1
|
Hunter JM, Blobner M. Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents: beware of the risks. Br J Anaesth 2024; 132:461-465. [PMID: 38135525 DOI: 10.1016/j.bja.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
The phenomena of residual curarisation and recurarisation after the use of long-acting non-depolarising neuromuscular blocking drugs such as tubocurarine and pancuronium were well recognised 60 years ago. But the incidence seemed to decline with the introduction of atracurium and vecuronium. However, recently there have been an increasing number of reports of residual and recurrent neuromuscular block. Some of these reports are a result of inappropriate doses of rocuronium, sugammadex or both, together with inadequate neuromuscular monitoring. We urge clinicians to review their practice to ensure the highest standards of clinical care when using neuromuscular blocking drugs and reversal agents. This includes the use of quantitative neuromuscular monitoring whenever neuromuscular blocking drugs are administered.
Collapse
Affiliation(s)
- Jennifer M Hunter
- Department of Musculoskeletal and Ageing Science, University of Liverpool, Liverpool, UK.
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| |
Collapse
|
2
|
Subramani Y, Rajarathinam M, Dabirzadeh A, Tawfic Q, Krause S, Avci Y, Nagappa M. Comparison of Different Weight Scalars to Dose Sugammadex for the Reversal of Neuromuscular Blockade in Morbidly Obese Patients: A Systematic Review. Cureus 2024; 16:e57057. [PMID: 38681306 PMCID: PMC11051669 DOI: 10.7759/cureus.57057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
This systematic review was conducted to evaluate the optimal weight scalar to dose sugammadex in a morbidly obese (MO) patient population (BMI≥40 kg/m2). The primary outcome was recovery time from moderate neuromuscular blockade (NMB) or deep NMB. Secondary outcomes included time to extubation and incidence of postoperative residual curarization (PORC). Eight randomized controlled trials (RCTs) involving 645 participants were included. The different dose scalars included were total body weight (TBW), ideal body weight (IBW), 20% corrected body weight (CBW) and 40% CBW). A dose of 2 mg/kg of sugammadex based on 40% CBW and a 4 mg/kg dose of sugammadex based on 40% CBW provide a reliable and timely reversal of moderate and deep NMB respectively in the MO patients.
Collapse
Affiliation(s)
- Yamini Subramani
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, Canada
| | - Manikandan Rajarathinam
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Anita Dabirzadeh
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Qutaiba Tawfic
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Sarah Krause
- Medical Sciences, Western University, London, CAN
| | - Yasin Avci
- Interdisciplinary Arts and Science, Western University, London, CAN
| | - Mahesh Nagappa
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| |
Collapse
|
3
|
Olesnicky BL, Farrell C, Clare P, Wen S, Leslie K, Delaney A. The effect of sugammadex on patient morbidity and quality of recovery after general anaesthesia: a systematic review and meta-analysis. Br J Anaesth 2024; 132:107-115. [PMID: 38036323 DOI: 10.1016/j.bja.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Residual neuromuscular block is associated with increased patient morbidity. Therefore prevention of residual neuromuscular block is an important component of general anaesthesia where neuromuscular blocking agents are used. Whereas sugammadex improves reversal based on neuromuscular twitch monitoring parameters, there have been no prospective, adequately powered definitive studies demonstrating that sugammadex is also associated with less patient morbidity. METHODS We performed a systematic review of randomised trials comparing sugammadex with anticholinesterase-based reversal or placebo reversal that reported important patient outcomes beyond the postanaesthesia care unit. RESULTS We identified 43 articles, including 5839 trial participants. Only one trial reported days alive and out of hospital to 30 days (DAOH-30), which showed that the number of DAOH-30 was similar in those allocated to sugammadex compared with neostigmine-based reversal (25 days [19-27] vs 24 days [21-27], median difference 0.00 [-2.15 to 2.15]). Pooled analyses of data from 16 trials showed an estimated odds ratio (OR) for postoperative pulmonary complications of 0.67 (95% confidence interval 0.47-0.95) with sugammadex use. Pooled analysis showed that pneumonia (eight trials OR 0.51 [0.24-1.01] with sugammadex use), hospital length of stay (23 trials, mean difference -0.31 [-0.84 to 0.22] with sugammadex use), and patient-reported quality of recovery (11 trials, varied depending on metric used) are similar in those allocated to sugammadex vs control. The difference seen in mortality (11 trials, OR 0.39 [0.15-1.01] with sugammadex use) would be considered to be clinically significant and warrants further investigation, however, the rarity of these events precludes drawing definitive conclusions. CONCLUSION Although few trials reported on DAOH-30 or important patient outcomes, sugammadex is associated with a reduction in postoperative pulmonary complications, however, this might not translate to a difference in hospital length of stay, patient-reported quality of recovery, or mortality. CLINICAL TRIAL REGISTRATION PROSPERO database (CRD42022325858).
Collapse
Affiliation(s)
- Benjamin L Olesnicky
- Department of Anaesthesia, Pain and Perioperative Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Northern Clinical School of Medicine, The University of Sydney, Sydney, NSW, Australia; Northern Sydney Anaesthetic Research Institute, Sydney, NSW, Australia.
| | - Clare Farrell
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Phoebe Clare
- Department of Anaesthesia, Pain and Perioperative Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Northern Sydney Anaesthetic Research Institute, Sydney, NSW, Australia
| | - Shelly Wen
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Anthony Delaney
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
| |
Collapse
|
4
|
Katerenchuk V, Calçada A, Louzada R, Rosinha D, Batista AC, Capelão A, Cordeiro L. Cardiac Arrest in the Post-anesthesia Care Unit (PACU): Postoperative Recurrence of Neuromuscular Block After Sugammadex Reversal. Cureus 2024; 16:e52681. [PMID: 38380199 PMCID: PMC10878829 DOI: 10.7759/cureus.52681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Sugammadex has transformed clinical practice by enabling the rapid reversal of rocuronium-induced neuromuscular block (NMB) at any depth. We present a case of cardiac arrest following postoperative recurarization despite the sugammadex-induced transient reversal of NMB. Despite its proven clinical reliability, this case highlights the often overlooked aspects that must be considered when using this drug. An 84-year-old male patient was scheduled for a laparoscopic partial gastrectomy for gastric cancer. At the end of the procedure, reversal of NMB was evidenced by an acceleromyographic train-of-four (TOF) ratio of ≥0.9 following sugammadex administration. In the post-anesthesia care unit (PACU), pulseless electrical activity was perceived, with a regression of TOF count to 1. After providing successful advanced cardiac life support, additional sugammadex administration led to uneventful extubation. When the concentration of free rocuronium decreases in the central compartment following sugammadex administration, redistribution of rocuronium from the peripheral to the central and effect-site compartments may cause recurarization. Special care is required in cases involving obese and elderly patients as well as those with renal impairment or hypothermia. To provide effective and predictable reversal of NMB, proper use of sugammadex should be pursued, including adequate dosing and monitoring.
Collapse
Affiliation(s)
| | | | - Raquel Louzada
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Daniela Rosinha
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Ana C Batista
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Andreia Capelão
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Lisbete Cordeiro
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| |
Collapse
|
5
|
Jansson PS, Pimentel MPT, Seethala RR. Emergency department usage of sugammadex in a large regional health system. Acad Emerg Med 2023. [PMID: 38112045 DOI: 10.1111/acem.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Paul S Jansson
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc P T Pimentel
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Dubois BFH, Fraessdorf J, Blobner M, Hollmann MW, Mouws EMJP. Muscle weakness after sugammadex: incomplete reversal of neuromuscular blockade or delayed postoperative recurarisation? Br J Anaesth 2023; 130:e409-e412. [PMID: 36586807 DOI: 10.1016/j.bja.2022.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/25/2022] [Accepted: 11/26/2022] [Indexed: 12/30/2022] Open
Affiliation(s)
- Bente F H Dubois
- Department of Anaesthesiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jan Fraessdorf
- Department of Anaesthesiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, Amsterdam, the Netherlands.
| | | |
Collapse
|
7
|
Motamed C. Sugammadex in Emergency Situations. J Pers Med 2023; 13:jpm13010159. [PMID: 36675820 PMCID: PMC9867288 DOI: 10.3390/jpm13010159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Cyrus Motamed
- Departement of Anesthesia, Gustave Roussy Cancer Campus, 94080 Villejuif, France
| |
Collapse
|
8
|
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: 61] [Impact Index Per Article: 61.0] [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.
Collapse
|
9
|
Liao JQ, Shih D, Lin TY, Lee M, Lu CW. Appropriate dosing of sugammadex for reversal of rocuronium-/vecuronium-induced muscle relaxation in morbidly obese patients: a meta-analysis of randomized controlled trials. J Int Med Res 2022; 50:3000605221116760. [PMID: 35983671 PMCID: PMC9393676 DOI: 10.1177/03000605221116760] [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] [Indexed: 12/04/2022] Open
Abstract
Objective To conduct a meta-analysis to compare different dosing scalars of sugammadex
in a morbidly obese population for reversal of neuromuscular blockade
(NMB). Methods PubMed®, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials
(CENTRAL) and Google Scholar were searched for relevant randomized
controlled trials (RCTs) comparing lower-dose sugammadex using ideal body
weight (IBW) or corrected body weight (CBW) as dosing scalars with
standard-dose sugammadex based on total body weight (TBW) among morbidly
obese people after NMB. Mean difference with SD was used to estimate the
results. Results The analysis included five RCT with a total of 444 morbidly obese patients.
The reversal time was significantly longer in patients receiving sugammadex
with dosing scalar based on IBW than in patients receiving sugammadex with
dosing scalar based on TBW (mean difference 55.77 s, 95% confidence interval
[CI] 32.01, 79.53 s), but it was not significantly different between
patients receiving sugammadex with dosing scalars based on CBW versus TBW
(mean difference 2.28 s, 95% CI –10.34, 14.89 s). Conclusion Compared with standard-dose sugammadex based on TBW, lower-dose sugammadex
based on IBW had 56 s longer reversal time whereas lower-dose sugammadex
based on CBW had a comparable reversal time.
Collapse
Affiliation(s)
- Jian-Qiang Liao
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City
| | - Darrell Shih
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City
| | - Tzu-Yu Lin
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City.,Department of Mechanical Engineering, Yuan Ze University, Taoyuan City
| | - Meng Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Puzi City
| | - Cheng-Wei Lu
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City.,Department of Mechanical Engineering, Yuan Ze University, Taoyuan City
| |
Collapse
|
10
|
Zhou Y, Zhang Y, Hu T, Li X, Fu Q. Anesthesia management of morbid obesity and ankylosing spondylitis with a difficult airway: a case report. Am J Transl Res 2022; 14:4860-4863. [PMID: 35958470 PMCID: PMC9360860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The anesthesia management in morbidly obese patients is challenging, because there may also be a number of complications in addition to predictable difficulties associated with airway and ventilation management. Potential complications require careful preoperative evaluation and intraoperative management to ensure rapid recovery and minimize adverse effects from anesthesia. CASE PRESENTATION This study involved a 39-year-old male patient who had ankylosing spondylitis complicated with morbid obesity (body mass index =48.8). He had severely limited head and neck mobility, severe obstructive sleep apnea syndrome as well as a high STOP-BANG score and Mallampati class IV. After administering local airway anesthesia, awake tracheal intubation was conducted under the guidance of fiberoptic bronchoscopy. Total intravenous anesthesia was adopted intraoperatively, and awake extubation was performed 5 minutes after the completion of the operation. The patient experienced no nausea or vomiting, and the pain score assessed by the Visual Analogue Scale was only 1-2 points. He did not suffer from painful memories relating to anesthesia. CONCLUSIONS We report a case of concurrent ankylosing spondylitis and morbid obesity associated with a difficult airway successfully treated with total intravenous anesthesia and awake intubation. This approach can be referred in patients with similar conditions.
Collapse
Affiliation(s)
- Ying Zhou
- Department of Anesthesiology, Third People's Hospital of Chengdu (Affiliated Hospital of Southwest Jiaotong University) Chengdu 610000, Sichuan, P. R. China
| | - Yu Zhang
- Department of Anesthesiology, Third People's Hospital of Chengdu (Affiliated Hospital of Southwest Jiaotong University) Chengdu 610000, Sichuan, P. R. China
| | - Tao Hu
- Department of Anesthesiology, Third People's Hospital of Chengdu (Affiliated Hospital of Southwest Jiaotong University) Chengdu 610000, Sichuan, P. R. China
| | - Xuan Li
- Department of Anesthesiology, Third People's Hospital of Chengdu (Affiliated Hospital of Southwest Jiaotong University) Chengdu 610000, Sichuan, P. R. China
| | - Qiang Fu
- Department of Anesthesiology, Third People's Hospital of Chengdu (Affiliated Hospital of Southwest Jiaotong University) Chengdu 610000, Sichuan, P. R. China
| |
Collapse
|
11
|
Blobner M, Hollmann MW, Luedi MM, Johnson KB. Pro-Con Debate: Do We Need Quantitative Neuromuscular Monitoring in the Era of Sugammadex? Anesth Analg 2022; 135:39-48. [PMID: 35709443 DOI: 10.1213/ane.0000000000005925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this Pro-Con article, we debate the merits of using quantitative neuromuscular blockade monitoring. Consensus guidelines recommend their use to guide the administration of nondepolarizing neuromuscular blockade and reversal agents. A major impediment to this guideline is that until recently, reliable quantitative neuromuscular blockade monitors have not been widely available. Without them, anesthesia providers have been trained with and are adept at using a variety of qualitative neuromuscular blockade monitors otherwise known as peripheral nerve stimulators. Although perhaps less accurate, anesthesia providers find them reliable and easy to use. They have a long track record of using them with the perception that their use leads to effective neuromuscular blockade reversal and minimizes clinically significant adverse events from residual neuromuscular blockade. In the recent past, 2 disruptive developments have called upon anesthesia care providers to reconsider their practice in neuromuscular blockade administration, reversal, and monitoring. These include: (1) commercialization of more reliable quantitative neuromuscular monitors and (2) widespread use of sugammadex, a versatile reversal agent of neuromuscular blockade. Sugammadex appears to be so effective at rapidly and effectively reversing even the deepest of neuromuscular blockades, and it has left anesthesia providers wondering whether quantitative monitoring is indeed necessary or whether conventional, familiar, and less expensive qualitative monitoring will suffice? This Pro-Con debate will contrast anesthesia provider perceptions with evidence surrounding the use of quantitative neuromuscular blockade monitors to explore whether quantitative neuromuscular monitoring (NMM) is just another technology solution looking for a problem or a significant advance in NMM that will improve patient safety and outcomes.
Collapse
Affiliation(s)
- Manfred Blobner
- From the Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ken B Johnson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| |
Collapse
|
12
|
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 .
Collapse
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
| |
Collapse
|