Critical Care Scenarios Episode 90: Sugammadex in the ICU
Aug 20, 2025
Sara J Hyland, PharmD, BCCCP, FCCP, is a researcher and clinical pharmacist specializing in perioperative and emergency medicine. She dives into the intricacies of neuromuscular blockade reversal in the ICU, particularly the use of sugammadex versus traditional agents. The conversation highlights the challenges of underutilization, the importance of rigorous monitoring for patient safety, and the risks associated with sugammadex, including rare complications. Hyland emphasizes the need for better protocols and collaborative practices to optimize patient outcomes.
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Limits Of Neostigmine
- Neostigmine works indirectly by boosting endogenous acetylcholine and cannot reverse deep neuromuscular blockade.
- It is effective only at minimal blockade and risks paradoxical weakness and cholinergic side effects if misused.
How Sugammadex Works
- Sugammadex directly encapsulates rocuronium/vecuronium and removes them via renal filtration for rapid reversal.
- It works at any blockade depth and produces fast, reliable restoration of neuromuscular function.
Use Quantitative Train‑Of‑Four
- Use objective quantitative neuromuscular monitoring (train-of-four ratio) before reversal and extubation.
- Target a train-of-four ratio of ≥0.9 to avoid residual blockade and related complications.