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What standard books have info about sugammadex dosage

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I now have comprehensive dosage information from all the major books. Here's a summary:

Books Covering Sugammadex Dosage

Four standard textbooks in the library contain detailed information on sugammadex dosage:

1. Miller's Anesthesia, 10th Edition

The most detailed source — dedicates an entire chapter subsection (Ch. 24) to sugammadex, including a dedicated dosage table (Table 24.20) and multiple clinical-use sections:
Depth of BlockSugammadex Dose
Moderate block (TOF count ≥2)2 mg/kg
Deep block (TOF count 1–PTC ≥1)4 mg/kg
Profound block (RSI, "can't intubate/can't ventilate")16 mg/kg
  • Dose range studied: 0.1–8.0 mg/kg in healthy volunteers; 16 mg/kg for RSI reversal
  • 4 mg/kg reverses rocuronium (0.6 mg/kg) block to TOF ratio ≥0.9 in <4 minutes
  • 16 mg/kg reverses rocuronium (1.2 mg/kg) with TOF ratio ≥0.9 in ~2.2 minutes — faster than spontaneous succinylcholine recovery
  • In obesity: dose based on actual body weight
  • Special sections on dosing in elderly, pediatric, renal failure, cardiac disease, and pregnant patients

2. Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition

Section: "Selective Relaxant Binding Drugs: Sugammadex" (Ch. 21)
  • TOF count ≥2 → 2 mg/kg → TOF ratio ≥0.9 in 2–4 minutes in most adults and pediatric patients (elderly may take longer)
  • TOF count 1 to PTC 1 → 4 mg/kg
  • Profound block (RSI dose rocuronium ≤1.2 mg/kg) → 16 mg/kg
  • Notes vecuronium binding is one-third as tight as rocuronium — same dose, but slower reversal
  • Also covers pediatric dosing (2 mg/kg after partial recovery in children/adolescents → TOF ≥0.9 in ~2 min)

3. Morgan and Mikhail's Clinical Anesthesiology, 7th Edition

Section: "SUGAMMADEX" (Ch. on neuromuscular pharmacology)
  • Dosage: 4–8 mg/kg; at 8 mg/kg given 3 min after rocuronium 0.6 mg/kg → TOF ≥0.9 within 2 minutes
  • Contraindicated (not recommended) in severe renal dysfunction (CrCl <30 mL/min)
  • Notes artifactual aPTT prolongation and hormonal contraceptive interaction

4. Lippincott Illustrated Reviews: Pharmacology

Section: "A. Sugammadex"
  • Concise overview — describes mechanism and notes rapid reversal of both shallow and profound blockade; no specific mg/kg table, focuses more on mechanism

Quick Reference Summary

Block LevelDoseRecovery to TOF ≥0.9
Moderate (TOF count ≥2)2 mg/kg~2–4 min
Deep (TOF count 1 – PTC ≥1)4 mg/kg~2–3 min
Profound / RSI reversal16 mg/kg~2–3 min
For clinical dosing detail and special populations (obesity, renal failure, elderly, pediatrics, pregnancy), Miller's Anesthesia Ch. 24 is the most comprehensive source, followed closely by Barash's Clinical Anesthesia Ch. 21.

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Here is the comprehensive sugammadex dosage information drawn from the standard textbooks:

Sugammadex Dosage — From Standard Textbooks

Standard Adult Dosing by Depth of Block

Depth of Neuromuscular BlockMonitoring CriterionSugammadex DoseExpected Recovery to TOF ≥0.9
Moderate blockTOF count ≥2 (reappearance of T2)2 mg/kg2–4 min
Deep blockTOF count 1 – PTC ≥14 mg/kg2–3 min
Profound / RSI reversalNo TOF or PTC response ("can't intubate, can't ventilate")16 mg/kg~2–3 min
Miller's Anesthesia 10e, Ch. 24, Table 24.20; Barash Clinical Anesthesia 9e, Ch. 21, p.1659
Recovery is dose-dependent — higher doses produce faster reversal. At 4 mg/kg, median recovery time was reduced from 21 minutes (placebo) to just 1.1 minutes.

Key Clinical Details

RSI / Profound Block (16 mg/kg)

  • 16 mg/kg given 3 minutes after rocuronium 1.2 mg/kg → mean TOF ≥0.9 recovery in 2.2 minutes
  • Faster than spontaneous recovery from succinylcholine (which takes ~10.9 min for 90% T1 recovery)
  • Spontaneous ventilation restored in a median of 216 seconds vs. 406 seconds with succinylcholine
  • Enables rocuronium + sugammadex as a succinylcholine alternative for RSI
Miller's Anesthesia 10e, p.3426–3427

Special Populations

Obesity (BMI >30 kg/m²)

  • Product monograph: dose based on actual body weight (ABW)
  • Lean/ideal body weight (IBW) dosing is insufficient — ~40% of morbidly obese patients had inadequate reversal when dosed on IBW
  • Pooled analysis of 27 trials confirmed that ABW-based dosing provides rapid recovery without dose adjustment
  • IBW + 40% has also been shown effective for moderate block reversal, but ABW remains recommended
Miller's Anesthesia 10e, p.3439–3441

Elderly Patients

  • No dose adjustment required
  • Recovery is slightly slower (~0.7 min longer) due to reduced cardiac output
  • In patients ≥75 years, some individuals required up to 9.9 minutes to reach TOF ≥0.9 with 2 mg/kg — quantitative monitoring is essential
  • Higher dose may be considered if rapid recovery is critical
Miller's Anesthesia 10e, p.3434; Barash 9e, p.1659

Pediatric Patients (2–17 years)

  • 2 mg/kg at reappearance of T2 → TOF ≥0.9 in ~2 minutes (equivalent to adults)
  • 4 mg/kg for deep block — reversal time equivalent to that seen with moderate block reversal
  • Recovery dose-dependent across all age groups (infants, children, adolescents)
  • Adolescents: reduces effectiveness of hormonal contraceptives for up to 1 week — counsel patients
  • Data in children <2 years is still limited
Miller's Anesthesia 10e, p.3433; Barash 9e (pediatric chapter)

Renal Impairment

  • Mild to moderate renal dysfunction: no dose adjustment needed; safety profile similar to healthy patients
  • Severe renal failure (CrCl <30 mL/min): not recommended — sugammadex–rocuronium complex accumulates; incomplete elimination
  • Exception: can still be used if clinically necessary; high-flux hemodialysis can remove the complex (low-flux is ineffective)
  • One cohort of 219 patients with GFR <15 mL/min tolerated it well, but caution is advised
Miller's Anesthesia 10e, p.3437; Morgan & Mikhail 7e, p.424

Hepatic Impairment

  • Biliary excretion of the sugammadex–rocuronium complex is unavailable (complex is too large)
  • Simulations: 16 mg/kg for profound block — minimal effect of hepatic impairment on reversal time
  • Lower doses (2 or 4 mg/kg) — recovery may be longer than in healthy patients
  • In Child class A cirrhosis: 4 mg/kg still effective — 80% reduction in recovery time (3.1 min) vs. neostigmine (14.5 min)
Miller's Anesthesia 10e, p.3438

Pregnancy / Caesarean Section

  • Uteroplacental transfer is very small (<2–6%)
  • No negative effects demonstrated on pregnancy, embryo, fetus, or postnatal development
  • Used safely in RSI for caesarean section
Miller's Anesthesia 10e, p.3509

Reintubation After Sugammadex

If re-paralysis is needed after sugammadex reversal:
  • Use a benzylisoquinoline NMBD (e.g., cisatracurium, atracurium) — these are unaffected by residual sugammadex
  • If rocuronium must be re-used, the dose required is higher and onset is delayed; allow time for sugammadex to clear
  • The interval between sugammadex administration and the repeat rocuronium dose inversely determines onset time
Miller's Anesthesia 10e, p.3575

Key Drug Interactions

InteractionEffect
Hormonal contraceptivesEquivalent to missing 1 daily pill — use non-hormonal contraception for 7 days
Toremifene (estrogen antagonist)High affinity for sugammadex; may delay reversal
Flucloxacillin, fusidic acidReported binding interactions
aPTTArtifactual prolongation (no increased bleeding risk)
Morgan & Mikhail 7e, p.424; Barash 9e, p.1660
Sources: Miller's Anesthesia 10e (Ch. 24) | Barash, Cullen & Stoelting's Clinical Anesthesia 9e (Ch. 21) | Morgan & Mikhail's Clinical Anesthesiology 7e
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