(1388) Pour Some Suga on Me: Sugammadex Following Rocuronium RSI in Critically Ill and Injured Patients

Introduction: Rocuronium has replaced succinylcholine as the neuromuscular blockade (NMB) agent of choice for rapid sequence induction (RSI) in the emergency department (ED) & ICU. Sugammadex, a specific NMB reversal agent which is used extensively in operating rooms (ORs) and surgical ICUs, remains underutilized in EDs. Meanwhile, the incidence of awareness with paralysis (AWP), a complication of NMB, is 10-100x greater among mechanically ventilated ED patients compared to OR patients. An algorithmic approach to the use of sugammadex in the hyperacute phase of critical illness following RSI could enable optimized analgosedation, facilitating critical neurologic examinations and minimizing AWP.

Methods: A retrospective analysis of all cases of sugammadex administration in a quaternary care center ED over a 7+ year period (Jan 2016 – May 2023) was performed. The electronic health record was interrogated to gather all data related to analgosedation, RSI, and NMB reversal, including adverse events following sugammadex administration. Multidisciplinary expert consensus was leveraged to interpret these data and develop a post-RSI algorithm for guiding appropriate sugammadex use in ED patients.

Results: During the study period, 26 unique cases of sugammadex administration in the ED were identified. No adverse events related to sugammadex were recorded. All patients received non-depolarizing NMB for intubation. Patients presented with traumatic injuries in 14 cases (56%). In 15 cases, RSI occurred prior to ED arrival. The average estimated time between RSI and NMB reversal was 103 minutes. In 9 cases (35%), there was no documented administration of analgesia or sedation between RSI and NMB reversal. Patients demonstrated significantly improved neurologic exam after NMB reversal in 8 cases (30%), 3 of which had not received prior analgosedation.

Conclusions: Sugammadex provided reliable and safe NMB reversal in the ED. Review of these cases raises concern for an unacceptably high incidence of potential AWP. Our proposed algorithm aims to identify those patients who may require rapid reversal (e.g. facilitating urgent neurologic examination), those with relative contraindications to sugammadex (e.g. severe ARDS), and those who may safely benefit from earlier reversal, including those at risk of AWP.