Reversal of moderate and intense neuromuscular block induced by rocuronium with low doses of sugammadex for intraoperative facial nerve monitoring

Effect of reversal of residual neuromuscular blockade on the amplitude of motor evoked potentials: a randomized controlled crossover study comparing sugammadex and placebo

PURPOSE

To compare the amplitude changes in motor evoked potentials (MEP) with reversal of residual neuromuscular blockade using sugammadex or placebo in patients with cervical myelopathy.

METHODS

In this prospective randomized double-blind, placebo-controlled crossover trial, 38 patients with cervical myelopathy undergoing posterior cervical decompression and fusion were randomized to either sugammadex (2mg/kg) or placebo. The primary outcome measure was the increase in amplitude of the MEP in the first dorsal interossei (FDI) muscle at 3 min. Mann-Whitney U test was used to analyze the primary outcome measure.

RESULTS

There was a significant increase in the amplitude of MEP at 3 min with sugammadex when compared to placebo group. The median (IQR) increase in MEP amplitude (μV) at 3 min from the left FDI in sugammadex and placebo group was 652.9 (142:1650) and 20.6 (-183.5:297.5) (p <0.001), respectively. Corresponding values from right FDI were 2153.4 (1400:4536.8) and 55(-65.2:480.8) (p=<0.001).

CONCLUSION

Our study showed that there was a 200% increase in the MEP amplitude in the first dorsal interosseous muscle at 3 min following reversal of residual neuromuscular blockade with sugammadex. By ensuring that maximal MEP amplitude is recorded at baseline, early commencement of neuromonitoring can be achieved.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

The study was registered at http://clinicaltrials.gov , ID NCT03087513, Feb 5^th 2018.

Repeated sugammadex reversal of muscle relaxation during lumbar spine surgery with intraoperative neurophysiological multimodal monitoring

Intraoperative neurophysiological monitoring during spine surgery is usually acomplished avoiding muscle relaxants. A case of intraoperative sugammadex partial reversal of the neuromuscular blockade allowing adequate monitoring during spine surgery is presented. A 38 year-old man was scheduled for discectomy and vertebral arthrodesis throughout anterior and posterior approaches. Anesthesia consisted of total intravenous anesthesia plus rocuronium. Intraoperatively monitoring was needed, and the muscle relaxant reverted twice with low dose sugammadex in order to obtain adequate responses. The doses of sugammadex used were conservatively selected (0.1mg/kg boluses increases, total dose needed 0.4mg/kg). Both motor evoqued potentials, and electromyographic responses were deemed adequate by the neurophysiologist. If muscle relaxation was needed in the context described, this approach could be useful to prevent neurological sequelae. This is the first study using very low dose sugammadex to reverse rocuronium intraoperatively and to re-establish the neuromuscular blockade.

Use of sugammadex in parotid surgery: a case report

Background

Parotid surgery is a common ear, nose, and throat procedure. Facial nerve paralysis is the main feared complication following this surgery. To avoid this paralysis, intraoperative facial nerve monitoring is often used, but neuromuscular blocking agents interfere with this technique. Therefore, the neuromuscular blocking agent used should have a short duration of muscle relaxation. With the discovery of sugammadex, a steroidal neuromuscular blocking agent has acquired the potential to be used in place of succinylcholine.

Case presentation

A 41-year-old African woman was scheduled for a parotidectomy at our hospital. Rocuronium-induced neuromuscular block was reversed intraoperatively with sugammadex to facilitate identification of facial nerve function. The facial nerve was identified without incident, and surgical conditions were good for the removal of the tumor. During postoperative follow-up, no evidence of residual paralysis has been noted.

Conclusions

In parotid surgery, the use of sugammadex allows free use of a steroidal neuromuscular blocking agent for intubation and thus intraoperative facial nerve monitoring can be done safely.

Sugammadex: What do we Know and What do we Still Need to Know? A Review of the Recent (2013 to 2014) Literature

Since its launch in 2008, sugammadex has been considered one of the most significant developments in anaesthesia-related pharmacology. With almost 500 sugammadex-related publications and over nine million patient exposures worldwide, user experience and scientific data have grown exponentially. However, several important questions are yet to be answered. This article reviews the sugammadex-related literature in 2013 and 2014 to determine which of these questions have been answered more fully over the last 18 months and which questions require more information and research.