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Maqusood S, Bele A, Verma N, Dash S, Bawiskar D. Sugammadex vs Neostigmine, a Comparison in Reversing Neuromuscular Blockade: A Narrative Review. Cureus 2024; 16:e65656. [PMID: 39205735 PMCID: PMC11352768 DOI: 10.7759/cureus.65656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBA) has grown due to the development of laparoscopic and minimally invasive procedures. Respiratory insufficiency, an elevated risk of aspiration, postoperative pulmonary complications, and subsequent reintubation are among the risks linked to the residual block. The normal clinical practice calls for the pharmacologic "reversal" of these agents with either sugammadex or neostigmine prior to extubation. The administration of neostigmine is linked to a number of potential complications. In response, anaesthesiologists have begun to prescribe sugammadex more frequently for treating residual block and reversing blockade with NMBA. This review article compares and assesses neostigmine and sugammadex thoroughly in order to determine the extent to which they work as agents to reverse neuromuscular blockade. The review's findings highlight sugammadex's considerable advantages - Sugammadex's ability to quickly and reliably achieve desired train-of-four (TOF) ratios - over neostigmine in reversing neuromuscular blockade in a variety of surgical settings. In contrast, neostigmine's limitations regarding efficacy and rate of reversal were consistently noted in all of the reviewed studies, despite the fact that it is still widely used due to its lower cost and extensive clinical experience. Sugammadex is a superior option for reversing neuromuscular blockade, but incorporating it into standard clinical practice necessitates carefully weighing its potential benefits and drawbacks. Sugammadex provides notable benefits over neostigmine in terms of speed, predictability, and safety.
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Affiliation(s)
- Shafaque Maqusood
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amol Bele
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neeta Verma
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sambit Dash
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dushyant Bawiskar
- Sports Medicine, Abhinav Bindra Targeting Performance, Bangalore, IND
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2
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Yang S, Sun Z, Zhou C, Wei W, Qu N, Shi R, Ma B, Xu W, Ji Q, Zhang J, Wang Y. Feasibility of the enhanced neuromuscular blockade recovery protocol with selective use of sugammadex in thyroid surgery with intraoperative neuromonitoring. Head Neck 2024. [PMID: 38877778 DOI: 10.1002/hed.27826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/31/2024] [Accepted: 05/20/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND To investigate feasibility of utilizing enhanced neuromuscular blocking agents with selective recovery protocol during thyroid surgery with intraoperative neuromonitoring (IONM). METHODS Two-hundred and ninety patients were randomized into two groups: group A 0.3 mg/kg rocuronium and group B 0.6 mg/kg. Sugammadex 2 mg/kg was injected if needed followed initial vagal stimulation (V0). Electromyography signals from vagus and recurrent laryngeal nerves before and after resection were recorded as V1, V2, R1, and R2. RESULTS In group B, 30 patients (20.7%) had V0 signals <100 μV, compared to 9 (6.2%) in group A. After sugammadex administration, 144 patients (99.3%) in both groups achieved positive V1 signals. Group B demonstrated a shorter surgical time from rocuronium injection to V2 stimulation compared to group A, accompanied by a significantly lower incidence of intraoperative body movement (0 vs. 16 patients). CONCLUSIONS 0.6 mg/kg rocuronium with selective use 2 mg/kg sugammadex for IONM in thyroid surgery can meet both anesthesia and surgery demands.
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Affiliation(s)
- Shuwen Yang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhirong Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Changming Zhou
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Wenjun Wei
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ning Qu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Rongliang Shi
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ben Ma
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Weibo Xu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qinhai Ji
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Wang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
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Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13-41. [PMID: 36520073 DOI: 10.1097/aln.0000000000004379] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.
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Togioka BM, Schenning KJ. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 2022; 39:749-761. [PMID: 35934764 DOI: 10.1007/s40266-022-00969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
| | - Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Kaddoum R, Tarraf S, Shebbo FM, Bou Ali A, Karam C, Abi Shadid C, Bouez J, Aouad MT. Reduction of Nonoperative Time Using the Induction Room, Parallel Processing, and Sugammadex: A Randomized Clinical Trial. Anesth Analg 2022; 135:406-413. [PMID: 35839499 PMCID: PMC9259044 DOI: 10.1213/ane.0000000000006102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND An important variable in the operating room is the nonoperative time (NOT), the time between skin closure on a previous case and skin incision on the following case. Mismanagement of NOT can result in significant financial losses and delays in the operating room (OR) schedule, which can negatively impact efficiency and patient, surgeon, and staff satisfaction. NOT includes general anesthesia induction time (IT), emergence time (ET), and turnover time (TOT), and can be calculated by adding the 3 components. OR efficiency can be increased by applying parallel processing for general anesthesia induction and OR cleaning and reversal of neuromuscular blockade with sugammadex to reduce the 3 components of NOT without compromising patient safety. METHODS This is a prospective, randomized study of 111 patients 18 to 75 years of age, American Society of Anesthesiologists (ASA) I-III, undergoing surgery requiring general anesthesia and muscle relaxation. Patients were randomly assigned to the control group (traditional linear processing for induction of anesthesia and OR cleaning and neuromuscular blockade reversal with neostigmine/glycopyrrolate) and the active group (parallel processing for induction of anesthesia and OR cleaning and neuromuscular blockade reversal with sugammadex). The primary outcome measured is the difference in the NOT. The secondary outcomes are surgeon and patient satisfaction. RESULTS NOT was significantly shorter in patients who underwent the parallel processing strategy and received sugammadex compared to the patients in the control group (25.0 [18.0-44.0] vs 48.0 [40.0-64.5] minutes; Cliff' delta = 0.57; P < .001). After excluding the cases in the experimental group that were put into sleep in the OR (ie, the first case of the room), IT, ET, TOT, and NOT were further reduced and remained statistically significantly lower than the control group. Satisfaction scores from surgeons were significantly higher in the active group than in the control group (P < .001). There was no significant difference in the satisfaction scores of patients between the 2 groups. CONCLUSIONS Our study showed that interventions, such as parallel processing during induction of anesthesia and room cleaning instead of linear processing and the use of the faster-acting sugammadex instead of the combination of neostigmine and glycopyrrolate for the reversal of rocuronium-induced neuromuscular blockade, resulted in shorter IT, ET, TOT, and therefore NOT, in addition to higher surgeon's satisfaction.
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Affiliation(s)
- Roland Kaddoum
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Said Tarraf
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadia M. Shebbo
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Arwa Bou Ali
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cynthia Karam
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Carol Abi Shadid
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joanna Bouez
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marie T. Aouad
- From the Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Zhang YG, Chen Y, Zhang YL, Yi J. Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial. Trials 2022; 23:376. [PMID: 35526047 PMCID: PMC9077960 DOI: 10.1186/s13063-022-06328-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively. Methods/design In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively. Discussion Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting. Trial registration ClinicalTrials.gov NCT05040490. Registered on 3 September 2021 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06328-3.
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Affiliation(s)
- Yu-Guan Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Ying Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yue-Lun Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jie Yi
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
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7
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Carron M, Andreatta G, Pesenti E, De Cassai A, Feltracco P, Linassi F, Sergi M, Di Bella C, Di Bello M, Neri F, Silvestre C, Furian L, Navalesi P. Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study. Perioper Med (Lond) 2022; 11:3. [PMID: 35022076 PMCID: PMC8756660 DOI: 10.1186/s13741-021-00231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. Methods A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. Results No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). Conclusions Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.
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Affiliation(s)
- M Carron
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy.
| | - G Andreatta
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - E Pesenti
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - A De Cassai
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Feltracco
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - F Linassi
- Department of Anesthesia and Intensive Care, Ca' Foncello Treviso Regional Hospital, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - M Sergi
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Di Bella
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - M Di Bello
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - F Neri
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Silvestre
- Kidney and Pancreas Transplantation Unit, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - L Furian
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Navalesi
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
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8
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Herring WJ, Mukai Y, Wang A, Lutkiewicz J, Lombard JF, Lin L, Watkins M, Broussard DM, Blobner M. A randomized trial evaluating the safety profile of sugammadex in high surgical risk ASA physical class 3 or 4 participants. BMC Anesthesiol 2021; 21:259. [PMID: 34711192 PMCID: PMC8555093 DOI: 10.1186/s12871-021-01477-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of this randomized, double-blind trial was to evaluate the safety and tolerability profile, including cardiac safety, of sugammadex-mediated recovery from neuromuscular block in participants undergoing surgery who met the American Society of Anesthesiologists (ASA) Physical Class 3 or 4 criteria. Specifically, this study assessed the impact of sugammadex on cardiac adverse events (AEs) and other prespecified AEs of clinical interest. METHODS Participants meeting ASA Class 3 and 4 criteria were stratified by ASA Class and NMBA (rocuronium or vecuronium) then randomized to one of the following: 1) Moderate neuromuscular block, sugammadex 2 mg/kg; 2) Moderate neuromuscular block, neostigmine and glycopyrrolate (neostigmine/glycopyrrolate); 3) Deep neuromuscular block, sugammadex 4 mg/kg; 4) Deep neuromuscular block, sugammadex 16 mg/kg (rocuronium only). Primary endpoints included incidences of treatment-emergent (TE) sinus bradycardia, TE sinus tachycardia and other TE cardiac arrhythmias. RESULTS Of 344 participants randomized, 331 received treatment (61% male, BMI 28.5 ± 5.3 kg/m2, age 69 ± 11 years). Incidence of TE sinus bradycardia was significantly lower in the sugammadex 2 mg/kg group vs neostigmine/glycopyrrolate. The incidence of TE sinus tachycardia was significantly lower in the sugammadex 2 and 4 mg/kg groups vs neostigmine/glycopyrrolate. No significant differences in other TE cardiac arrythmias were seen between sugammadex groups and neostigmine/glycopyrrolate. There were no cases of adjudicated anaphylaxis or hypersensitivity reactions in this study. CONCLUSIONS Compared with neostigmine/glycopyrrolate, incidence of TE sinus bradycardia was significantly lower with sugammadex 2 mg/kg and incidence of TE sinus tachycardia was significantly lower with sugammadex 2 mg/kg and 4 mg/kg. These results support the safety of sugammadex for reversing rocuronium- or vecuronium-induced moderate and deep neuromuscular block in ASA Class 3 or 4 participants. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03346057 .
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Affiliation(s)
- W Joseph Herring
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA.
| | - Yuki Mukai
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Aobo Wang
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - John F Lombard
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Li Lin
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Molly Watkins
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - Manfred Blobner
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany.,Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
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9
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Oh MY, Lee JM, Won D, Huang TY, Wu CW, Dionigi G, Kim HY, Seo M, Choi HS, Chai YJ. Investigation of potential neuropharmacological activity of neostigmine-glycopyrrolate for intraoperative neural monitoring in thyroid surgery. Kaohsiung J Med Sci 2021; 38:59-64. [PMID: 34562340 DOI: 10.1002/kjm2.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022] Open
Abstract
Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine-glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle-twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine-glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine-glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine-glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine-glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.
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Affiliation(s)
- Moon Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Dongwook Won
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Miyeon Seo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyun Suk Choi
- Department of Nursing, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
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Yu J, Park JY, Lee Y, Hwang JH, Kim YK. Sugammadex versus neostigmine on postoperative pulmonary complications after robot-assisted laparoscopic prostatectomy: a propensity score-matched analysis. J Anesth 2021; 35:262-269. [PMID: 33683444 DOI: 10.1007/s00540-021-02910-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/14/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Robot-assisted laparoscopic prostatectomy (RALP) requires particular surgical conditions, such as carbon dioxide pneumoperitoneum and steep Trendelenburg positioning, which may have adverse effects on the respiratory system. The effect of sugammadex on postoperative pulmonary complications (PPCs) is controversial. Therefore, we evaluated the incidence of PPCs according to the type of neuromuscular blockade reversal agents in RALP. METHODS We retrospectively analyzed RALP patients. We compared the incidence of PPCs between patients receiving neostigmine (neostigmine group) and those receiving sugammadex (sugammadex group) as a neuromuscular blockade reversal agent. Propensity score-matched analysis was performed. Other postoperative outcomes, such as duration of hospital stays, major adverse cardiac events during hospital stays, and death during hospital stays, were also compared between the two groups. RESULTS The incidence of PPCs was 28.9% (137/474) in RALP. The incidence of PPCs was significantly lower in the sugammadex group than in the neostigmine group (18.6% [44/237] vs. 39.2% [93/237], p < 0.001). The incidence of atelectasis was significantly lower in the sugammadex group than in the neostigmine group (18.6% vs. 39.2%, p < 0.001). The incidence of pneumonia was not significantly different between the sugammadex and neostigmine groups after RALP (0.0% vs. 0.4%, p > 0.999). Besides these, other postoperative outcomes were not significantly different between the two groups. CONCLUSIONS The incidence of PPCs after RALP was significantly lower in patients receiving sugammadex than in those receiving neostigmine. These results can provide useful information on the appropriate selection of neuromuscular blockade reversal agents in RALP.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yongsoo Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Martinez-Ubieto J, Aragón-Benedí C, de Pedro J, Cea-Calvo L, Morell A, Jiang Y, Cedillo S, Ramírez-Boix P, Pascual-Bellosta AM. Economic impact of improving patient safety using Sugammadex for routine reversal of neuromuscular blockade in Spain. BMC Anesthesiol 2021; 21:55. [PMID: 33593283 PMCID: PMC7888144 DOI: 10.1186/s12871-021-01248-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background Neuromuscular blocking (NMB) agents are often administered to facilitate tracheal intubation and prevent patient movement during surgical procedures requiring the use of general anesthetics. Incomplete reversal of NMB, can lead to residual NMB, which can increase the risk of post-operative pulmonary complications. Sugammadex is indicated to reverse neuromuscular blockade induced by rocuronium or vecuronium in adults. The aim of this study is to estimate the clinical and economic impact of introducing sugammadex to routine reversal of neuromuscular blockade (NMB) with rocuronium in Spain. Methods A decision analytic model was constructed reflecting a set of procedures using rocuronium that resulted in moderate or deep NMB at the end of the procedure. Two scenarios were considered for 537,931 procedures using NMB agents in Spain in 2015: a scenario without sugammadex versus a scenario with sugammadex. Comparators included neostigmine (plus glycopyrrolate) and no reversal agent. The total costs for the healthcare system were estimated from the net of costs of reversal agents and overall cost offsets via reduction in postoperative pneumonias and atelectasis for which incidence rates were based on a Spanish real-world evidence (RWE) study. The model time horizon was assumed to be one year. Costs were expressed in 2019 euros (€) and estimated from the perspective of a healthcare system. One-way sensitivity analysis was carried out by varying each parameter included in the model within a range of +/− 50%. Results The estimated budget impact of the introduction of sugammadex to the routine reversal of neuromuscular blockade in Spanish hospitals was a net saving of €57.1 million annually. An increase in drug acquisition costs was offset by savings in post-operative pulmonary events, including 4806 post-operative pneumonias and 13,996 cases of atelectasis. The total cost of complications avoided was €70.4 million. All parameters included in the model were tested in sensitivity analysis and were favorable to the scenario with sugammadex. Conclusions This economic analysis shows that sugammadex can potentially lead to cost savings for the reversal of rocuronium-induced moderate or profound NMB compared to no reversal and reversal with neostigmine in the Spanish health care setting. The economic model was based on data obtained from Spain and from assumptions from clinical practice and may not be valid for other countries.
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Affiliation(s)
| | | | | | | | - A Morell
- Hospital Universitario de la Princesa, Madrid, Spain
| | - Y Jiang
- MSD Ltd., Hoddesdon, Hertfordshire, UK
| | - S Cedillo
- Covance Clinical Development, Madrid, Spain
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12
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Vargas M, Buonanno P, Sica A, Sabatella E, D'Alessio FP, Alfieri S, Iacovazzo C, Carrano R, Servillo G. Effects of Sugammadex Plus Rocuronium vs Neostigmine Plus Cisatracurium During Renal Transplantation on Graft Function: A Retrospective, Case-Control Study. Transplant Proc 2020; 53:818-824. [PMID: 33069485 DOI: 10.1016/j.transproceed.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/27/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rocuronium can be used in patients with severe renal failure (creatinine clearance <30 mL/min), but the duration of muscle relaxation is longer and results in an increased risk of postoperative residual neuromuscular block. Rocuronium can be antagonized by sugammadex, but the elimination of the complex they make (rocuronium-sugammadex complex) varies according to the renal function. Two case reports/series have reported the use of rocuronium-sugammadex complex during renal transplantation. A recently published retrospective study showed no differences in postoperative creatinine levels in patients receiving kidney transplantation. This retrospective case-control study aims to investigate the effects of rocuronium-sugammadex, used during renal transplantation, on transplanted kidney function. METHODS We analyzed 113 medical records of patients undergoing kidney transplantation from January 2015 to December 2018. Forty-seven medical records were excluded because they did not report the administration of one of the following drugs during the transplantation: rocuronium, sugammadex, cisatracurium, neostigmine. The demographics of patients and donors were collected along with the following data: blood urea and creatinine, serum and urinary electrolytes, and diuresis. Marginal, single, or double kidney transplantations; Karpinski scores; and histologic evaluations of transplanted kidney were collected. RESULTS We included data from 66 medical reports from January 2015 to December 2018. Blood creatinine levels at 6, 12, and 24 hours were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (creatinine 6 hours P = .05, creatinine 12 hours P = .038, creatinine 24 hours P = .049). Blood urea levels for 24 hours after transplantation were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (urea 0 hours P = .025, urea 6 hours P = .011, urea 12 hours P = .03, urea 24 hours P = .011). We found no statistically significant differences in blood sodium, blood potassium, blood calcium, diuresis, urinary sodium, or urinary potassium levels before and after transplantation. CONCLUSIONS In this retrospective case-control study, the use of rocuronium and sugammadex during renal transplant surgery did not affect relevant kidney recovery outcomes in the first week after transplantation.
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Andrea Sica
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Emanuele Sabatella
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Francesco P D'Alessio
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Simone Alfieri
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Rosa Carrano
- Department of Public Health, Section of Nephrology and Renal Transplantation, "Federico II" University, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
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Niu L, Wang Y, Yao C, Sun Y, Yao S, Lin Y. Efficacy and Safety of Neuromuscular Blockade in Overweight Patients Undergoing Nasopharyngeal Surgery. Med Sci Monit 2020; 26:e926452. [PMID: 32936790 PMCID: PMC7519943 DOI: 10.12659/msm.926452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Adequate muscle relaxation and rapid recovery of neuromuscular function are essential in the perioperative period. We therefore compared various anesthetic regimens of neuromuscular blockers and antagonists administered to overweight patients undergoing nasopharyngeal surgery. MATERIAL AND METHODS This prospective, randomized, double-blind study was conducted in overweight patients undergoing nasopharyngeal surgery. We randomly assigned 102 patients into 3 groups (each n=34) treated with various muscle relaxant agents and antagonists: rocuronium and sugammadex (Group RS), rocuronium and neostigmine (Group RN), and cisatracurium and neostigmine (Group CN). Then, we compared the efficacy and safety indexes of the 3 groups. RESULTS Onset times of muscular relaxation in Group RS and Group RN (110 s and 120 s) were shorter than in Group CN (183 s). Time from administration of antagonist to recovery of the TOF ratio to 0.9 was shorter in Group RS (3.3 min) than in other groups (20.7 min and 19.1 min, respectively). The incidence of postoperative residual curarization (PORC) was significantly lower in Group RS (5.9%) than in the other 2 groups (both 41.2%). The hemodynamic parameter changes before extubation were significantly higher in Group RN and Group CN than in Group RS. The postoperative pain scores were lowest in Group RS. CONCLUSIONS For overweight patients undergoing nasopharyngeal surgery, the use of rocuronium with sugammadex had the shortest onset time of neuromuscular relaxation, accelerated the reversion of neuromuscular blockade, effectively reduced the occurrence of PORC, relieved postoperative pain, and maintained hemodynamic stability before extubation. The combination of rocuronium and sugammadex may be the best anesthetic regimen for overweight patients undergoing nasopharyngeal surgery.
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Affiliation(s)
- Lingxia Niu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Chunlin Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yan Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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Yorulmaz IS, Demiraran Y, Özlü O, Dost B. The effect of vitamin D status on different neuromuscular blocker agents reverse time. Turk J Med Sci 2020; 50:749-755. [PMID: 32151115 PMCID: PMC7379448 DOI: 10.3906/sag-1901-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/05/2020] [Indexed: 11/06/2022] Open
Abstract
Background/aim This study is aimed to investigate the effects of vitamin D levels on sugammadex and neostigmine reversal times. Material and methods Eighty patients between the ages of 18 and 65 years, with ASA I-III status who were undergoing surgery under general anesthesia were included in the study. A double blind fashion was used to randomly divide all the patients into two groups. At the end of the operation, sugammadex 2 mg/kg was administered to one group (Group sugammadex) and atropine and neostigmine was administered to the other group (Group neostigmine) intravenously. In the data analysis stage, the group was divided into two subgroups according to sugammadex and group neostigmine in itself, with vitamin D levels above and below 30 ng/mL. Statistical analysis was performed on these 4 groups (Group neostigmine and vitamin D < 30 ng/mL), (Group neostigmine and vitamin D ≥ 30 ng/mL), ( Group sugammadex and vitamin D < 30 ng/mL), (Group sugammadex and vitamin D ≥ 30 ng/mL).When two responses to train of four (TOF) stimulation were taken, the following times were recorded until extubation phase. The time until TOF value 50%, 70%, 90%, and extubation were recorded. Results There were statistically significant differences between Group sugammadex and vitamin D < 30 ng/mL and Group sugammadex and vitamin D ≥ 30 ng/mL (P = 0.007) for extubation times and 50% TOF reach times (P = 0.015). However, there was no difference observed between Group neostigmine and vitamin D < 30 ng/mL and Group neostigmine and vitamin D ≥ 30 ng/mL (P = 0.999). Conclusion Vitamin D deficiency is important for anesthesiologists in terms of muscle strength and extubation time. Vitamin D deficiency seems to affect sugammadex reverse times but seems not to affect neostigmine reverse times. This conclusion needs further studies.
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Affiliation(s)
- Ilknur Suidiye Yorulmaz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Düzce University, Düzce, Turkey
| | - Yavuz Demiraran
- Department of Anesthesiology and Reanimation, Medipol University Mega Hospital Complex, İstanbul, Turkey
| | - Onur Özlü
- Department of Anesthesiology and Reanimation, TOBB Economy and Technology University, Faculty of Medicine, Ankara, Turkey
| | - Burhan Dost
- Department of Anesthesiology and Reanimation, Ondokuz Mayıs University, Samsun, Turkey
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A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength. Can J Anaesth 2020; 67:959-969. [PMID: 32405975 DOI: 10.1007/s12630-020-01695-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Residual neuromuscular blockade after surgery is associated with airway obstruction, hypoxia, and respiratory complications. Compared with neostigmine, sugammadex reverses neuromuscular blockade to a train-of-four ratio > 0.9 more rapidly. It is unknown, however, whether the superior reversal profile of sugammadex improves clinically relevant measures of strength in the early postoperative period. METHODS Patients undergoing general, gynecological, or urologic surgery were randomized to receive either neostigmine (70 µg·kg-1, maximum 5 mg) or sugammadex (2 or 4 mg·kg-1) to reverse neuromuscular blockade. The primary outcome was the ability to breathe deeply measured by incentive spirometry at 30, 60, and 120 min after reversal. RESULTS We randomized 62 patients to either a neostigmine (n = 31) or sugammadex (n = 31) group. The incentive spirometry volume recovery trajectory was not different between the two groups (P = 0.35). Median spirometry volumes at baseline, 30, 60, and 120 min postoperatively were 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, and 1800 vs 1950 mL for the sugammadex and neostigmine groups, respectively. Postoperative incentive spirometry decrease from baseline was not different between the two groups. Hand grip strength, the ability to sit unaided, train-of-four ratio on postanesthesia care unit (PACU) admission, time to extubation, time to PACU discharge readiness, and Quality of Recovery-15 scores were also not different between the groups. CONCLUSIONS Measures of postoperative strength, such as incentive spirometry, hand group strength, and the ability to sit up in the early postoperative period were not different in patients who received neostigmine or sugammadex for the reversal of neuromuscular blockade. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02909439); registered: 21 September, 2016.
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Togioka BM, Yanez D, Aziz MF, Higgins JR, Tekkali P, Treggiari MM. Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery. Br J Anaesth 2020; 124:553-561. [DOI: 10.1016/j.bja.2020.01.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 12/20/2022] Open
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Williams WH, Cata JP, Lasala JD, Navai N, Feng L, Gottumukkala V. Effect of reversal of deep neuromuscular block with sugammadex or moderate block by neostigmine on shoulder pain in elderly patients undergoing robotic prostatectomy. Br J Anaesth 2020; 124:164-172. [DOI: 10.1016/j.bja.2019.09.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 12/13/2022] Open
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Comparison of neostigmine vs. sugammadex for recovery of muscle function after neuromuscular block by means of diaphragm ultrasonography in microlaryngeal surgery. Eur J Anaesthesiol 2020; 37:44-51. [DOI: 10.1097/eja.0000000000001055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Algorithmusbasierte Präventionsstrategien zur Vermeidung neuromuskulärer Restblockaden. Anaesthesist 2019; 68:744-754. [DOI: 10.1007/s00101-019-00677-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Neostigmine-based reversal of intermediate acting neuromuscular blocking agents to prevent postoperative residual paralysis: A systematic review. Eur J Anaesthesiol 2019; 35:184-192. [PMID: 29189420 DOI: 10.1097/eja.0000000000000741] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neostigmine is widely used to antagonise residual paralysis. Over the last decades, the benchmark of acceptable neuromuscular recovery has increased progressively to a train-of-four (TOF) ratio of at least 0.9. Raising this benchmark may impact on the efficacy of neostigmine. OBJECTIVE(S) The systematic review evaluates the efficacy of neostigmine to antagonise neuromuscular block to attain a TOF ratio of at least 0.9. DESIGN We performed a systematic search of the literature from January 1992 to December 2015. DATA SOURCES OR SETTING PubMed, EMBASE and the Cochrane Controlled Clinical Trials database were searched for randomised controlled human studies. Search was performed without language restrictions, using the following free text terms: 'neostigmine', 'sugammadex', 'edrophonium' or 'pyridostigmine' AND 'neuromuscular block', 'reversal' or 'reverse'. ELIGIBILITY CRITERIA Studies were accepted for inclusion if they used quantitative neuromuscular monitoring and neostigmine as the reversal agent. Selected trials were checked by two of the authors for data integrity. Trials relevant for inclusion had to report the number of patients included, the type of anaesthetic maintenance, the type of neuromuscular blocking agent used, the reversal agent and dose used, the depth of neuromuscular block when neostigmine was administered and the reversal time (time from injection of neostigmine until a TOF ratio ≥0.9 was attained). RESULTS 19 trials were eligible for quantitative analysis. In patients with deep residual block [T1 (first twitch height) <10%] 70 μg kg neostigmine was used (five trials, 118 patients), and the mean reversal time was 17.1 min (95% confidence interval (CI) [12.4 to 21.8]). In patients with moderate residual block (T1 10% to <25%) the mean neostigmine dose was 56 μg kg (seven trials, 342 patients), and the mean reversal time was 11.3 min (95% CI [9.2 to 13.4]). In patients with a shallow residual block (T1 ≥ 25%) the mean neostigmine dose was 40 μg kg (13 trials, 535 patients), and the mean reversal time was 8.0 min (95% CI [6.8 to 9.2]). CONCLUSION Based on the findings of this systematic review, we recommend that the administration of neostigmine be delayed until an advanced degree of prereversal recovery has occurred (i.e. a T1 >25% of baseline), or that a recovery time longer than 15 min be accepted.
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Hunter JM. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation. Br J Anaesth 2019; 119:i53-i62. [PMID: 29161387 DOI: 10.1093/bja/aex318] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The use of anticholinesterases to reverse residual neuromuscular block at the end of surgery became routine practice in the 1950s. These drugs could only be used when recovery from block was established [two twitches of the train-of-four (TOF) count detectable] and concern was expressed about their cholinergic side-effects. By the 1990s, it was recognized that failure to reverse residual block adequately to a TOF ratio (TOFR) >0.7 was associated with increased risk of postoperative pulmonary complications (POPCs) following the long-acting non-depolarizing neuromuscular blocking drug (NDNMBD) pancuronium. By 2003, and the introduction of acceleromyography, a TOFR ≥0.9 was considered necessary to protect the airway from aspiration before tracheal extubation. It was also considered that four, not two, twitches of the TOF should be detectable before neostigmine was given. Use of any NDNMBD was subsequently shown to be associated with increased risk of POPCs, but it was thought that neostigmine reduced that risk. Recently, there has been conflicting evidence that use of neostigmine might increase the incidence of POPCs. Although sugammadex has been shown to rapidly reverse profound neuromuscular block from aminosteroidal agents, there is currently no evidence that sugammadex is superior to neostigmine in its effect on POPCs. Other new antagonists, including cysteine to degrade CW002 and calabadion 1 and 2 to antagonize aminosteroidal and benzylisoquinolium NDNMBDs, are being studied in preclinical and clinical trials. Quantitative neuromuscular monitoring is essential whenever a NDNMBD is used to ensure full recovery from neuromuscular block.
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Affiliation(s)
- J M Hunter
- University of Liverpool, Institute of Ageing and Chronic Disease, Liverpool L69 3GA, UK
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Sugammadex is associated with better respiratory recovery than neostigmine following reversal of anaesthesia-associated neuromuscular blockade in the morbidly obese patients following elective laparoscopic surgery. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2018. [DOI: 10.1016/j.lers.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Zealley K, Taylor A, Raju P, Rodney G. Is appropriately conducted neostigmine reversal inferior to sugammadex? Anaesthesia 2018; 73:1166-1167. [DOI: 10.1111/anae.14340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K. Zealley
- Ninewells Hospital and Medical School; Dundee UK
| | - A. Taylor
- Ninewells Hospital and Medical School; Dundee UK
| | - P. Raju
- Ninewells Hospital and Medical School; Dundee UK
| | - G. Rodney
- Ninewells Hospital and Medical School; Dundee UK
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Abdulatif M, Lotfy M, Mousa M, Afifi MH, Yassen K. Sugammadex antagonism of rocuronium-induced neuromuscular blockade in patients with liver cirrhosis undergoing liver resection: a randomized controlled study. Minerva Anestesiol 2018; 84:929-937. [DOI: 10.23736/s0375-9393.18.12217-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
A growing proportion of patients undergoing surgical procedures are obese, providing anesthesiologists with numerous challenges for patient management. The current pooled analysis evaluated recovery times following sugammadex reversal of neuromuscular blockade by body mass index (BMI) in general, and in particular, in patients with BMIs ≥30 kg/m (defined as obese) and <30 kg/m (defined as non-obese). Data were pooled from 27 trials evaluating recommended sugammadex doses for reversal of moderate [reappearance of the second twitch of the train-of-four (TOF); sugammadex 2 mg/kg] or deep (1-2 post-tetanic counts or 15 minutes after rocuronium; sugammadex 4 mg/kg) rocuronium- or vecuronium-induced neuromuscular blockade. All doses of sugammadex were administered based on actual body weight. The recovery time from sugammadex administration to a TOF ratio ≥0.9 was the primary efficacy variable in all individual studies and in the pooled analysis. This analysis comprised a total of 1418 adult patients treated with sugammadex; 267 (18.8%) of these patients had a BMI ≥30 kg/m. The average time to recovery of the TOF ratio to 0.9 was 1.9 minutes for rocuronium-induced blockade and 3.0 minutes for vecuronium-induced blockade. No clinically relevant correlation was observed between BMI and recovery time. The recommended sugammadex doses based on actual body weight provide rapid recovery from neuromuscular blockade in both obese and non-obese patients; no dose adjustments are required in the obese patient.
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Affiliation(s)
- Christoph Unterbuchner
- Department of Anesthesiology, University Medical Centre Regensburg Franz-Josef-Strauss-Allee 11 93053 Regensburg, Germany
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Park WY, Choi JC, Yun HJ, Jeon YG, Park G, Choi JB. Optimal dose of combined rocuronium and cisatracurium during minor surgery: A randomized trial. Medicine (Baltimore) 2018; 97:e9779. [PMID: 29517695 PMCID: PMC5882426 DOI: 10.1097/md.0000000000009779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/14/2017] [Accepted: 01/11/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Combined rocuronium and cisatracurium have synergistic effects. We investigated whether reduced doses are effective during coadministration, by monitoring neuromuscular relaxation during surgery. METHODS This randomized, controlled clinical trial was registered at http://clinicaltrials.gov (registration number NCT02495038). The participants were 81 patients scheduled for elective mastoidectomy and tympanoplasty. Participants were assigned to groups, including the intubating dose group (Group I, n = 27; combined ED95 rocuronium and ED95 cisatracurium), the small reduction group (Group S, n = 27; dose reduced by 10% of each ED95), or the large reduction group (Group L, n = 27; dose reduced by 20% of each ED95). Drugs were administered to patients and a timer was started using TOF-Watch monitoring. TOF (train-of-four) was monitored at the ulnar nerve, at a setting of 2 Hz/12 s. We recorded the time to TOF ratio = 0 (onset), time to first TOF ratio > 25% (duration 25%), and TOF 25-75% (recovery index) under total intravenous anesthesia. One-way analysis of variance was used for statistical analyses (α = 0.05, β = 0.2). RESULTS There were no significant demographic differences between groups. Group L had a longer duration to onset (mean ± standard deviation, 399.3 ± 147.8 seconds) and shorter duration 25% (39.4 ± 6.8 minutes) compared to Group I (212.8 ± 56.0 s and 51.3 ± 8.47 minutes, respectively) and Group S (230.7 ± 60.6 s and 47.9 ± 10.7 minutes, respectively). There were no other significant differences between groups. CONCLUSION Our findings contribute to determining clinically effective combinations of rocuronium and cisatracurium, as well as to predicting the pharmacokinetic characteristics of the synergistic effects. We suggest that reducing doses of both drugs by approximately 10% of their respective ED95 values is sufficient to maintain neuromuscular relaxation during minor surgery.
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Affiliation(s)
- Woo Young Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Anesthesia, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | - Jae Chan Choi
- Department of Anesthesiology and Pain Medicine, Intensive Care Medicine, Brain Research Group, Yonsei University Wonju College of Medicine, Wonju
| | - Hey Jeong Yun
- Department of Anesthesia, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | | | - Gisoon Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon, Republic of Korea
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Cappellini I, Picciafuochi F, Ostento D, Danti G, De Gaudio AR, Adembri C. Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial. Trials 2018; 19:135. [PMID: 29467022 PMCID: PMC5822666 DOI: 10.1186/s13063-018-2525-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 02/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background The extensive use of neuromuscular blocking agents (NMBAs) during surgical procedures still leads to potential residual paralyzing effects in the postoperative period. Indeed, neuromuscular monitoring in an intra-operative setting is strongly advocated. Acetylcholinesterase inhibitors can reverse muscle block, but their short half-life may lead to residual curarization in the ward, especially when intermediate or long-acting NMBAs have been administered. Sugammadex is the first selective reversal drug for steroidal NMBAs; it has been shown to give full and rapid recovery of muscle strength, thus minimizing the occurrence of residual curarization. Acceleromyography of the adductor pollicis is the gold standard for detecting residual curarization, but it cannot be carried out on conscious patients. Ultrasonography of diaphragm thickness may reveal residual effects of NMBAs in conscious patients. Methods/design This prospective, double-blind, single-center randomized controlled study will enroll patients (of American Society of Anesthesiologists physical status I–II, aged 18–80 years) who will be scheduled to undergo deep neuromuscular block with rocuronium for ear, nose, or throat surgery. The study’s primary objective will be to compare the effects of neostigmine and sugammadex on postoperative residual curarization using two different tools: diaphragm ultrasonography and acceleromyography of the adductor pollicis. Patients will be extubated when the train-of-four ratio is > 0.9. Diaphragm ultrasonography will be used to evaluate the thickening fraction, which is the difference between the end expiratory thickness and the end inspiratory thickness, normalized to the end expiratory thickness. Ultrasonography will be performed before the initiation of general anesthesia, before extubation, and 10 and 30 min after discharging patients from the operating room. The secondary objective will be to compare the incidence of postoperative complications due to residual neuromuscular block between patients who receive neostigmine and those who receive sugammadex. Discussion Postoperative residual curarization is a topic of paramount importance, because its occurrence can cause complications and increase the length of stay in hospital and the related costs. Diaphragm ultrasound assessment may become a bedside integrative tool in the neuromuscular monitoring field to detect concealed residual curarization in surgical patients who have received paralyzing agents. Trial registration EudraCT, 2013-004787-62. Registered on 18 June 2014, as “Evaluation of muscle function recovery after deep neuromuscular blockade by acceleromyography of the adductor pollicis or diaphragmatic echography: comparison between sugammadex and neostigmine.” ClinicalTrials.gov,NCT02698969. Registered on 15 February 2016, as “Recovery of Muscle Function After Deep Neuromuscular Block by Means of Diaphragm Ultrasonography and Adductor Pollicis Acceleromyography: Comparison of Neostigmine vs. Sugammadex as Reversal Drugs.” Electronic supplementary material The online version of this article (10.1186/s13063-018-2525-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Iacopo Cappellini
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - Fabio Picciafuochi
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Daniele Ostento
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Ginevra Danti
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Angelo Raffaele De Gaudio
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Chiara Adembri
- Department of Health Sciences, Section of Anesthesiology and Critical Care, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
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Hristovska AM, Duch P, Allingstrup M, Afshari A. The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta-analysis and trial sequential analysis. Anaesthesia 2017; 73:631-641. [DOI: 10.1111/anae.14160] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2017] [Indexed: 12/14/2022]
Affiliation(s)
- A.-M. Hristovska
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - P. Duch
- Department of Neuroanaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - M. Allingstrup
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Afshari
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
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Herring WJ, Woo T, Assaid CA, Lupinacci RJ, Lemmens HJ, Blobner M, Khuenl-Brady KS. Sugammadex efficacy for reversal of rocuronium- and vecuronium-induced neuromuscular blockade: A pooled analysis of 26 studies. J Clin Anesth 2017; 41:84-91. [DOI: 10.1016/j.jclinane.2017.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/19/2017] [Accepted: 06/16/2017] [Indexed: 12/17/2022]
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Hristovska A, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev 2017; 8:CD012763. [PMID: 28806470 PMCID: PMC6483345 DOI: 10.1002/14651858.cd012763] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non-depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant-binding agent specifically developed for rapid reversal of non-depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. OBJECTIVES The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non-depolarizing neuromuscular agents in adults. SEARCH METHODS We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled-trials.com, clinicaltrials.gov, and www.centerwatch.com. We re-ran the search on 10 May 2017. SELECTION CRITERIA We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non-depolarizing neuromuscular blocking agents for an elective in-patient or day-case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train-of-four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. MAIN RESULTS We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta-analysis of primary outcomes (n = 949), 28 trials were eligible for meta-analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta-analysis.We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium-induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I2 = 84%; 10 studies, n = 835; GRADE: moderate quality).We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium-induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post-tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I2 = 0%; two studies, n = 114; GRADE: low quality).For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I2= 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I2= 0%; 10 studies, n = 959; GRADE: low quality).Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. AUTHORS' CONCLUSIONS Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium-induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality).
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Affiliation(s)
- Ana‐Marija Hristovska
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013Blegdamsvej 9CopenhagenDenmark2100
| | - Patricia Duch
- Copenhagen University Hospital HvidovreDepartment of Anaesthesiology and Intensive Care MedicineKettegård Alle 39HvidovreDenmark2650
| | - Mikkel Allingstrup
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013Blegdamsvej 9CopenhagenDenmark2100
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013Blegdamsvej 9CopenhagenDenmark2100
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Dexamethasone Does Not Inhibit Sugammadex Reversal After Rocuronium-Induced Neuromuscular Block. Anesth Analg 2017; 122:1826-30. [PMID: 27028777 DOI: 10.1213/ane.0000000000001294] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sugammadex is a relatively new molecule that reverses neuromuscular block induced by rocuronium. The particular structure of sugammadex traps the cyclopentanoperhydrophenanthrene ring of rocuronium in its hydrophobic cavity. Dexamethasone shares the same steroidal structure with rocuronium. Studies in vitro have demonstrated that dexamethasone interacts with sugammadex, reducing its efficacy. In this study, we investigated the clinical relevance of this interaction and its influence on neuromuscular reversal. METHODS In this retrospective case-control study, we analyzed data from 45 patients divided into 3 groups: dexamethasone after induction group (15 patients) treated with 8 mg dexamethasone as an antiemetic drug shortly after induction of anesthesia; dexamethasone before reversal group (15 patients) treated with dexamethasone just before sugammadex injection; and control group (15 patients) treated with 8 mg ondansetron. All groups received 0.6 mg/kg rocuronium at induction, 0.15 mg/kg rocuronium at train-of-four ratio (TOF) 2 for neuromuscular relaxation, and 2 mg/kg sugammadex for reversal at the end of the procedure at TOF2. Neuromuscular relaxation was monitored with a TOF-Watch® system. RESULTS The control group had a recovery time of 154 ± 54 seconds (mean ± SD), the dexamethasone after induction group 134 ± 55 seconds, and the dexamethasone before reversal group 131 ± 68 seconds. The differences among groups were not statistically significant (P = 0.5141). CONCLUSIONS Our results show that the use of dexamethasone as an antiemetic drug for the prevention of postoperative nausea and vomiting does not interfere with reversal of neuromuscular blockade with sugammadex in patients undergoing elective surgery with general anesthesia in contrast to in vitro studies that support this hypothesis.
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Öztürk Ö, Sezen GY, Ankaralı H, Özlü O, Demiraran Y, Ateş H, Dost B. Effect of Smoking on Reversing Neuromuscular Block. Turk J Anaesthesiol Reanim 2016; 44:206-211. [PMID: 27909595 DOI: 10.5152/tjar.2016.97720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/17/2016] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Rocuronium is a non-depolarising, intermediate-acting, monoquaternary amino steroid and was brought into clinical use as a potentially ideal muscle relaxant. Post-operative residual curarisation (PORC) results from the prolonged effects of non-depolarising neuromuscular blocking agents. This is a common problem and seriously affects patient safety. No recent study has investigated the effects of sugammadex on smokers, which is often used to restore neuromuscular block and avoid PORC. This study compares the severity of the effects of sugammadex used for antagonising rocuronium bromide and antagonism durations in smokers and non-smokers. METHODS This randomised, prospective study included 40 patients scheduled for elective surgery and belonging to classes I and II based the American Society of Anesthesiologists classification, who were either smokers for at least 10 years or non-smokers. Patients underwent routine and neuromuscular monitoring. At induction, 2 mg kg-1 propofol and 1 mcg kg-1 intravenous fentanyl were applied. After the loss of eyelash reflex, 0.6 mg kg-1 intravenous rocuronium was administered. Patients were intubated at train of four (TOF) 2. Anaesthesia was continued with 50% O2+50% air and 2% sevoflurane. Rocuronium, 0.15 mg kg-1, was administered at TOF 2 during the operation. At the end of the operation, 2 mg kg-1 sugammadex was administered. The times until TOF 0.7, 0.8 and 0.9 were recorded. RESULTS Intubation time was 132.8±46.4 s for smokers and 127.6±32.7 s for non-smokers. After sugammadex administration, the time to TOF 0.7 was 153.3±54.7 s in smokers and 125±67.2 s in non-smokers. The times were 178.4±58.8 and 146.6±72.6 s for TOF 0.8 and 200.8±55.8 s and 170.4±77.8 s for TOF 0.9 in smokers and non-smokers, respectively. CONCLUSION Although not statistically significant, the time to reach each TOF was longer for smokers. Larger populations and different perspectives are needed to find if sugammadex use is affected by smoking, which has negative effects on the body.
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Affiliation(s)
- Ömür Öztürk
- Department of Anaesthesiology and Reanimation, Kafkas University School of Medicine, Kars, Turkey
| | - Gülbin Yalçın Sezen
- Department of Anaesthesiology and Reanimation, Düzce University School of Medicine, Düzce, Turkey
| | - Handan Ankaralı
- Department of Biostatistics, Düzce University School of Medicine, Düzce, Turkey
| | - Onur Özlü
- Department of Anaesthesiology and Reanimation, Düzce University School of Medicine, Düzce, Turkey
| | - Yavuz Demiraran
- Department of Anaesthesiology and Reanimation, Düzce University School of Medicine, Düzce, Turkey
| | - Hakan Ateş
- Department of Anaesthesiology and Reanimation, Düzce University School of Medicine, Düzce, Turkey
| | - Burhan Dost
- Department of Anaesthesiology and Reanimation, Düzce University School of Medicine, Düzce, Turkey
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Carron M, Zarantonello F, Tellaroli P, Ori C. Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials. J Clin Anesth 2016; 35:1-12. [DOI: 10.1016/j.jclinane.2016.06.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 12/17/2022]
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Insinga RP, Joyal C, Goyette A, Galarneau A. A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada. BMC Anesthesiol 2016; 16:114. [PMID: 27852231 PMCID: PMC5112647 DOI: 10.1186/s12871-016-0281-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/08/2016] [Indexed: 12/18/2022] Open
Abstract
Background The objective of this analysis is to explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex (Bridion™, Merck & Co., Inc., Kenilworth, NJ USA) versus neostigmine for neuromuscular block reversal in Canada. Methods A discrete event simulation (DES) model was developed to compare ORs using either neostigmine or sugammadex for NMB reversal over one month. Selected inputs included OR procedure and turnover times, hospital policies for paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use. Trials show sugammadex’s impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four ratio ≥0.9) is verified prior to extubation in the OR. Scenarios were therefore evaluated reflecting varied assumptions for neuromuscular reversal practices. Results With use of moderate neuromuscular block, when full neuromuscular recovery is verified prior to extubation (93 procedures performed with sugammadex, 91 with neostigmine), use of sugammadex versus neostigmine avoided 2.4 procedural cancellations due to OR time over-run and 33.5 h of paid staff overtime, while saving an average of 62 min per OR day. No difference was observed between comparators for these endpoints in the scenario when full neuromuscular recovery was not verified prior to extubation, however, per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 51 cases prevented), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (23 cases avoided). Sugammadex impact in reversing deep neuromuscular block was evaluated in an exploratory analysis. When it was hypothetically assumed that 30 min of OR time were saved per procedure, the number of paid hours of staff over-time dropped from 84.1 to 32.0, with a 93% reduction in the per patient risk of residual blockade. Conclusions In clinical practice within Canada, for the majority of patients currently managed with moderate neuromuscular block, the principal impact of substituting sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications. For patients maintained at a deep level of block to the end of the procedure, sugammadex is likely to both enhance OR efficiency and reduce residual block complications. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0281-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ralph P Insinga
- Department of Predictive & Economic Modeling, Merck & Co., Inc, PO Box 1000, UG1CD-32, North Wales, PA, 19454-1099, USA.
| | - Cédric Joyal
- Department of Health Economics and Observational Research, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
| | - Alexandra Goyette
- Department of Health Economics and Observational Research, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
| | - André Galarneau
- Department of Medical Affairs, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. The July 2016 monograph topics are pimavanserin, venetoclax, defibrotide, lifitegrast ophthalmic solution 5%, and atezolizumab. The Safety MUE is on pimavanserin.
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Won YJ, Lim BG, Lee DK, Kim H, Kong MH, Lee IO. Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4678. [PMID: 27559972 PMCID: PMC5400339 DOI: 10.1097/md.0000000000004678] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Previous studies have shown that sugammadex, a modified γ-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. The aim of this meta-analysis was to evaluate the efficacy and safety of sugammadex in the reversal of rocuronium-induced NMB during surgery under general anesthesia in pediatric patients. METHODS A literature search was performed using the Pubmed, EMBASE: Drugs and pharmacology, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Analysis was conducted using RevMan 5.3. Data collected from different trials were pooled; the weighted mean difference or the pooled risk ratio and the corresponding 95% confidence interval (CI) were used for analysis, and heterogeneity (I) assessment was performed. RESULTS Six randomized controlled trials comparing 253 pediatric patients (age range, 2-18 years) were included in the final analysis. The mean time taken to reach a train-of-four ratio of ≥0.9 was significantly shorter in the sugammadex groups (2 and 4 mg/kg) than in the control group (neostigmine or placebo), although the heterogeneity was high. The weighted mean differences of the 2 and 4 mg/kg sugammadex groups were -7.15 (95% CI: -10.77 to -3.54; I = 96%; P = 0.0001) and -17.32 (95% CI: -29.31 to -5.32; I = 98%; P = 0.005), respectively. The extubation time in the sugammadex group was shorter than that in the control group; the weighted mean difference of the sugammadex group was -6.00 (95% CI: -11.46 to -0.53; I = 99%; P = 0.03). There was no significant difference between the groups in terms of the incidence of postanesthetic adverse events; the pooled risk ratio was 0.67 (95% CI: 0.27-1.71; I = 59%; P = 0.41). CONCLUSION We suggest that sugammadex is fast and effective in reversing rocuronium-induced NMB in pediatric patients. Although there was no evidence of a higher incidence of adverse events with sugammadex compared to that with neostigmine or placebo, much more data regarding the safety of sugammadex in pediatric patients may be still required.
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Affiliation(s)
- Young Ju Won
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Abstract
Although neuromuscular block (NMB) allows immobility for airway management and surgical exposure, termination of its effect is limited by and associated with side effects of acetylcholinesterase inhibitors. Sugammadex is a selective relaxant binding agent that has been shown to reverse deep NMB, even when administered 3 minutes following a 1.2 mg/kg dose of rocuronium. This novel drug is a modified gamma cyclodextrin, that through encapsulation process terminates the effects of rocuronium and vecuronium (aminosteroid muscle relaxants), and enables the anesthesiologists rapidly to reverse profound NMB induced by rocuronium or vecuronium, in a "can't ventilate, can't intubate" crisis. In this review, data from published phase 1, 2, and 3 clinical trials are reviewed and presented. In addition, clinical trials on special patient populations (patients with pulmonary disease and renal insufficiency) are evaluated. Each article reviewed will conclude with a discussion of relevance, focus on adverse event profile, and clinical usefulness.
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Haerter F, Eikermann M. Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion. Expert Opin Pharmacother 2016; 17:819-33. [PMID: 26799963 DOI: 10.1517/14656566.2016.1145667] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Acetylcholinesterase inhibitors (neostigmine, edrophonium) and encapsulating agents (sugammadex and calabadion) can be used to reverse residual neuromuscular blockade (NMB). AREAS COVERED This review provides information about efficacy, effectiveness, and side effects of drugs (acetylcholinesterase inhibitors and encapsulating agents) used to reverse neuromuscular blocking agents (NMBAs). EXPERT OPINION The therapeutic range of acetylcholinesterase-inhibitors is narrow and effectiveness studies demonstrate clinicians don't use these unspecific reversal agents effectively to increase postoperative respiratory safety. The encapsulating drugs sugammadex and calabadion reverse all levels of NMB, and complete recovery of muscle strength can be achieved almost immediately after administration. For this reason encapsulating agents can be used as a solution for "cannot intubate cannot ventilate"- situations. Poor binding selectivity of encapsulating agents carries the risk of displacement of the NMBA by a competitively binding drug, which may lead to recurarization. In order to avoid side-effects, related to unspecific binding of endogenous proteins and drugs administered perioperatively it is prudent to titrate the dose of reversal agents to the minimal effective dose, depending on the depth of neuromuscular transmission block identified by neuromuscular transmission monitoring. Calabadions provide a diversified (increased binding selectivity) and expanded (reversal of benzylisoquinolines) spectrum of possible indications.
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Affiliation(s)
- Friederike Haerter
- a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
| | - Matthias Eikermann
- a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA.,b Department of Anesthesia and Critical Care Medicine , University Hospital Essen, University Duisburg-Essen , Essen , Germany
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Isik Y, Palabiyik O, Cegin BM, Goktas U, Kati I. Effects of Sugammadex and Neostigmine on Renal Biomarkers. Med Sci Monit 2016; 22:803-9. [PMID: 26963316 PMCID: PMC4791087 DOI: 10.12659/msm.897608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Neostigmine, the currently commonly used agent for reversal of neuromuscular blockade. Sugammadex is a novel and unique compound designed as an antagonist of steroidal neuromuscular blockers. In this study, we evaluated the effects of sugammadex or neostigmine on kidney functions in patients scheduled for elective surgery. Material/Methods Patients scheduled for a surgical procedure under desflurane/opioid anesthesia received an intubating dose rocuronium. Patients were divided into 2 groups receiving either sugammadex or neostigmine atropine to reverse neuromuscular blockade. Cystatin C, creatinine, urea, blood urea nitrogen, sodium, potassium, and calcium levels in the blood and α1microglobulin, β2microglobulin, and microalbumin levels in the urine were measured. Results There was no significant difference between the groups with regard to the demographic data. In the Neostigmine Group, although β2microglobulin and microalbumin were similar, a significant increase was found in the postoperative α1microglobulin and cystatin C values. In the Sugammadex Group, although β2-microglobulin and cystatin C were similar, a significant increase was found in the postoperative α1-microglobulin and microalbumin values. The only significant difference was cystatin C value variation in the Neostigmine Group compared to the Sugammadex Group. Conclusions We believe that the use of more specific and sensitive new-generation markers like cystatin C to evaluate kidney function will provide a better understanding and interpretation of our results. Sugammadex has more tolerable effects on kidney function in patients than does neostigmine. However, when compared to preoperative values, there is a negative alteration of postoperative values. Neostigmine and sugammadex do not cause renal failure but they may affect kidney function.
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Affiliation(s)
- Yasemin Isik
- Department of Anesthesiology and Intensive Care, Izmir Katip Celebi University, Faculty of Medicine, Izmir, Turkey
| | - Onur Palabiyik
- Department of Anesthesiology and Intensive Care, Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Bilal Muhammed Cegin
- Department of Anesthesiology and Intensive Care, Yuzuncu Yil University, Faculty of Medicine, Van, Turkey
| | - Ugur Goktas
- Department of Anesthesiology and Intensive Care, Yuzuncu Yil University, Faculty of Medicine, Van, Turkey
| | - Ismail Kati
- Department of Anesthesiology and Intensive Care, Gazi University, Faculty of Medicine, Ankara, Turkey
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Abad-Gurumeta A, Ripollés-Melchor J, Casans-Francés R, Espinosa A, Martínez-Hurtado E, Fernández-Pérez C, Ramírez JM, López-Timoneda F, Calvo-Vecino JM. A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade. Anaesthesia 2016; 70:1441-52. [PMID: 26558858 DOI: 10.1111/anae.13277] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 12/28/2022]
Abstract
We reviewed systematically sugammadex vs neostigmine for reversing neuromuscular blockade. We included 17 randomised controlled trials with 1553 participants. Sugammadex reduced all signs of residual postoperative paralysis, relative risk (95% CI) 0.46 (0.29-0.71), p = 0.0004 and minor respiratory events, relative risk (95% CI) 0.51 (0.32-0.80), p = 0.0034. There was no difference in critical respiratory events, relative risk (95% CI) 0.13 (0.02-1.06), p = 0.06. Sugammadex reduced drug-related side-effects, relative risk (95% CI) 0.72 (0.54-0.95), p = 0.02. There was no difference in the rate of postoperative nausea or the rate of postoperative vomiting, relative risk (95% CI) 0.94 (0.79-1.13), p = 0.53, and 0.87 (0.65-1.17), p = 0.36 respectively.
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Affiliation(s)
- A Abad-Gurumeta
- Department of Anaesthesia, Hospital Universitario la Paz, Madrid, Spain
| | - J Ripollés-Melchor
- Department of Anaesthesia, Complutense University of Madrid, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anaesthesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - A Espinosa
- Department of Anaesthesia, Örebro University Hospital, Örebro, Sweden
| | - E Martínez-Hurtado
- Department of Anaesthesia, Complutense University of Madrid, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - C Fernández-Pérez
- Department of Consultant Preventive Medicine and Public Health, Complutense University of Madrid, Madrid, Spain
| | - J M Ramírez
- Department of Colorectal Surgery, University of Zaragoza, Zaragoza, Spain
| | - F López-Timoneda
- Department of Anaesthesia, Complutense University of Madrid, Hospital Clínico San Carlos, Madrid, Spain
| | - J M Calvo-Vecino
- Department of Anaesthesia, Complutense University of Madrid, Hospital Universitario Infanta Leonor, Madrid, Spain
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Kaufhold N, Schaller S, Stäuble C, Baumüller E, Ulm K, Blobner M, Fink H. Sugammadex and neostigmine dose-finding study for reversal of residual neuromuscular block at a train-of-four ratio of 0.2 (SUNDRO20) † †This report was previously presented, in part, at the Annual Meeting of the International Society for Anaesthetic Pharmacology, San Diego, CA, USA, on October 15, 2010. , # #This Article is accompanied by Editorial Aev448. Br J Anaesth 2016; 116:233-40. [DOI: 10.1093/bja/aev437] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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AMORIM P, LAGARTO F, GOMES B, ESTEVES S, BISMARCK J, RODRIGUES N, NOGUEIRA M. Neostigmine vs. sugammadex: observational cohort study comparing the quality of recovery using the Postoperative Quality Recovery Scale. Acta Anaesthesiol Scand 2014; 58:1101-10. [PMID: 25179550 DOI: 10.1111/aas.12389] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Quality of postoperative recovery is an important outcome after surgery. An observational cohort study was designed to assess the quality of postoperative recovery using the Portuguese version of the Postoperative Quality Recovery Scale (PQRS) in patients treated with neostigmine vs. sugammadex as neuromuscular blocking reversal agents. METHODS A convenience sample of 101 adult patients undergoing elective surgery with general anaesthesia and treated with neostigmine (n=48) or sugammadex (n=53) as neuromuscular blocking reversal agents was included. Patients were evaluated using the Portuguese PQRS version at baseline and postoperatively at 15 (T15) and 40 (T40) min and also at days 1 and 3. Recovery was defined as return to baseline values (or better) at each time points. RESULTS The PQRS overall recovery rates were similar in both groups, but recoveries in the nociceptive (96.2% vs. 81.3%, P=0.02) and physiological (96.2% vs. 70.2%, P=0.001) domains at T40 were higher in the sugammadex group than in the neostigmine group. Also, there was a trend that patients treated with sugammadex reported significantly better global perspective on the impact of surgery on working capacity and daily activities, as well as higher satisfaction with anaesthetic care. CONCLUSIONS This pilot study suggests that sugammadex may improve physiological and nociceptive postoperative recovery as well as patient satisfaction with anaesthetic care. Although we lack an explanation for a possible favourable impact of sugammadex on quality of recovery, our results may provide sufficient preliminary data to justify a randomised trial to explore this possibility.
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Affiliation(s)
- P. AMORIM
- Department of Anesthesiology; Hospital de Santo António; Porto Portugal
| | - F. LAGARTO
- Department of Anesthesiology; Hospital de Santo António; Porto Portugal
| | - B. GOMES
- Department of Anesthesiology; Hospital de Santo António; Porto Portugal
| | - S. ESTEVES
- Department of Anesthesiology; Hospital de Santo António; Porto Portugal
| | - J. BISMARCK
- Department of Anesthesiology; Hospital da Luz; Lisboa Portugal
| | - N. RODRIGUES
- Department of Anesthesiology; Hospital da Luz; Lisboa Portugal
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A miracle that accelerates operating room functionality: sugammadex. BIOMED RESEARCH INTERNATIONAL 2014; 2014:945310. [PMID: 25202709 PMCID: PMC4150404 DOI: 10.1155/2014/945310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 07/23/2014] [Indexed: 12/17/2022]
Abstract
Background. Sugammadex offers a good alternative to the conventional decurarisation process currently performed with cholinesterase inhibitors. Sugammadex, which was developed specifically for the aminosteroid-structured rocuronium and vecuronium neuromuscular blockers, is a modified cyclodextrin made up of 8 glucose monomers arranged in a cylindrical shape. Methods. In this study, the goal was to investigate the efficacy of sugammadex. Sugammadex was used when there was insufficient decurarisation following neostigmine. This study was performed on 14 patients who experienced insufficient decurarisation (TOF <0.9) with neostigmine after general anaesthesia in the operating rooms of a university and a state hospital between June, 2012, and January, 2014. A dose of 2 mg/kg of sugammadex was administered. Results. Time elapsed until sugammadex administration following neostigmine 37 ± 6 min, following sugammadex it took 2.1 ± 0.9 min to reach TOF ≥0.9, and the extubation time was 3.2 ± 1.4 min. No statistically significant differences were detected in the hemodynamic parameters before and after sugammadex application. From the time of administration of sugammadex to the second postoperative hour, no side effects or complications occurred. None of the patients experienced acute respiratory failure or residual block during this time period. Conclusion. Sugammadex was successfully used to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient.
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Efficacy of Sugammadex for the Reversal of Moderate and Deep Rocuronium-induced Neuromuscular Block in Patients Pretreated with Intravenous Magnesium. Anesthesiology 2014; 121:59-67. [DOI: 10.1097/aln.0000000000000204] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Background:
Magnesium enhances the effect of rocuronium. Sugammadex reverses rocuronium-induced neuromuscular block. The authors investigated whether magnesium decreased the efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular block.
Methods:
Thirty-two male patients were randomized in a double-blinded manner to receive magnesium sulfate (MgSO4) 60 mg/kg or placebo intravenously before induction of anesthesia with propofol, sufentanil, and rocuronium 0.6 mg/kg. Neuromuscular transmission was monitored using TOF-Watch SX® acceleromyography (Organon Ltd., Dublin, Ireland). In 16 patients, sugammadex 2 mg/kg was administered intravenously at reappearance of the second twitch of the train-of-four (moderate block). In 16 further patients, sugammadex 4 mg/kg was administered intravenously at posttetanic count 1 to 2 (deep block). Primary endpoint was recovery time from injection of sugammadex to normalized train-of-four ratio 0.9. Secondary endpoint was recovery time to final T1.
Results:
Average time for reversal of moderate block was 1.69 min (SD, 0.81) in patients pretreated with MgSO4 and 1.76 min (1.13) in those pretreated with placebo (P = 0.897). Average time for reversal of deep block was 1.77 min (0.83) in patients pretreated with MgSO4 and 1.98 min (0.58) in those pretreated with placebo (P = 0.572). Times to final T1 were longer compared with times to normalized train-of-four ratio 0.9, without any difference between patients pretreated with MgSO4 or placebo.
Conclusion:
Pretreatment with a single intravenous dose of MgSO4 60 mg/kg does not decrease the efficacy of recommended doses of sugammadex for the reversal of a moderate and deep neuromuscular block induced by an intubation dose of rocuronium.
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Fujita A, Ishibe N, Yoshihara T, Ohashi J, Makino H, Ikeda M, Setoguchi H. Rapid reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. ACTA ACUST UNITED AC 2014; 52:54-8. [PMID: 25016508 DOI: 10.1016/j.aat.2014.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 03/14/2014] [Accepted: 03/19/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Sugammadex rapidly reverses neuromuscular blockade (NMB) induced by rocuronium. NMB induced by rocuronium is prolonged in patients with liver dysfunction, because the drug is mainly excreted into the bile. However, the efficacy and safety of sugammadex in terms of reversing rocuronium-induced NMB in patients with liver dysfunction undergoing hepatic surgery have not been evaluated. This observational study investigated the efficacy and safety of sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. METHODS Remifentanil/propofol anesthesia was administered to 31 patients: 15 patients in the control group, and 16 patients from a group with liver dysfunction. Rocuronium (0.6 mg/kg) was administered, followed by continuous infusion. The enrolled patients were then subdivided into two groups according to the dose of sugammadex. In the first group a single dose of sugammadex (2.0 mg/kg) was given at the reappearance of the second twitch (T2). In the second group a single dose of sugammadex (4.0 mg/kg) was given at the first twitch response if T2 did not reappear in 15 minutes after stopping rocuronium. The primary outcome was time from administration of sugammadex to recovery of a train-of-four ratio to 0.9. RESULTS The dose of rocuronium required in the liver dysfunction group was lower than that in the control group (6.2 vs. 8.2 μg/kg/min, p = 0.002). The mean time from the administration of sugammadex to recovery of the train-of-four ratio to 0.9 was not significantly different between the liver dysfunction group and the control group (2.2 minutes vs. 2.0 minutes in the 2 mg/kg administration group, p = 0.44 and 1.9 minutes vs. 1.7 minutes in the 4 mg/kg administration group, p = 0.70, respectively). No evidence of recurarization was observed in any of the patients. Most of the adverse events were found to be mild and such events were not related to the use of sugammadex. None of the patients was eliminated from the study because of an adverse event. One patient died due to cholestatic liver cirrhosis because of repeated hepatic surgery. CONCLUSION Sugammadex can rapidly reverse NMB after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. Sugammadex was found to be safe and well tolerated. However, further studies of sugammadex under similar conditions should be conducted involving a large number of patients with liver dysfunction undergoing hepatic surgery.
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Affiliation(s)
- Ai Fujita
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Natsuki Ishibe
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tatsuya Yoshihara
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Ohashi
- Doctoral Program in Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | | | - Mizuko Ikeda
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
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POMPEI L, DELLA ROCCA G. Is TOF normalization suitable on daily clinical practice? Acta Anaesthesiol Scand 2014; 58:497-9. [DOI: 10.1111/aas.12288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lobaz S, Clymer M, Sammut M. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. ACTA ACUST UNITED AC 2014. [DOI: 10.4137/cmt.s10241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.
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Affiliation(s)
- Steven Lobaz
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mark Clymer
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mario Sammut
- Department of Anaesthetics and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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