SUGARED: Sugammadex for neuromuscular blockade reversal in the emergency department

Bottom line

In this 11-site retrospective cohort of 362 ED patients with TBI or sICH reversed from rocuronium with sugammadex, 54% showed a GCS increase of ≥1 point within 30 minutes, but responders also received more new analgesic and sedation agents in that window, so the association is plausible but not proven causal by this single-arm, retrospective design. Median sugammadex dose was 3.9 mg/kg.

PICO at a glance

• Population: Adult ED patients (≥18 years) with TBI or sICH intubated using rocuronium, across 11 US EDs, December 2015-June 2024 (N=362 in the primary analysis).
• Intervention or exposure: Sugammadex to reverse rocuronium-induced blockade (median 3.9 mg/kg, IQR 2 to 4.2, given a median 72 minutes after rocuronium).
• Comparator: None, a single-arm cohort of GCS responders versus non-responders, not sugammadex versus neostigmine or no reversal.
• Outcomes: Primary: proportion with a GCS increase of ≥1 point within 30 minutes. Secondary: change in analgosedation requirements, and rate of neurosurgical procedures.
• Study design: Multicenter, retrospective, observational cohort study.

Clinical question and design

In ED patients requiring rapid airway control, rocuronium is a common paralytic for intubation, but its prolonged neuromuscular blockade can leave a patient paralyzed well past the window when clinicians need a reliable neurologic exam, particularly in TBI or sICH, where serial GCS drives triage and neurosurgical decisions. Sugammadex selectively reverses rocuronium and could, in principle, "unmask" a valid exam sooner, but this is an off-label ED application distinct from its labeled anesthesia-reversal indication, and prospective evidence is lacking. The multicenter SUGARED study, on behalf of the EMPHARM-NET investigators, offers retrospective, real-world data on exactly this practice.

This was a multicenter, retrospective, observational cohort study across 11 US EDs. Adult patients (≥18 years) intubated using rocuronium who subsequently received sugammadex, with a primary diagnosis of TBI or sICH, were screened from December 15, 2015 to June 30, 2024. The primary outcome analysis included 362 patients. The abstract omitted dosing, but the full text reports a median sugammadex dose of 3.9 mg/kg (IQR 2 to 4.2) given a median 72 minutes after rocuronium.

Intervention and outcomes measured

The intervention studied was sugammadex administration to reverse rocuronium-induced neuromuscular blockade, with no comparator arm, a single-arm cohort comparing responders against non-responders, not sugammadex against neostigmine or against no reversal. The primary outcome was the proportion of patients with a positive neurologic response, defined as a GCS increase of ≥1 point within 30 minutes of sugammadex.

Results

A GCS increase within 30 minutes of sugammadex occurred in 54% of patients (196/362), with a median GCS change of 3 points (IQR, 2-4; range, 1-9); that median belongs to the 196 responders, since responders are defined by a GCS increase of at least 1 point while non-responders had no change or a decrease, and it is presented here exactly as reported. The authors' own conclusion frames this as an association, sugammadex "was associated with" a significant change in GCS, language that stops short of a causal claim, appropriate for a single-arm retrospective design with no true comparator.

Secondary findings

Positive responders were significantly more likely, within that same 30-minute window, to have received a newly added analgesic agent (30.6% vs 13.9%; difference 16.8%; 95% CI, 8.4-25.1) and a newly added sedation agent (33.7% vs 14.5%; difference 19.2%; 95% CI, 10.7-27.7). Neurosurgical procedure rates were numerically higher among responders (43.4% vs 33.7%; difference 9.6%; 95% CI, -0.4 to 19.7), but this did not reach statistical significance, as the interval crosses zero.

Uncertainty and limitations

This is a retrospective, observational, single-arm design with no reversal-versus-no-reversal or sugammadex-versus-neostigmine comparator, so causality cannot be established. The association between "positive response" and concurrent new analgesic/sedation dosing is a plausible unaddressed confounder, some observed GCS improvement could reflect concurrent sedation-practice changes rather than the reversal itself. The nearly nine-year enrollment window (2015-2024) spans evolving ED sedation practice that could bias comparisons over time. Dosing and timing are now known from the full text, a median 3.9 mg/kg given a median 72 minutes after rocuronium, which closes the earlier dosing gap. The design limits remain: GCS-assessor blinding and missing-data handling are not described, and the analysis is not adjusted for the concurrent sedation and analgesia changes.

Literature review and evidence synthesis

This SUGARED analysis extends a sugammadex evidence base built largely in the operating room into an ED setting. A 2017 Cochrane review comparing sugammadex with neostigmine for reversing neuromuscular blockade in adults (PMID 28806470) established its efficacy and safety profile in the anesthesia context this ED application borrows from, while an earlier 2009 Cochrane review on sugammadex as a selective reversal agent for postoperative residual blockade (PMID 19821409) laid the original evidence foundation. Most directly relevant, a 2021 Journal of Emergency Medicine review, "What is the Role of Sugammadex in the Emergency Department?" (PMID 32962903), addressed this same off-label ED-reversal question years before this cohort's data were analyzed.

How this fits with the broader evidence

• This cohort (direct evidence): Just over half of TBI/sICH patients reversed with sugammadex showed a meaningful GCS improvement within 30 minutes, but responders also received more new analgesic and sedation agents in the same window, a confounder the design cannot rule out.
• 2017 and 2009 Cochrane reviews (PMID 28806470, PMID 19821409): Establish sugammadex's reversal efficacy and safety in the labeled anesthesia setting; this cohort tests whether that translates into a meaningful ED neuro-exam benefit, which it cannot itself prove causal.
• 2021 JEM review (PMID 32962903): Shows the off-label ED-reversal question predates this cohort, this study adds real-world numbers without resolving it.

ACPE UAN: 0683-0000-26-036-H01-P

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Study source: PMID:42349235