Appropriateness of Sugammadex usage within the OR


Appropriateness of Sugammadex usage within the OR


Publication Date



oregon; portland; psvmc


Pharmacy and Pharmaceutical Sciences



Sugammadex is a unique neuromuscular reversal drug used to counteract the effects of the aminosteroidnon-depolarizing muscle relaxing drugs; rocuronium and vecuronium •Neuromuscular blocking agents (NMBs) are frequently used in surgical procedures to assist with intubation, patient immobilization, etc. •Sugammadex, a synthetic cyclodextrin molecule, encapsulates rocuronium (and vecuronium, pancuronium) rendering it inactive •Onset of action of rocuronium is within 1-2 minutes, duration of action is about 30 minutes, though t1/2elimination is between 1.4-2.4 hours and true duration varies greatly patient to patient •Sugammadex pharmacokinetic/dynamic profile: non-protein bound, unchanged renal elimination, onset of action < 3 min, t1/2 : 2 hours •Sugammadex is an expensive medication, and so far, there are no guidelines or criteria in place to ensure its use is optimized and that overuse and waste are minimized •The medication comes in 2 vial sizes: 200 mg/2 mL, and 500 mg/5 mL •Providence Oregon P&T committee has put forth suggested appropriate use criteria for the use of Sugammadex within the OR •The purpose of this project is to evaluate the impact of these criteria, and to assess the current cost and potential cost savings obtainable through criteria justifying the use of sugammadex •Goals include: •Ensuring appropriate vial sizes are used to minimize waste and reduce hospital costs •Interpreting whether the use, and dose of sugammadex is justified •Evaluate the impact of the P&T committee’s proposed appropriate use criteria


Primary outcomes •Evaluate appropriateness of sugammadex use •Identify methods of reducing waste and achieve cost savings through implementation of appropriate use criteria •Secondary outcomes •Assess impact of appropriate use criteria as put forth by system P&T committee


Study design •Retrospective •Utilization review of OR cases from March,2020 through October 2020 •Cases randomly selected •Inclusion criteria •All OR cases within the time frame during which sugammadex was administered •Exclusion criteria •N/A


Results •Proposed appropriate use criteria encourages restriction of sugammadex dosing to max of 200 mg for patients weighing•Doses greater than 200 mg should be reserved for more complex scenarios, requiring justification for increased dose and subsequent larger vial (5 mL) size use •Use criteria evaluated include: •Age > 70 •Overall poor health (ASA >3) •Surgical cases < 1 hour Findings: •Currently, dosing varies drastically, ranging from as low as 1.11 mg/kg, to 5.71 mg/kg •Literature states that NMB reversal can be seen by 2 mg/kg, though new literature suggests this threshold may be lower than previously thought •In addition to this, appropriate vial selection reaches only 29% of administered sugammadex doses, indicating much room for improvement and potential cost savings of upwards of $3,475 •Furthermore, of the 58 cases studied, only 21 (36%) of them had sugammadex administered within 2 hours of last rocuronium administration. Considering rocuronium’s short half life, cases lasting longer than this are less likely to require sugammadex as time goes on •Selected appropriate use criteria (age > 70, ASA >3, case time <1 >hour) indicate that implementation of these criteria would drastically reduce sugammadex use Exceptional finding: •One patient received 400 mg sugammadex (5.71 mg/kg) though zeroNMB agent was used during the case Data Limitations •Not all proposed appropriate use criteria put forth by P&T committee were able to be evaluated in this study

Conclusions & Next Steps

• Improved justification of sugammadex dosage selection would result in drastic reduction of medication waste, and subsequent cost savings • Primary focus should be placed on maintaining a max of 200 mg of sugammadex, unless other criteria are met in certain circumstances • In addition to that, adhering to a strict 2 mL vial selection for doses of <200 >mg, would have saved $3,474 dollars for a sample size of 58 alone, without factoring in additional savings with appropriate dose selection • It is important to note that sugammadex does have benefits and is associated with reduced PACU/post-op recovery time compared to neostigmine/glycopyrrolate • Further approval of the proposed appropriate use criteria and buy in from anesthesia to adhere to these criteria would reduce patient exposure to unnecessarily high doses of sugammadex, and result in minimization of waste and increased cost savings



Conference / Event Name

Academic Achievement Day, 2021


Providence St. Vincent Medical Center

Appropriateness of Sugammadex usage within the OR