Sugammadex reverses rocuronium and vecuronium by which pharmacological mechanism, and at what dose is it used for immediate reversal of rocuronium after high-dose intubating dose?

• A Competitive antagonism at nicotinic receptor; 2 mg/kg
• B Acetylcholinesterase inhibition increasing ACh at NMJ; 0.04 mg/kg
• C Allosteric modulation of nicotinic receptor increasing sensitivity to ACh; 4 mg/kg
• D Encapsulation of the aminosteroid drug within its cyclodextrin cavity, reducing free plasma and tissue concentrations; 16 mg/kg ✓

Explanation

Sugammadex is a modified gamma-cyclodextrin that forms a tight (1:1) inclusion complex with rocuronium (and to a lesser degree vecuronium) in plasma, creating a concentration gradient that draws the drug away from NMJ receptors. For routine reversal at 1–2 post-tetanic counts: 4 mg/kg; for moderate block (T2 on TOF): 2 mg/kg. For immediate reversal after a 1.2 mg/kg rocuronium intubating dose (can't intubate, can't oxygenate scenario), the dose is 16 mg/kg, providing reversal within ~3 minutes.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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