Actions and Interactions of Mirror-Image Cyclodextrins

Cyclodextrins (CDs) were the first identified molecules and arguably the most consequential molecules in the areas of macrocyclic science and technology. As carbohydrates, their intrinsic architecture and chirality have played a fundamental role in their response to and effect on guest molecules. Indeed, the nature of inclusion complexation was formalized with CD-based hosts. A recent report on the first synthesis of unnatural mirror-image l-cyclodextrins foreshadows a new era of stereochemical research involving macrocyclic entities. Here, we show the inherently difficult, but rapid and sensitive, separation of enantiomeric CDs. The absolute configurations of CD antipodes have been investigated and distinguished by vibrational circular dichroism (VCD). Results indicated that the most intense VCD band at 1150 cm-1 arises from the C-O stretching of the glucosidic bonds lining the CD torus. It follows that chiroptical radiation can excite either d- or l-CD selectively. The enzymatic susceptibilities of mirror-image CDs are vastly different, suggesting the possibility of different biochemical and medicinal uses. The electrophoretic migration of small chiral molecules, e.g., amino acids is easily and predictably reversed with d- and l-CDs.

The Use of Premedication for Intubating Very Low Birth Weight Infants in the Neonatal Intensive Care Unit: Results of a National Survey

OBJECTIVE

 This study aimed to explore barriers and perspectives of premedication use for non-emergent intubations of very low birth weight (VLBW) infants (<1,500 g).

STUDY DESIGN

 A cross-sectional, online survey was distributed from January to April 2023 to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Data was analyzed using descriptive statistics and chi-square tests.

RESULTS

 Of the 521 respondents, the majority (81%, n = 415) were neonatologists. Over half of respondents (69%, n = 359) consider patient weight when selecting premedication. Most providers (78%, n = 407) agreed that premedication should be used for non-emergent intubation of VLBW infants, while only 41% (n = 216) felt similarly that muscle relaxants should be used. For infants over 1,500 g, 43% (n = 153) reported frequent or regular muscle relaxant use compared with 28% (n = 101) for VLBW infants. The most cited barrier to muscle relaxant use was surfactant delivery with a planned return to non-invasive support. Unit guidelines were associated with significantly more premedication and muscle relaxant use (56 vs. 44%; odds ratio [OR] = 5.2, 95% confidence interval [CI]: 3.4-7.7, p < 0.0001).

CONCLUSION

 Most neonatal providers favor premedication for non-emergent intubation but are hesitant to use muscle relaxants for VLBW infants. Premedication guidelines may facilitate the use of both premedication and muscle relaxants for this population.

KEY POINTS

· Study of intubation premedication perceptions and practices for VLBW infants.. · Premedication is used less for intubation of VLBW infants compared to their larger peers.. · Unit premedication guidelines and available intubation backup may facilitate premedication use..

Comparison of the Effects of Sugammadex Recommended Dose (2 mg/kg) and Fixed Dose of 200 mg on the Reversal of Moderate Neuromuscular Block and Recovery Profile in Adult Patients

Background and Objectives: Neuromuscular blocking agents are essential to ensure optimal surgical conditions during general anesthesia. Sugammadex, a selective binding agent, is widely used to reverse neuromuscular blockade. While weight-based dosing (2 mg/kg for moderate blockade) is recommended, many clinicians administer a fixed dose of 200 mg in clinical practice, potentially leading to overdosing. This study aimed to compare the efficacy and recovery profiles of weight-based and fixed-dose sugammadex in patients undergoing general anesthesia. Materials and Methods: In this randomized controlled trial, 20 patients were divided into two groups: the recommended dose group (R group, 2 mg/kg) and the fixed dose group (F group, 200 mg). Primary outcomes included time to achieve a normalized train-of-four (TOF) ratio of 0.9. Secondary outcomes included recovery time, time to spontaneous respiration, response to verbal commands and extubation, and adverse events. Results: The median time to achieve a normalized TOF ratio of 0.9 was 2.3 min in the R group and 2.0 min in the F group (p = 0.529). Secondary outcomes, including recovery time and time to extubation showed no significant differences. Adverse events were minimal and comparable between groups. Conclusions: The fixed-dose sugammadex (200 mg) demonstrated similar efficacy and safety to weight-based dosing (2 mg/kg) in reversing moderate neuromuscular blockade. These findings do not allow abandoning the recommendation of adjustment for body weight, particularly in patients with low body weight or comorbidities.

Dynamic and Assembly Characteristics of Deep-Cavity Basket Acting as a Host for Inclusion Complexation of Mitoxantrone in Biotic and Abiotic Systems

We describe the preparation, dynamic, assembly characteristics of vase-shaped basket 13- along with its ability to form an inclusion complex with anticancer drug mitoxantrone in abiotic and biotic systems. This novel cavitand has a deep nonpolar pocket consisting of three naphthalimide sides fused to a bicyclic platform at the bottom while carrying polar glycines at the top. The results of 1 H Nuclear Magnetic Resonance (NMR), 1 H NMR Chemical Exchange Saturation Transfer (CEST), Calorimetry, Hybrid Replica Exchange Molecular Dynamics (REMD), and Microcrystal Electron Diffraction (MicroED) measurements are in line with 1 forming dimer [12 ]6- , to be in equilibrium with monomers 1(R) 3- (relaxed) and 1(S) 3- (squeezed). Through simultaneous line-shape analysis of 1 H NMR data, kinetic and thermodynamic parameters characterizing these equilibria were quantified. Basket 1(R) 3- includes anticancer drug mitoxantrone (MTO2+ ) in its pocket to give stable binary complex [MTO⊂1]- (Kd =2.1 μM) that can be precipitated in vitro with UV light or pH as stimuli. Both in vitro and in vivo studies showed that the basket is nontoxic, while at a higher proportion with respect to MTO it reduced its cytotoxicity in vitro. With well-characterized internal dynamics and dimerization, the ability to include mitoxantrone, and biocompatibility, the stage is set to develop sequestering agents from deep-cavity baskets.

Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication

Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.

The influence of different sugammadex doses on neural tube development in early-stage chick embryos

BACKGROUND

Sugammadex is a modified gamma-cyclodextrin that has been developed with the goal of reversing the steroidal neuromuscular blocking agents. The aim of the present study is to investigate the effects of different sugammadex doses on embryologic and neural tube development in an early-stage chick embryo model.

METHODS

A total of 100 specific pathogen-free, fertilized domestic chicken eggs were randomly divided into five groups (n = 20, each), and placed in an automatic cycle incubator. The eggs in the "control (C)" group were incubated without administration of any drug till the end of the experiment. Sub-blastodermic administration of 0.9% NaCl as vehicle control (VC) and different doses of sugammadex solutions prepared with the latter [2 mg/mL (LD), 4 mg/mL (MD), 16 mg/mL (HD)] were performed at 30 hr of incubation. All embryos were removed from the eggs at 72 hr when they were expected to reach Hamburger-Hamilton (HH) stages 19-20, then they were fixed, and evaluated histo-morphologically.

RESULTS

Embryonic development was not observed in 11 eggs (1 in C, 1 in VC; 3 in LD, 3 in MD, and 3 in HD). All the developed embryos were compatible with the HH stages 19-20. A neural tube closure defect was detected in one embryo in the HD group. No statistically significant difference was found between the groups in terms of embryonic and neural tube developments.

CONCLUSIONS

No significant association was found between the drug and adverse outcomes; however, a trend with dosing was seen. Further studies are required before conclude on safety and extrapolate these results to human beings.

Triarylborane-"Click" Fluorescent Tag for Orthogonal Amino Acid Labelling, Interactions with DNA, Protein, and Cyclodextrins

The innovative design of a triarylborane (TB)-dye with one NMe2-alkylated (propargylated) group and one NMe2 group yielded a system that is both an NMe2 π-donor and an inductive NMe2-alkyl cationic acceptor. Consequently, the new TB-dye was highly sensitive to a "click" reaction with an azide-substituted lysine side chain (yielding TB-lysine), resulting in a bathochromic shift of emission of 100 nm. In addition, fluorene attached to the lysine C-terminus showed FRET with the TB-chromophore, also sensitive to interactions with targets. Both the TB-dye and TB-lysine showed high affinities towards both DNA and proteins, reporting binding by an opposite fluorimetric response for DNA/RNA (quenching) vs. BSA (increase). Thus, the novel TB-dye is an ideal fluorimetric probe for orthogonal incorporation into bio-targets by "click" reactions due to fluorescence reporting of the progress of the "click" reaction and further sensing of the binding site composition. The TB-dye is moderately toxic to human cell lines after 2-3 days of exposure, but efficiently enters cells in 90 min, being non-toxic at short exposure. The most important product of the "click" reaction, TB-lysine, was non-toxic to cells and showed equal distribution between mitochondria and lysosomes. Further studies would focus particularly on the very convenient monitoring of the progress of "click" conjugation of the TB-dye with biorelevant targets inside living cells by confocal microscopy.

The electrochemical quantitation method for sugammadex via a molecularly imprinted polymer-based sensor

Sugammadex (SUG) is a synthetically modified γ-cyclodextrin derivative used in hospitals after surgeries to reverse the neuromuscular blockade induced by rocuronium or vecuronium. In this study, we aimed to develop the first electroanalytical quantification method for sugammadex by using molecular imprinting (MIP) via the electropolymerization (EP) technique. An EP-MIP film was formed by EP on a screen-printed gold electrode (SPAuE) and a new electrochemical sensor, EP-MIP(SUG)/SPAuE, was fabricated using the 4-aminophenol monomer with copper ions to enhance the MIP-binding site. Surface and electrochemical characterization of the EP-MIP(SUG)/SPAuE sensor have been done via scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDX), cyclic voltammetry (CV) and electrochemical impedance spectroscopy (EIS). After screening and optimization studies were carried out to fabricate a MIP-based electrochemical sensor, the analytical performance of EP-MIP(SUG)/SPAuE and the validation parameters were tested according to the ICH guidelines. The specificity/selectivity of the developed sensor has been shown by using common interferents found in the biological fluids and also molecules having similar structures, such as α-cyclodextrin, β-cyclodextrin, and γ-cyclodextrin. As a result, a quantitative analysis method has been developed and validated by using the EP-MIP(SUG)/SPAuE sensor in the concentration range of 0.1-1.0 pM with very high sensitivity (limit of detection: 27.3 fM). The applicability of the method has been shown for bulk drug substances, pharmaceutical dosage forms, and commercial serum samples with good recovery and RSD% results. The EP-MIP(SUG)/SPAuE is the first electrochemical sensor developed for the determination of sugammadex serving the aims of simplicity, short analysis time, and low cost, and has the potential to be adapted in the future as a portable and/or wearable sensor via miniaturization.

Cyclodextrin-Based Displacement Strategy of Sterigmatocystin from Serum Albumin as a Novel Approach for Acute Poisoning Detoxification

This study demonstrates that sterigmatocystin (STC) interacts non-covalently with various cyclodextrins (CDs), showing the highest binding affinity for sugammadex (a γ-CD derivative) and γ-CD, and an almost order of magnitude lower affinity for β-CD. This difference in affinity was studied using molecular modelling and fluorescence spectroscopy, which demonstrated a better insertion of STC into larger CDs. In parallel, we showed that STC binds to human serum albumin (HSA) (a blood protein known for its role as a transporter of small molecules) with an almost two order of magnitude lower affinity compared to sugammadex and γ-CD. Competitive fluorescence experiments clearly demonstrated an efficient displacement of STC from the STC-HSA complex by cyclodextrins. These results are a proof-of-concept that CDs can be used to complex STC and related mycotoxins. Similarly, as sugammadex extracts neuromuscular relaxants (e.g., rocuronium and vecuronium) from blood and blocks their bioactivity, it could also be used as first aid upon acute intoxication to encapsulate a larger part of the STC mycotoxin from serum albumin.

Investigation of proarrhythmic effect of high sugammadex doses: an experimental animal study

BACKGROUND

Studies on higher doses of sugammadex effect on QT interval and leading arrhythmia have been limited. In this study, we aimed to investigate possible proarrhythmic effect of higher doses of sugammadex in conditions that required urgent reversal of neuromuscular blockade during general anesthesia in an experimental animal model.

METHODS

It was experimental animal study. Total of 15 male New Zealand rabbits were randomly divided into three groups for low (4 mg/kg, n = 5), moderate (16 mg/kg, n = 5), and high dose of sugammadex (32 mg/kg, n = 5). All rabbits were premedicated by intramuscular ketamine 10 mg/kg, and general anesthesia was inducted by intravenous injection of 2 mg/kg of a propofol, 1 mcg/kg fentanyl, and 0.6 mg/kg rocuronium injection. Airway was provided by V-gel rabbit and connected to anesthetic device and ventilated at about 40 cycle/min and 10 ml/kg; oxygen 50% plus air 50% mixture was used with 1 MAC isoflurane to maintain anesthesia. Electrocardiographic monitorization and arterial cannulation were provided to follow-up mean arterial pressure and for arterial blood gas analyses. Intravenous sugammadex in three different doses were injected at 25th min of induction. After observing adequate respiration of all rabbits, V-gel rabbit was removed. Parameters and ECG recordings were taken basal value before induction and at the 5th, 10th, 20th, 25th, 30th, and 40th min to measure corrected QT intervals and were stored on digital media. QT interval was calculated as the time from the beginning of the Q wave to the end of the T wave. Corrected QT interval was calculated according to the Bazett's formula. Possible adverse effects were observed and recorded.

RESULTS

In all three groups, there was no significant statistical difference in mean arterial blood gases parameters, arterial pressures, heart rates, and Bazett QTc values, and no serious arrhythmia was recorded.

CONCLUSION

We found in animal study that low, moderate, and high doses of sugammadex did not significantly altered corrected QT intervals and did not cause any significant arrhythmia.

The Strategy to Use Sugammadex to Reduce Postoperative Pulmonary Complications after da Vinci Surgery: A Retrospective Study

In 2000, the da Vinci Surgery System was approved by the United States Food and Drug Administration for general laparoscopic surgery and it became the first commercially available robotic surgery system. The aim of this study was to identify the incidence of postoperative pulmonary complications (PPCs) in patients undergoing da Vinci surgery and to observe whether the incidence of PPCs was affected by the usage of Sugammadex. Sugammadex is a gamma-cyclodextrin that encapsulates and subsequently inactivates steroidal neuromuscular blocking agents. A retrospective study was conducted on patients who had undergone da Vinci surgery in a single medical center in southern Taiwan during the period from January 2018 to December 2018. We extracted data on patient characteristics, usage of Sugammadex and PPCs for analysis. Three hundred and thirty-three patients were enrolled in the final analysis. While the overall incidence of PPCs was 30.3% (101/333 patients), the incidence of PCC in patients who received Sugammadex (24.2%) was significantly lower than those without (37.3%) (p = 0.001). Risk factors that appeared to be closely associated with PCC included age, malignancy, hypertension, chronic kidney disease, blood loss amount and anemia. The use of Sugammadex decreased the risk of PPC. In order to enhance early recovery after da Vinci surgery, the use of Sugammadex to rapidly reverse muscle relaxants may be an appropriate choice.

A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery

BACKGROUND

Neuromuscular blocking agents provide muscular relaxation for tracheal intubation and surgery. However, the degree of neuromuscular block may disturb neuromuscular transmission and lead to weak electromyography during intraoperative neuromonitoring. This study aimed to investigate a surgeon-friendly neuromuscular block degree titrated sugammadex protocol to maintain both intraoperative neuromonitoring quality and surgical relaxation during thyroid surgery.

METHODS

A total of 116 patients were enrolled into two groups and underwent elective thyroid surgery with intraoperative neuromonitoring. All patients followed a standardized intraoperative neuromonitoring protocol with continuous neuromuscular transmission monitoring and received 0.6 mg/kg rocuronium for tracheal intubation. Patients were allocated into two groups according to the degree of neuromuscular block when the anterior surface of the thyroid gland was exposed. The neuromuscular block degree was assessed by the train-of-four (TOF) count and ratio. Patients in group I received sugammadex 0.25 mg/kg for non-deep neuromuscular block degree (TOF count = 1~4). Patients in group II were administered sugammadex 0.5 mg/kg for deep neuromuscular block degree (TOF count = 0). The quality of the intraoperative neuromonitoring was measured using the V₁ electromyography (EMG) amplitude. An amplitude less than 500 μV and greater than 500 μV was defined as weak and satisfactory, respectively.

RESULTS

The quality of the intraoperative neuromonitoring was not different between groups I and II (satisfactory/weak: 75/1 vs. 38/2, P = 0.14). The quality of surgical relaxation was acceptable after sugammadex injection and showed no difference between groups [55/76 (72.3%) in group I vs. 33/40 (82.5%) in group II, P = 0.23].

CONCLUSIONS

This surgeon-centered sugammadex protocol guided by neuromuscular block degree (0.5 mg/kg for deep block and 0.25 mg/kg for others) showed comparably high intraoperative neuromonitoring quality and adequate surgical relaxation. The results expanded the practicality of sugammadex for precise neuromuscular block management during monitored thyroidectomy.

Alkoxysulfenylation of alkenes: development and recent advances

Among the wide variety of synthetic transformations of inexpensive and abundant feedstock alkenes, vicinal difunctionalization of carbon-carbon double bonds represent one of the most powerful and effective strategies for the introduction of two distinct functional groups into target compounds in a one-pot process. In this context, the direct alkoxysulfenylation of alkenes has emerged as an elegant method to construct valuable β-alkoxy sulfides in an atom- and pot-economic manner utilizing readily accessible starting materials. Here, we review the available literature on this appealing research topic by hoping that it will be beneficial for eliciting further research and thinking in this domain.

Application of carbohydrates in approved small molecule drugs: A review

Carbohydrates are an important energy source and play numerous key roles in all living organisms. Carbohydrates chemistry involved in diagnosis and treatment of diseases has been attracting increasing attention. Carbohydrates could be one of the major focuses of new drug discovery. Currently, however, carbohydrate-containing drugs account for only a small percentage of all drugs in clinical use, which does not match the important roles of carbohydrates in the organism. In other words, carbohydrates are a relatively untapped source of new drugs and therefore may offer exciting novel therapeutic opportunities. Here, we presented an overview of the application of carbohydrates in approved small molecule drugs and emphasized and evaluated the roles of carbohydrates in those drugs. The potential development direction of carbohydrate-containing drugs was presented after summarizing the advantages and challenges of carbohydrates in the development of new drugs.

Best Practices in Facial Nerve Monitoring

OBJECTIVES/HYPOTHESIS

Facial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high-level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications.

STUDY DESIGN

Literature review and expert opinion.

METHODS

Given the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM.

RESULTS

Over the years, two models of monitoring have become well-established: 1) monitoring by the surgeon using a stand-alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set-up and provide a basis for context-appropriate interpretation and troubleshooting of recorded signals.

CONCLUSIONS

We trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:S1-S42, 2021.

[Effects of rocuronium, sugammadex and rocuronium-sugammadex complex on coagulation in rats]

BACKGROUND AND OBJECTIVES

Sugammadex is an alternative pharmacological drug capable of reversing neuromuscular blockades without the limitations that are presented by anticholinesterase drugs. Coagulation disorders that are related to treatment with sugammadex were reported. The exact mechanism of the effects on coagulation are not fully understood. The objective of this research is to evaluate the effects of rocuronium, sugammadex and the rocuronium-sugammadex complex on coagulation in an experimental model in rats.

METHODS

This is an experimental randomized animal study. Wistar rats were randomly assigned into the following groups: the Control Group; the Ssal Group - 0.5 mL of intravenous saline; the Sugammadex Group - intravenous sugammadex (100 mg.kg^-1); and the Rocuronium-Sugammadex Group - intravenous solution with rocuronium (3.75 mg.kg^-1) and sugammadex (100 mg.kg^-1). Anesthesia was performed by using isoflurane with controlled ventilation. Coagulation factors were measured 10 minutes after the end of the preoperative preparation and 30 minutes after the administration of the drugs in accordance with the chosen groups.

RESULTS

Platelet counts, prothrombin times and activated partial thromboplastin times were similar between the groups and between the moments within each group. There were reductions in the plasma fibrinogen levels between sample times 1 and 2 in the Rocuronium-Sugammadex group (p=0.035).

CONCLUSIONS

The rocuronium-sugammadex complex promoted reductions in plasma fibrinogen counts, although the levels were still within normal limits.

Effects of rocuronium, sugammadex and rocuronium-sugammadex complex on coagulation in rats

Background and objectives

Sugammadex is an alternative pharmacological drug capable of reversing neuromuscular blockades without the limitations that are presented by anticholinesterase drugs. Coagulation disorders that are related to treatment with sugammadex were reported. The exact mechanism of the effects on coagulation are not fully understood. The objective of this research is to evaluate the effects of rocuronium, sugammadex and the rocuronium-sugammadex complex on coagulation in an experimental model in rats.

Methods

This is an experimental randomized animal study. Wistar rats were randomly assigned into the following groups: the Control Group; the Ssal Group – 0.5 mL of intravenous saline; the Sugammadex Group – intravenous sugammadex (100 mg kg⁻¹); and the Rocuronium-Sugammadex Group – intravenous solution with rocuronium (3.75 mg kg⁻¹) and sugammadex (100 mg kg⁻¹). Anesthesia was performed by using isoflurane with controlled ventilation. Coagulation factors were measured 10 minutes after the end of the preoperative preparation and 30 minutes after the administration of the drugs in accordance with the chosen groups.

Results

Platelet counts, prothrombin times, and activated partial thromboplastin times were similar between the groups and between the moments within each group. There were reductions in the plasma fibrinogen levels between sample times 1 and 2 in the Rocuronium-Sugammadex group (p = 0.035).

Conclusions

The rocuronium-sugammadex complex promoted reductions in plasma fibrinogen counts, although the levels were still within normal limits.

Comparison of the Effects of Sugammadex, Neostigmine, and Pyridostigmine on Postoperative Nausea and Vomiting: A Propensity Matched Study of Five Hospitals

Thus far, few studies have compared the effects of sugammadex and cholinesterase inhibitors on postoperative nausea and vomiting (PONV), and the results have been controversial. Here, we compared the effects of sugammadex, neostigmine, and pyridostigmine on PONV by means of a five hospital analysis with propensity score matching. We analyzed adults aged ≥ 18 years who underwent general anesthesia between January 2014 and December 2019. Following propensity score matching, 7793 patients were included in each of the neostigmine and sugammadex matched patient groups (absolute standardized difference (ASD), 0.01–0.07), and 10,197 patients were included in each of the pyridostigmine and sugammadex matched patient groups (ASD, 0.01–0.02), while 19,377 patients were included in each of the pyridostigmine and neostigmine matched patient groups. (ASD, 0.01–0.19). The odds of PONV were low in the sugammadex group (odds ratio, 0.65; 95% confidence interval, 0.59–0.72; p < 0.0001) and pyridostigmine group (odds ratio, 0.22; 95% confidence interval, 0.20–0.24; p < 0.0001) compared to the neostigmine group, while there was no difference between sugammadex and pyridostigmine (odds ratio, 0.95; 95% confidence interval, 0.86–1.04; p = 0.281). Therefore, sugammadex and pyridostigmine may lower the incidence of PONV compared to neostigmine in patients undergoing general anesthesia.

Noncovalent Complexes of Cyclodextrin with Small Organic Molecules: Applications and Insights into Host-Guest Interactions in the Gas Phase and Condensed Phase

Cyclodextrins (CDs) have drawn a lot of attention from the scientific communities as a model system for host–guest chemistry and also due to its variety of applications in the pharmaceutical, cosmetic, food, textile, separation science, and essential oil industries. The formation of the inclusion complexes enables these applications in the condensed phases, which have been confirmed by nuclear magnetic resonance (NMR) spectroscopy, X-ray crystallography, and other methodologies. The advent of soft ionization techniques that can transfer the solution-phase noncovalent complexes to the gas phase has allowed for extensive examination of these complexes and provides valuable insight into the principles governing the formation of gaseous noncovalent complexes. As for the CDs’ host–guest chemistry in the gas phase, there has been a controversial issue as to whether noncovalent complexes are inclusion conformers reflecting the solution-phase structure of the complex or not. In this review, the basic principles governing CD’s host–guest complex formation will be described. Applications and structures of CDs in the condensed phases will also be presented. More importantly, the experimental and theoretical evidence supporting the two opposing views for the CD–guest structures in the gas phase will be intensively reviewed. These include data obtained via mass spectrometry, ion mobility measurements, infrared multiphoton dissociation (IRMPD) spectroscopy, and density functional theory (DFT) calculations.

Precision Neuromuscular Block Management for Neural Monitoring During Thyroid Surgery

INTRODUCTION

Titration of neuromuscular block (NMB) plays a key role in intraoperative recurrent laryngeal nerve monitoring during thyroid surgery. The combination of neuromuscular blocking agent and timely partial reversal of NMB was investigated in both animal experiments and clinical neuro-monitored thyroidectomy.

METHODS

In animal experiments, 8 piglets received sugammadex to assess the laryngeal EMG recovery after rocuronium-induced NMB. In clinical monitored thyroidectomy, 40 patients each were allocated to conventional group and sugammadex group. Conventional group received rocuronium 0.3 mg/kg at anesthesia induction, while sugammadex group received partial NMB recovery protocol- 0.6 mg/kg of rocuronium at anesthesia induction and 0.5 mg/kg of sugammadex. Main outcome was assessed by first (V1) and final (V2) EMG signal induced by vagal stimulation.

RESULTS

In the porcine model, 50% recovery of laryngeal EMG amplitude was achieved at 16.8 ± 1.9 and 6 ± 2.7 minutes respectively after 0.5 and 1 mg/kg of sugammadex (p < 0.01). In monitored thyroidectomy, EMG amplitudes at V1 in group S and group C were 1214 ± 623 and 915 ± 476 μV, respectively (p = 0.02). Positive and adequately high EMG amplitudes were observed at the early surgical stage for all patients. Sugammadex groups were superior to conventional group in EMG tube placement (p < 0.001).

CONCLUSION

Both porcine model and clinical application showed that precise NMB management by low-dose sugammadex was effective for intraoperative neural monitoring (IONM). The regimen ensured optimal conditions for tracheal intubation and timely neuromuscular function restoration for high-quality EMG signal.

Evaluation of the Toxicity of Sugammadex in Zebrafish Larvae

BACKGROUND

Sugammadex is a new neuromuscular blockade reversal agent. Recently, it has been used in patients under general anesthesia. However, sugammadex could be toxic to fetuses and pediatric patients under 3 years of age. In this study, we demonstrated the safety of sugammadex in fetuses, using zebrafish larvae. Furthermore, its neurotoxicity was evaluated using neuronal cell lines.

METHODS

We used SH-SY5Y cells to determine the viability of neuronal cells treated with sugammadex. Zebrafish larvae were used to determine the teratogenic effects of sugammadex.

RESULTS

Sugammadex showed no adverse effects on neuronal cells and zebrafish larvae. The survival rates of neuronal cells were not different in all concentrations. In addition, the heart formation of zebrafish embryos, which were exposed to various concentrations of sugammadex, were not different.

CONCLUSION

This study demonstrated the feasibility of using sugammadex during pregnancy. However, further clinical studies will be required to extrapolate these results to humans.

Does sugammadex decrease the severity of agitation and complications in pediatric patients undergoing adenotonsillectomy?

Objectives:

To evaluate the effectiveness of sugammadex in reducing or eliminating postoperative agitation levels, early respiratory complications and nausea/vomiting in children undergoing adenotonsillectomy.

Methods:

A total of 70 patients (age range: 5-13 years) who underwent an adenotonsillectomy in the Otolaryngology Clinic, Sakarya University, Sakarya, Turkey between May 2015 and September 2017 were included in the study. The patients were randomized into a sugammadex group (Group S) and a neostigmine + atropine (Group N); each group contained 35 patients. Time to extubation, postoperative agitation levels, and early postoperative complications were evaluated and recorded. Data from both groups were statistically evaluated and compared.

Results:

The time to extubation was significantly shorter in Group S than Group N (p<0.05). Agitation scores during recovery were significantly lower in Group S than Group N (p<0.05). More complications were observed in Group N than in Group S; the number of patients seen coughing and experiencing nausea/vomiting in Group S was statistically significantly lower (p<0.05).

Conclusion:

This study demonstrated that the use of sugammadex results in less time to recovery and less agitation in comparison to conventional administration of neostigmine + atropine in the reversal of neuromuscular blocking after adenotonsillectomy.

Supramolecular neuromuscular blocker inhibition by a pillar[5]arene through aqueous inclusion of rocuronium bromide

A water-soluble pillar[5]arene, decafunctionalized with thioether and carboxylate fragments, was synthesized as a structural analogue of Sugammadex. Its ability to restore the contraction of the diaphragm muscle by encapsulating the muscle relaxant rocuronium bromide was demonstrated. Using UV-vis, NMR and fluorescence spectroscopy, it was shown that the muscle relaxant is associated with the pillar[5]arene with an association constant of 4500 M-1 and a stoichiometry of 1 : 1. The structure of the inclusion complex of the pillar[5]arene with rocuronium bromide was additionally investigated by quantum chemical methods.

Neuromuscular blockade management for intraoperative neural monitoring

This article reviews the literature on development of neuromuscular blockade management in thyroid surgery with intraoperative neural monitoring (IONM) in the past decade. Neuromuscular blockade management includes the choice of neuromuscular blocking agents (NMBAs) and reversal of neuromuscular blockade by sugammadex. A series of animal study and clinical trials showed NMBAs effect on IONM in thyroid surgery. We summarized five NMBA regimens for IONM: (a) relaxant-free regimen, (b) depolarizing NMBA-succinylcholine, (c) titration of nondepolarizing NMBA, and (d) rocuronium combined with sugammadex. The proper management of neuromuscular blockade during IONM has greatly developed over the past decade. The misuse of NMBAs is associated with false IONM interpretations to surgeons. A detailed understanding of NMBAs and neuromuscular blockade management by sugammadex may optimize IONM quality in patients receiving monitored thyroid surgery.

Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey

Background

Neuromuscular blocking agents (NMBAs) and neuromuscular monitoring in anesthetic management are integral for endotracheal intubation, better visualization of the surgical field, and prevention of residual neuromuscular blockade and pulmonary complications. Sugammadex is a drug that reduces risk of residual neuromuscular blockade, with more rapid recovery compared to anticholinesterase. The purpose of this study was to investigate current usage status of NMBAs and antagonist with neuromuscular monitoring, among anesthesiologists in Korea.

Methods

Anesthesiologists working in Korea were invited to participate in an online survey via email January 2–February 28, 2018. The questionnaire consisted of 45 items, including preferred NMBAs, antagonists, neuromuscular monitoring, and complications related to the use sugammadex. A total of 174 responses were analyzed.

Results

Rocuronium was a commonly used NMBA for endotracheal intubation (98%) of hospitals, and maintenance of anesthesia (83.3%) in of hospitals. Sugammadex, pyridostigmine, and neostigmine were used in 89.1%, 87.9%, and 45.4% of hospitals. Neuromuscular monitoring was employed in 79.3% of hospitals; however only 39.7% of hospitals used neuromuscular monitoring before antagonist administration. Usual dosage range of sugammadex was 2.1–4 mg/kg in 35.1% of hospitals, within 2 mg/kg in 34.5% of hospitals, and 1 vial regardless of body weight in 22.4% of hospitals. Sugammadexrelated complications were encountered by 14.9% of respondents.

Conclusions

This survey indicates several minor problems associated with the use of antagonists and neuromuscular monitoring. However, most anesthesiologists appear to have appropriate information regarding the usage of NMBAs and sugammadex.

Effects of magnesium chloride on rocuronium-induced neuromuscular blockade and sugammadex reversal in an isolated rat phrenic nerve-hemidiaphragm preparation: An in-vitro study

BACKGROUND

Magnesium potentiates the effects of nondepolarising muscle relaxants. However, few studies have used magnesium chloride (MgCl2). Sugammadex reverses neuromuscular block by steroidal nondepolarising muscle relaxants.

OBJECTIVES

To assess the effects of MgCl2 on rocuronium-induced neuromuscular blockade and its reversal by sugammadex.

DESIGN

In-vitro experimental study.

SETTING

Animal laboratory, Asan Medical Center, Seoul, South Korea, from 20 March 2016 to 3 April 2016.

ANIMALS

Forty male Sprague Dawley rats.

INTERVENTION

Left phrenic nerve-hemidiaphragms from 40 Sprague Dawley rats were allocated randomly to four groups (1, 2, 3 and 4 mmol l MgCl2 group, n = 10 each). Rocuronium was administered cumulatively until the first twitch of train-of-four (TOF) disappeared completely. Then, equimolar sugammadex was administered.

MAIN OUTCOME MEASURES

The effective concentration (EC) of rocuronium was obtained in each group. After administering sugammadex, recovery of the first twitch height and the TOF ratio were measured for 30 min.

RESULTS

EC50, EC90 and EC95 significantly decreased as the concentration of MgCl2 increased (all P ≤ 0.001), except the comparison between the 3 and 4 mmol l MgCl2 groups. After administration of sugammadex, the maximal TOF ratio (%) was lower in the 4 mmol l MgCl2 group than the 1 mmol l MgCl2 group [median 91.7 interquartile range (83.4 to 95.8) vs. 98.3 interquartile range (92.2 to 103.4), P = 0.049]. The mean time (s) from sugammadex injection to achieving maximal first twitch was significantly prolonged in the 4 mmol l MgCl2 group vs. the 1 mmol l MgCl2 and 2 mmol l MgCl2 groups [1483.9 (± 237.0) vs. 1039.0 (± 351.8) and 926.0 (± 278.1), P = 0.022 and 0.002, respectively].

CONCLUSION

Increases in MgCl2 concentration reduce the ECs of rocuronium. In addition, administering sugammadex equimolar to the administered rocuronium shows limited efficacy as MgCl2 concentration is increased.

TRIAL REGISTRATION

The in-vitro study was not registered in a database.

An Anesthesiologist's Perspective on the History of Basic Airway Management: The "Modern" Era, 1960 to Present

This fourth and last installment of my history of basic airway management discusses the current (i.e., "modern") era of anesthesia and resuscitation, from 1960 to the present. These years were notable for the implementation of intermittent positive pressure ventilation inside and outside the operating room. Basic airway management in cardiopulmonary resuscitation (i.e., expired air ventilation) was de-emphasized, as the "A-B-C" (airway-breathing-circulation) protocol was replaced with the "C-A-B" (circulation-airway-breathing) intervention sequence. Basic airway management in the operating room (i.e., face-mask ventilation) lost its predominant position to advanced airway management, as balanced anesthesia replaced inhalation anesthesia. The one-hand, generic face-mask ventilation technique was inherited from the progressive era. In the new context of providing intermittent positive pressure ventilation, the generic technique generated an underpowered grip with a less effective seal and an unspecified airway maneuver. The significant advancement that had been made in understanding the pathophysiology of upper airway obstruction was thus poorly translated into practice. In contrast to consistent progress in advanced airway management, progress in basic airway techniques and devices stagnated.

Sugammadex affects emergence agitation in children undergoing strabismus surgery

Objective Emergence agitation (EA) has a multifactorial origin, and the effect of sugammadex on EA has not been established. We investigated the effect of sugammadex on EA incidence and severity. Methods We performed a retrospective study of children aged 1 to 13 years who underwent strabismus surgery. Patients received sugammadex or conventional neuromuscular reversal agents. The primary outcome variables were EA incidence and severity. Secondary outcome variables were postoperative fentanyl use, postoperative nausea and vomiting, time from reversal agent administration to extubation, time from the end of surgery to arrival in the post-anesthesia care unit (PACU) and time spent in the PACU. We used propensity score matching to eliminate baseline imbalances. Results Age, sex, use of desflurane, and intraoperative fentanyl were significant predictors of agitation severity using a multivariable analysis. Sugammadex did not significantly affect EA in logistic regression and multiple regression analyses. In the propensity-matched analysis, patients in the sugammadex group showed rapid recovery, but there was no difference in the EA incidence or severity. Conclusion Sugammadex did not affect EA incidence or severity compared with conventional cholinesterase inhibitors, although it showed a favorable recovery profile in children undergoing strabismus surgery.

Profile of sugammadex for reversal of neuromuscular blockade in the elderly: current perspectives

The number of elderly patients is increasing worldwide. This will have a significant impact on the practice of anesthesia in future decades. Anesthesiologists must provide care for an increasing number of elderly patients, who have an elevated risk of perioperative morbidity and mortality. Complications related to postoperative residual neuromuscular blockade, such as muscle weakness, airway obstruction, hypoxemia, atelectasis, pneumonia, and acute respiratory failure, are more frequent in older than in younger patients. Therefore, neuromuscular blockade in the elderly should be carefully monitored and completely reversed before awakening patients at the end of anesthesia. Acetylcholinesterase inhibitors are traditionally used for reversal of neuromuscular blockade. Although the risk of residual neuromuscular blockade is reduced by reversal with neostigmine, it continues to complicate the postoperative course. Sugammadex represents an innovative approach to reversal of neuromuscular blockade induced by aminosteroid neuromuscular-blocking agents, particularly rocuronium, with useful applications in clinical practice. However, aging is associated with certain changes in the pharmacokinetics of sugammadex, and to date there has been no thorough evaluation of the use of sugammadex in elderly patients. The aim of this review was to perform an analysis of the use of sugammadex in older adults based on the current literature. Major issues surrounding the physiologic and pharmacologic effects of aging in elderly patients and how these may impact the routine use of sugammadex in elderly patients are discussed.

Effects of cyclodextrins on the chemical stability of drugs

Cyclodextrins (CDs) are enabling pharmaceutical excipients that can enhance both solubility and stability of wide variety of drugs in aqueous solutions through formation of drug/CD inclusion complexes where apolar moieties of the drug molecules are located inside the CD cavity. In properly designed pharmaceutical formulations CDs will improve physiochemical properties of lipophilic drugs without affecting their intrinsic ability to permeate biological membranes. Here the effect of CD complexes on the chemical stability of drugs is reviewed. Numerous studies shown that in aqueous solutions CD complexation can hamper hydrolysis, oxidation, photodegradation, isomerization and enzyme catalyzed degradation of dissolved drugs. However, some drugs, such as β-lactam antibiotics, can under certain conditions undergo CD catalyzed degradation in aqueous solutions. Also, some drugs that are stabilized by CDs in aqueous solutions are destabilized by the same CDs in solid dosage forms. Thus, the effects of CDs on drug stability have to be tested and verified in the final drug formulation and under the recommended storage conditions.

An in vivo strategy to counteract post-administration anticoagulant activity of azido-Warfarin

Drugs, usually long acting and metabolically stable molecules, might be the source of adverse effects triggered by complex drug interactions, anaphylaxis and drug-induced coagulopathy. To circumvent this growing drug safety issue, we herein investigate the opportunity offered by bio-orthogonal chemistry for in vivo drug neutralization. We design a small-molecule anticoagulant drug (Warfarin) containing an azide group that acts as a safety pin. It allows drug deactivation and restoration of physiological coagulation via in vivo click reaction with a suitable cyclooctyne-based neutralizing agent. In this strategy, the new molecule formed by reaction of the drug and the antidote is deprived of biological activity and prone to fast renal clearance. This 'Click &Clear' approach lays ground for new strategies in designing drugs with switchable biophysical properties.

The Use of Sugammadex in a Patient With Guillain-Barre Syndrome: A Case Report

Sugammadex encapsulates and inactivates rocuronium and vecuronium. It is used to reverse neuromuscular blockade from these nondepolarizing agents. The safety of sugammadex in patients with neuromuscular disease has not been established. Guillain-Barre Syndrome (GBS) is a neuromuscular disease characterized by acute inflammatory polyneuropathy. Patients with GBS may exhibit autonomic dysfunction, chronic pain, abnormal reactions to neuromuscular blocking agents, and may require postoperative mechanical ventilation. We report the successful use of sugammadex to reverse rocuronium in a patient with chronic GBS, who presented for a hemicolectomy.

Current evidence for the use of sugammadex in children

Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade with a mechanism that differs from the commonly used, acetylcholinesterase inhibitors. Although sugammadex has not received approval from the United States Food & Drug administration in children, its use has already been reported to reverse neuromuscular blockade in several clinical scenarios in the pediatric population including the 'cannot intubate-cannot ventilate' scenario. To date, there remains limited data from prospective trials in the pediatric-aged patient. Anecdotal use has been reported for the reversal of neuromuscular blockade in difficult clinical scenarios such as children with neuromuscular diseases including myasthenia gravis, Duchenne muscular dystrophy, and myotonic dystrophy.

Neuronal Effects of Sugammadex in combination with Rocuronium or Vecuronium

Rocuronium (ROC) and Vecuronium (VEC) are the most currently used steroidal non-depolarizing neuromuscular blocking (MNB) agents. Sugammadex (SUG) rapidly reverses steroidal NMB agents after anaesthesia. The present study was conducted in order to evaluate neuronal effects of SUG alone and in combination with both ROC and VEC. Using MTT, CASP-3 activity and Western-blot we determined the toxicity of SUG, ROC or VEC in neurons in primary culture. SUG induces apoptosis/necrosis in neurons in primary culture and increases cytochrome C (CytC), apoptosis-inducing factor (AIF), Smac/Diablo and Caspase 3 (CASP-3) protein expression. Our results also demonstrated that both ROC and VEC prevent these SUG effects. The protective role of both ROC and VEC could be explained by the fact that SUG encapsulates NMB drugs. In BBB impaired conditions it would be desirable to control SUG doses to prevent the excess of free SUG in plasma that may induce neuronal damage. A balance between SUG, ROC or VEC would be necessary to prevent the risk of cell damage.

A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

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.

γ-Cyclodextrin

γ-Cyclodextrin (γCD) is a cyclic oligosaccharide formed by bacterial digestion of starch and used as solubilizing agent and stabilizer in a variety of pharmaceutical and food products. γCD is a large (molecular weight 1297Da) hydrophilic molecule that does not readily permeate biological membranes and is rapidly digested by bacteria in the gastrointestinal tract. In humans γCD is metabolized by α-amylase that is found in, for example, saliva, bile fluid and tears. Thus, bioavailability of γCD is negligible. Also, γCD is readily excreted unchanged in the urine after parenteral administration. Like other cyclodextrins, γCD can form water-soluble inclusion complexes with many poorly-soluble compounds. In comparison with the natural αCD and βCD, γCD has the largest hydrophobic cavity, highest water solubility and the most favorable toxicological profile. The focus of this review is production, physiochemical properties, pharmacokinetics, toxicity and applications of γCD and its derivatives. Also, the aggregation behavior of γCD in aqueous media is discussed.

Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion

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.

Effect of Sugammadex on Postoperative Bleeding and Coagulation Parameters After Septoplasty: A Randomized Prospective Study

Backround

Sugammadex is a reversal agent with well known advantages but it’s effects on haemostasis and bleeding have been a topic of interest. Septoplasty is a common surgical procedure with postoperative respiratory complications and bleeding. The aim of this study is to investigate the effects of sugammadex on postoperative coagulation parameters and bleeding after septoplasty procedure.

Material/Methods

In this randomized controlled study, fifty patients were grouped into two groups; neostigmine (Group N) vs. sugammadex (Group S). For the evaluation of PT, aPTT and INR, blood samples were taken for at the postoperative 120^th minutes and alteration of these values with respect to preoperative values were documented. Postoperative bleeding was measured by evaluating the amount of blood absorbed on the nasal tip dressing during 3 hours postoperatively.

Results

Postoperative bleeding amount was significantly higher in the Group S compared to Group N (p=0.013). No significant difference was observed between two groups according to coagulation parameters (PT; p=0.953, aPTT; p=0.734, INR; p=0.612).

Conclusions

Sugammadex was associated with higher amount of postoperative bleeding than neostigmine in septoplasty patients. In surgical procedures having high risk of bleeding the safety of sugammadex need to be verified.

Comparison of effects of sugammadex and neostigmine on QTc prolongation in rabbits under general anesthesia

PURPOSE

To compare the effects of sugammadex and neostigmine, used to antagonize the effects of rocuronium, on the QTc interval.

METHODS

This study used 10 adult New Zealand white rabbits of 2.5-3.5 kg randomly divided into two groups: sugammadex group (Group S, n:5) and neostigmine group (Group N, n:5). For general anesthesia administering 2 mg/kg iv propofol and 1 mcg/kg iv fentanyl, 0.6 mg/kg iv rocuronium was given. Later to provide reliable airway for all experimental animals V-Gel Rabbit was inserted. The rabbits were manually ventilated by the same anesthetist. After the V-Gel Rabbit was inserted at 2, 5, 10, 20, 25, 27, 30 and 40 minutes measurements were repeated and recorded. At 25 minutes after induction Group N rabbits were given 0.05 mg/kg iv neostigmine + 0.01 mg/kg iv atropine. Group S were administered 2 mg/kg iv sugammadex.

RESULTS

Comparing the QTc interval in the rabbits in Group S and Group N, in the 25th, 27th and 30th minute after muscle relaxant antagonist was administered the QTc interval in the neostigmine group rabbits was significantly increased (p<0.05).

CONCLUSION

While sugammadex, administered to antagonize the effect of rocuronium, did not significantly affect the QTc interval, neostigmine+atropine proloned the QTc interval.

Rapid reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery

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.

Inhibitors of acetylcholinesterase and butyrylcholinesterase meet immunity

Acetylcholinesterase (AChE) inhibitors are widely used for the symptomatic treatment of Alzheimer’s disease and other dementias. More recent use is for myasthenia gravis. Many of these inhibitors interact with the second known cholinesterase, butyrylcholinesterase (BChE). Further, evidence shows that acetylcholine plays a role in suppression of cytokine release through a “cholinergic anti-inflammatory pathway” which raises questions about the role of these inhibitors in the immune system. This review covers research and discussion of the role of the inhibitors in modulating the immune response using as examples the commonly available drugs, donepezil, galantamine, huperzine, neostigmine and pyridostigmine. Major attention is given to the cholinergic anti-inflammatory pathway, a well-described link between the central nervous system and terminal effector cells in the immune system.

Hypersensitivity associated with sugammadex administration: a systematic review

Sugammadex is a drug used to reverse neuromuscular blockade induced by rocuronium or vecuronium. It has not yet been approved by the Food and Drug Administration in the USA due to concerns regarding hypersensitivity. The objective of this review was to identify similarities in the presentation of hypersensitivity reactions to sugammadex. A comprehensive search was performed in PubMed, Scopus and Web of Science for cases reporting hypersensitivity reactions to sugammadex. In addition, we contacted regulatory agencies and the company marketing the drug for unpublished reports. Reports were included if they were in English, primary investigations, lacked an alternative probable explanation for the reaction and included a comprehensive description of the hypersensitivity. We identified 15 cases of hypersensitivity following sugammadex administration. All cases that reported exact timing (14/15) occurred in 4 min or less. Most of the patients (11/15; 73%) met World Anaphylaxis Organization criteria for anaphylaxis. Awareness must be raised for the possibility of drug-induced hypersensitivity during the critical 5-min period immediately following sugammadex administration.

Anesthesia for cesarean section in a patient with Guillain-Barre syndrome: Case report

BACKGROUND AND OBJECTIVES

Guillain-Barre syndrome during pregnancy is considered a rare neurological complication, and there is no consensus in literature for anesthetic management for cesarean section in such patients. The objective of this paper is to report the case of a pregnant woman with Guillain-Barre syndrome undergoing cesarean section.

CASE REPORT

Female patient, 22-year old, 35 weeks and 5 days of gestation, undergoing cesarean section, hospitalized, reporting decreased strength and lower limb paresthesias. Cerebrospinal fluid (CSF) analysis showed increased protein (304 mg.dL(-1)) without increased cellularity. The anesthetic technique used was general anesthesia induced with propofol (1.5 mg.kg(-1)) and maintained with 2% sevoflurane in oxygen and fentanyl (3 μg.kg(-1)). The procedure was uneventful for both mother and neonate. The patient was discharged 10 days after admission, after progressive improvement of neurological symptoms.

CONCLUSION

The anesthetic technique for pregnant women with Guillain-Barre syndrome requiring cesarean section remains at the discretion of the anesthesiologist, who should be guided by the clinical conditions and comorbidities of each patient.

Cucurbit[n]uril type hosts for the reversal of steroidal neuromuscular blocking agents

The ideal neuromuscular blocking agent (NMBA) is regarded as being a non-depolarizing equivalent of succinylcholine, having a rapid onset and short duration of action, with minimal side effects. In the absence of a single drug, the administration of an aminosteroid NMBA, such as rocuronium, followed by reversal using an acetylcholinesterase inhibitor, such as neostigmine, is commonly employed. A different and safer approach to rapidly reversing the action of the NMBA, by encapsulating it with a macrocyclic or acyclic host molecule, such as the cyclodextrin sugammadex or more recently, cucurbituril-type hosts such as cyclic cucurbit[7]uril and the acyclic glycoluril tetramer calabadion 1, is described.