Critical Care Scenarios Episode 90: Sugammadex in the ICU, with Sara J Hyland
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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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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.
Measure, Dose, Then Confirm
- Measure blockade depth first, dose sugammadex based on that depth and patient's weight, then reassess before extubation.
- Confirm a ≥0.9 train-of-four ratio after reversal prior to pulling the tube.
PACU Recurarization Story
- Sara J Hyland recounted a PACU patient who recurarized after initial sugammadex and required an additional dose to recover breathing.
- Rapid re-dosing of sugammadex immediately reversed the re‑onset of paralysis.