Rational Utilization of Sugammadex Through Quantitative Twitch Monitoring: A Process Improvement Project at a Large Academic Medical Center

Background Sugammadex rapidly became the standard of care for neuromuscular blockade reversal at our institution, leading to a substantial increase in pharmacy costs. We hypothesized that administering sugammadex in 75 mg aliquots, rather than 200 mg vials, would improve adherence to FDA dosing guidelines, reduce costs, and promote greater use of quantitative neuromuscular monitoring. Methods This retrospective study analyzed a departmental process improvement initiative. Baseline sugammadex use (Phase 1) was assessed between July 2021 and January 2022, during which only qualitative neuromuscular monitoring was employed. From February to August 2022 (Phase 2), pre-filled 75 mg sugammadex syringes were introduced. In Phase 3, from September 2022 to January 2023, these aliquots were used alongside quantitative twitch monitoring. The primary outcome was the average sugammadex dose per case. Patient characteristics and secondary outcomes, including neuromuscular blockade monitoring and documentation, as well as safety event reporting, were also evaluated. Results There were no significant differences in patient demographics or comorbidities across phases. With the introduction of 75 mg sugammadex aliquots, the average dose per case decreased by 55.4 mg (95% CI: 52.1-58.8). Following the implementation of quantitative monitoring, the dose increased by 10.8 mg (95% CI: 7.3-14.3). Documentation of neuromuscular blockade improved, and no changes in reported safety events were observed across phases. Conclusions The use of smaller compounded sugammadex aliquots, combined with quantitative monitoring and appropriate education, can improve neuromuscular blockade reversal practices while reducing healthcare costs.