Use of Sugammadex in "Cannot Intubate, Cannot Ventilate" Scenarios: A Systematic Review of Case Reports

After an induction dose of rocuronium, sugammadex in a dose of 16 mg.kg -1 has been shown to provide early reversal of the neuromuscular blockade. However, the use of sugammadex to rescue a "cannot intubate, cannot ventilate" (CICV) scenario remains controversial. The aim of this systematic review was to discuss case reports describing the use of sugammadex as a rescue reversal in CICV scenarios and analyze the influencing factors potentially shaping the outcome of such reversal. The study has been registered on International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024514255). We conducted a systematic review of the literature using PubMed, Medline, and Embase. Records were included if they were case reports or case series published in peer-reviewed journals, describing the administration of sugammadex as a rescue reversal in CICV scenarios, and including clinical outcomes and details of the management. Sources were last searched on November 30, 2023. The articles selected were initially screened based on their titles and abstracts, and then complete articles were examined to determine their eligibility and compliance with the inclusion criteria. Two independent authors evaluated the quality of the individual studies using the Joanna Briggs Institute Critical Appraisal Checklist for Case Reports. Eight articles were included in our review. In all patients, CICV scenarios were declared minutes following induction. In 6/8 cases (75%), adequate spontaneous ventilation was restored after the administration of sugammadex. In the remaining 2 cases, sugammadex administration resulted in an obstructed pattern of breathing, and surgical airway was the successful rescue technique. There was wide variability in the sugammadex dose with a median (range) of 14 (5-16) mg.kg -1 and median timing (range) from rocuronium administration of 6 (2-10) minutes. This case-report-based review is susceptible to reporting bias and may not encompass all pertinent data and adverse events. Also, cases with both favorable and unfavorable outcomes may have not been published, and the heterogeneity of cases limits the ability to draw definitive conclusions. In summary, although these case reports suggest that sugammadex might be helpful in CICV scenarios, further research is needed to confirm its effectiveness. However, due to the rare occurrence of CICV events, gathering sufficient data for conclusive evidence may be challenging.

Sugammadex Safely Reduces Total Intubation Time in the Intensive Care Unit Following Coronary Artery Bypass Grafting (CABG) at a Real-World Community Hospital

Background/Objectives: Early extubation is crucial for enhancing recovery from coronary artery bypass grafting (CABG). Residual neuromuscular blockade (NMB) effects can hinder early extubation, potentially leading to reintubation, lung infection, and prolonged post-anesthesia stay. Sugammadex, a modified gamma-cyclodextrin, reverses the non-depolarizing NMB effects of the steroidal muscle relaxants rocuronium and vecuronium. The American Society of Anesthesiologists recommends sugammadex administration when patients display a train-of-four (TOF) ratio of less than 0.9. Previous studies show that sugammadex decreases extubation times, reduces postoperative complications, and enhances patient comfort. Methods: This single-center, retrospective cohort study evaluated the efficacy of sugammadex in achieving extubation within six hours of intensive care unit (ICU) arrival post-CABG, defined as fast-track extubation (FTE). Results: Here, we report that although the total time of intubation in the ICU following CABG did not drop to the six-hour benchmark, it was substantially reduced by the administration of sugammadex in accordance with an FTE protocol. Furthermore, the risks of adverse events (e.g., anaphylaxis, heart failure) and postoperative complications (e.g., acidemia, hypoxemia, tachypnea) were unaltered. Conclusions: The use of sugammadex could, thus, reduce costs associated with prolonged intubation time and related complications without increasing morbidity or mortality.

Sugammadex in Emergency Situations

Sugammadex may be required or used in multiple emergency situations. Moderate and high doses of this compound can be used inside and outside the operating room setting. In this communication, recent developments in the use of sugammadex for the immediate reversal of rocuronium-induced neuromuscular blockade were assessed. In emergency surgery and other clinical situations necessitating rapid sequence intubation, the tendency to use rocuronium followed by sugammadex instead of succinylcholine has been increasing. In other emergency situations such as anaphylactic shock caused by rocuronium or if intubation or ventilation is not possible, priority should be given to resuming ventilation maintaining hemodynamic stability, in accordance with the traditional guidelines. If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion.

Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery

BACKGROUND

Postoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery.

METHODS

Three hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed.

RESULTS

Two hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19-90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18-94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0-10) vs. 3 (0-12) days, p = 0.036), and reduced time to first stool (median 2 (0-10) vs. 3 (0-12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2.

CONCLUSIONS

Patients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

Potential Neuroprotective Role of Sugammadex: A Clinical Study on Cognitive Function Assessment in an Enhanced Recovery After Cardiac Surgery Approach and an Experimental Study

Background

Postoperative cognitive dysfunction affects the quality of recovery, particularly affecting the elderly, and poses a burden on the health system. We hypothesize that the use of sugammadex (SG) could optimize the quality of postoperative cognitive function and overall recovery through a neuroprotective effect.

Methods

A pilot observational study on patients undergoing cardiac surgery with enhanced recovery after cardiac surgery (ERACS) approach, was designed to compare SG-treated (n = 14) vs. neostigmine (NG)-treated (n = 7) patients. The Postoperative Quality Recovery Scale (PQRS) was used at different times to evaluate cognitive function and overall recovery of the patients. An online survey among anesthesiologists on SG use was also performed. Additionally, an animal model study was designed to explore the effects of SG on the hippocampus.

Results

Sugammadex (SG) was associated with favorable postoperative recovery in cognitive domains particularly 30 days after surgery in patients undergoing aortic valve replacement by cardiopulmonary bypass and the ERACS approach; however, it failed to demonstrate a short-term decrease in length of intensive care unit (ICU) and hospital stay. The survey information indicated a positive appreciation of SG recovery properties. SG reverts postoperative memory deficit and induces the expression of anti-inflammatory microglial markers.

Conclusion

The results show a postoperative cognitive improvement by SG treatment in patients undergoing aortic valve replacement procedure by the ERACS approach. Additionally, experimental data from an animal model of mild surgery confirm the cognitive effect of SG and suggest a potential effect over glia cells as an underlying mechanism.

The use of sugammadex in critical events in anaesthesia: A retrospective review of the webAIRS database

Sugammadex has been used for more than ten years in Australia and New Zealand and has been implicated as an effective treatment, and in some cases a potential cause, of a critical incident. We aimed to identify and analyse critical incidents involving sugammadex reported to webAIRS, a de-identified voluntary online critical incident reporting system in Australia and New Zealand. We identified 116 incidents where the reporter implicated sugammadex as either a cause (23 cases) or a treatment (93 cases) during anaesthesia. There were 17 incidents suggestive of sugammadex anaphylaxis, although not all were confirmed by skin testing. There were six incidents when bradycardia was temporally related to sugammadex administration, although it was not possible to exclude other causes or contributory factors. There were nine incidents in which sugammadex was used to reverse aminosteroid-related neuromuscular blockade successfully in a 'can't intubate, can't oxygenate' (CICO) situation, and a further 67 incidents in which sugammadex was used to reverse aminosteroid neuromuscular blockade as part of the management of other critical incidents. While sugammadex was used during the management of 16 cases of anaphylaxis, there was no clear indication that this altered the course of the anaphylaxis in any of the cases. These reports indicate that sugammadex can be a potential trigger for anaphylaxis and that its use may be associated with the development of significant bradycardia. However, it is not possible to estimate or even speculate on the incidence of these sugammadex-related incidents on the basis of voluntary reporting to a database such as webAIRS. The reports also indicate that sugammadex has been used successfully to reverse residual or deep aminosteroid neuromuscular blockade in critical incident situations and to help rescue CICO scenarios. These findings provide further support for ensuring the ready availability of sugammadex wherever aminosteroid muscle relaxants are used.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.

Cheaper drugs and techniques to fulfill chief executive officer perspectives - any choices?

PURPOSE OF REVIEW

Against the background of increasing healthcare costs and diminishing budgets, this review aims to present clinicians with ethically viable options to overcome budgetary restraints when seeking to introduce novel products.

RECENT FINDINGS

Healthcare administrators and primary healthcare providers are not unlikely to have different opinions when discussing the introduction of novel products. However, rather than taking a 'no' for an answer, doctors may be able to argue for a change - even if this may seem to come at a higher cost. The recent introduction of the reversal agent sugammadex may provide a timely example for the possibility of success 'against all financial odds'.

SUMMARY

Health professionals have the responsibility to deliver high-quality care while acknowledging the financial budget constraints. However, evidence (vs. perception) for outcome benefits of novel drugs or devices should stimulate a robust desire for their timely introduction. Demonstrating actual benefits understandable to administrators, seeking alliances with other medical specialties or patient groups, as well as negotiations with the healthcare industry may all represent viable options. Simply waiting for patents to expire should remain a measure of last resort.