keep the ECG running and atropine at the bedside. The 16 mg/kg dose has not been studied.
• Neonates: studied from birth. The studied group had a median age of about 100 days. No age-based dose change.
• Pregnancy: there are no clinical trial data. Sugammadex binds progesterone. The manufacturer's modeling says 4 mg/kg may lower free progesterone by about 34%. The 2019 Society for Obstetric Anesthesia and Perinatology (SOAP) statement advises avoiding it in early pregnancy and prefers neostigmine-based reversal. It supports 16 mg/kg only for a cannot-intubate, cannot-ventilate event.
• Lactation: the label has no human data. A 2026 study at cesarean (n=10) found sugammadex undetectable, or below quantification, in every breast-milk sample. SOAP 2019 says breastfeeding is likely safe once the patient has recovered. Pump-and-discard is likely unnecessary. SOAP still preferred neostigmine-based reversal in early postpartum patients.
• Older Adults: recovery runs a little slower: 3.6 min at 75 yr or older vs 2.2 min at 18–64 yr. No dose change.
• Renal Impairment: at CrCl 30–80 mL/min, no dose change. With CrCl <30 mL/min or on dialysis, it is not recommended. The half-life stretches to about 19 hr there, and exposure climbs up to 17-fold. With mild to moderate impairment, wait 24 hr before re-paralysis, or use rocuronium 1.2 mg/kg if you need it sooner (see Interactions).
• Hepatic Impairment: the liver does not clear it, so no dose change. Use caution with coagulopathy or severe edema.
• Obesity: dose on actual body weight, including at BMI ≥40 kg/m². Dosing on ideal weight halved exposure.
• Myasthenia Gravis and Other Neuromuscular Disease: these patients are very sensitive to rocuronium. Neostigmine reversal is unreliable, so SOAP favors sugammadex. Dose to the measured depth.
• Cardiac Disease and ASA Class 3–4: no dose change. Sinus bradycardia shows up in 1–2% after 2–4 mg/kg, and in 7.4% after 16 mg/kg.

• Scope: anesthesia, ED, ICU and critical-care transport clinicians (RN/CCT) give it under orders. It is not an EMS drug. Scope varies by state and agency protocol.
• Reversal Is Not Airway Rescue: reversal does not open the airway. Keep moving through the failed-airway plan (supraglottic airway, front-of-neck access).
• Storage & Stability: 25 °C (77 °F), excursions 15–30 °C (59–86 °F); protect from light, and use within 5 days once out of light protection.
• Carried Concentration: 100 mg/mL: mL = (mg/kg × kg) ÷ 100. A 16 mg/kg dose for 70 kg (1,120 mg, 11.2 mL) takes more than two 5 mL vials. Check your stock.
• Paralyzed Transfers: a paralyzed patient stays sedated and ventilated. Reversal is a destination decision, unless it is ordered and monitoring is available.
• Handoff Essentials: blocker, dose and time; TOF before and after; heart rate and blood pressure response; any reaction; when rocuronium or vecuronium may be reused; contraception counseling.

Mechanism of Action

• A modified γ-cyclodextrin ring wraps around free rocuronium (highest affinity) or vecuronium, 1:1, in plasma. Free blocker falls. Transmission returns from deep as well as shallow block when the dose matches the measured depth.
• No acetylcholinesterase effect means no ceiling and no anticholinergic needed. Marked bradycardia still happens, rarely with cardiac arrest.

Pharmacokinetics

• IV: it works within minutes. Median TOF ratio reaches ≥0.9 in about 2–3 min. The effect is sustained, with recurrence under 1% at labeled doses.

• Half-life: about 2 hr in adults (1–2 hr in children); 4, 6 and 19 hr in mild, moderate and severe renal impairment.
• Metabolism: none. Elimination: the kidneys clear it, unchanged and as the complex. 96% leaves in urine, more than 90% within 24 hr.
• Distribution: volume of distribution 11–14 L; no plasma protein binding.

Generic Name

Sugammadex (as sugammadex sodium; 100 mg sugammadex = 108.8 mg of the sodium salt)

Brand Names

Bridion (Merck); generic injections from multiple US manufacturers since 2026, listed on DailyMed (generic labels: 2 yr and older)

Pharmacologic Class

Selective relaxant binding agent (modified γ-cyclodextrin)

Therapeutic Class

Neuromuscular blockade reversal agent

Controlled Substance

Not controlled

ISMP High-Alert

No (the ISMP list covers the neuromuscular blockers, not their reversal agents)

Look-Alike / Sound-Alike

None on the ISMP confused drug names list as updated through June 2024; check your pharmacy's current list