(1019) Appropriateness and Cost Analysis of High-Dose Sugammadex

Introduction: Sugammadex is indicated for reversal of paralysis by rocuronium or vecuronium. The package insert offers three dosing regimens: 2 mg/kg, 4 mg/kg, and 16 mg/kg based on the depth of paralysis and urgency of reversal from paralytic agent administration. The 16 mg/kg high dose is indicated for urgent reversal of neuromuscular blockade, which is defined as approximately 3 minutes after administration of a single rocuronium dose of 1.2 mg/kg. Sugammadex high dose has been utilized in post-operative patient cases at our institution. The study sought to evaluate the cost impact and clinical appropriateness of the sugammadex high dose utilization according to the package insert recommendations.

Methods: A retrospective analysis of 50 randomly selected patients who received high dose sugammadex (~16 mg/kg) between August 2020 to August 2023 was conducted to determine the percentage of cases where sugammadex high dose was administered based on package insert recommendations. Secondary outcomes included to determine the potential medication cost savings if package insert recommended dosing was utilized and evaluate the percentage of cases where train-of-four (TOF) monitoring was documented.

Results: The majority of patients received rocuronium for paralysis (98%) with an average dose of 0.96 +/- 0.34 mg/kg. The average procedure length was 127 +/- 111 minutes. The mean dose of sugammadex was 1260 +/- 376 mg. Two (4%) patients had their paralysis reversed within 5 minutes of receiving a paralytic as indicated by package insert recommendation for sugammadex 16 mg/kg (average time to reversal 41 +/- 28 minutes). Twenty-four (48%) cases documented TOF prior to administration of sugammadex. Most cases had a TOF of 0 when documented. If package insert recommended dosing of 4 mg/kg was used for the 48 patients, an estimated potential cost savings of $19,802.80 which equals a cost saving of $412.56 per patient case.

Conclusions: In this retrospective review cohort, high dose sugammadex was frequently utilized in patients who may not be indicated by package insert recommendations. Discussion with the anesthesia department to further examine the high dose sugammadex practice and the potential medication cost savings is recommended.