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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.
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Affiliation(s)
- Cyrus Motamed
- Departement of Anesthesia, Gustave Roussy Cancer Campus, 94080 Villejuif, France
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Kelbesa Olika M, Teku Ayano G, Ilala TT. Perioperative Anesthesia Management for a Patient Presented with Acute Cardiopulmonary Compromise Secondary to a Complicating Retropharyngeal Abscess Extending to the Mediastinum. A Rare Case Report. OPEN ACCESS SURGERY 2022. [DOI: 10.2147/oas.s383062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ghimire A, Olbrecht VA, Tobias JD. Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports. Paediatr Anaesth 2022; 32:706-715. [PMID: 35212434 DOI: 10.1111/pan.14424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/01/2022]
Abstract
Allergic reactions are generalized hypersensitivity processes triggered by different antigenic stimuli, resulting in the end effect of mast cell degranulation and adverse physiologic effects. During the perioperative period, the most commonly identified agents include antibiotics, neuromuscular blocking agents (rocuronium and succinylcholine), chlorhexidine, and iodinated dyes for radiologic imaging. Sugammadex is a novel agent for the reversal of neuromuscular blockade achieved with rocuronium or vecuronium. Its unique mechanism of action, whereby it encapsulates and forms a one-to-one complex with rocuronium, has led to its anecdotal use as an adjunct in the treatment of anaphylactic and anaphylactoid reactions following rocuronium. The current manuscript discusses the potential use of sugammadex in the treatment of allergic reactions following the administration of rocuronium, reviews previous anecdotal reports of its use in these scenarios, and provides recommendations for future care.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Olesnicky BL, Trumper R, Chen V, Culwick MD. The use of sugammadex in critical events in anaesthesia: A retrospective review of the webAIRS database. Anaesth Intensive Care 2022; 50:220-226. [PMID: 35172631 DOI: 10.1177/0310057x211039859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sugammadex has been used for more than ten years in Australia and New Zealand and has been implicated as an effective treatment, and in some cases a potential cause, of a critical incident. We aimed to identify and analyse critical incidents involving sugammadex reported to webAIRS, a de-identified voluntary online critical incident reporting system in Australia and New Zealand. We identified 116 incidents where the reporter implicated sugammadex as either a cause (23 cases) or a treatment (93 cases) during anaesthesia. There were 17 incidents suggestive of sugammadex anaphylaxis, although not all were confirmed by skin testing. There were six incidents when bradycardia was temporally related to sugammadex administration, although it was not possible to exclude other causes or contributory factors. There were nine incidents in which sugammadex was used to reverse aminosteroid-related neuromuscular blockade successfully in a 'can't intubate, can't oxygenate' (CICO) situation, and a further 67 incidents in which sugammadex was used to reverse aminosteroid neuromuscular blockade as part of the management of other critical incidents. While sugammadex was used during the management of 16 cases of anaphylaxis, there was no clear indication that this altered the course of the anaphylaxis in any of the cases. These reports indicate that sugammadex can be a potential trigger for anaphylaxis and that its use may be associated with the development of significant bradycardia. However, it is not possible to estimate or even speculate on the incidence of these sugammadex-related incidents on the basis of voluntary reporting to a database such as webAIRS. The reports also indicate that sugammadex has been used successfully to reverse residual or deep aminosteroid neuromuscular blockade in critical incident situations and to help rescue CICO scenarios. These findings provide further support for ensuring the ready availability of sugammadex wherever aminosteroid muscle relaxants are used.
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Affiliation(s)
- Benjamin L Olesnicky
- Department of Anaesthesia, 60086Royal North Shore Hospital, Royal North Shore Hospital, St Leonards, Australia.,School of Medicine, 4334The University of Sydney, The University of Sydney, Sydney, Australia
| | - Rosie Trumper
- Department of Anaesthesia, 60086Royal North Shore Hospital, Royal North Shore Hospital, St Leonards, Australia
| | - Vanessa Chen
- Department of Anaesthesia, 60086Royal North Shore Hospital, Royal North Shore Hospital, St Leonards, Australia
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, Australia.,Australian and New Zealand Tripartite Anaesthetic Data Committee, Australia
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De La Cruz I, Errando C, Calaforra S. Treatment of Anaphylaxis to Rocuronium with Sugammadex: A Case Report with Bronchospasm as the Only Symptom. Turk J Anaesthesiol Reanim 2019; 47:69-72. [PMID: 31276114 DOI: 10.5152/tjar.2019.21298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022] Open
Abstract
Anaphylaxis during anaesthesia is a rare event occurring in up to 1:20,000 anaesthetics and in 33%-63% neuromuscular blocking agents are involved. Several case reports suggested the effectiveness of sugammadex in the treatment of rocuronium-induced anaphylactic shock refractory to conventional treatment. We report a case of anaphylactic reaction to rocuronium that caused isolated respiratory symptoms and showed no improvement in oxygen saturation after intravenous corticosteroids and intratracheal beta-2 agonists and that was successfully treated with sugammadex. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are not completely known. We briefly review the literature regarding this topic.
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Affiliation(s)
- Itziar De La Cruz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Carlos Errando
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Susana Calaforra
- Department of Allergy and Clinical Immunology, La Fe University and Polytechnic Hospital, Valencia, Spain
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Spoerl D, D'Incau S, Roux-Lombard P, Harr T, Czarnetzki C. Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016; 169:256-62. [PMID: 27240836 DOI: 10.1159/000446182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
We present 3 cases of pseudoallergic (anaphylactoid) reactions to perioperatively administered rocuronium, which rapidly resolved after sugammadex injection. Allergological workup showed no evidence for immediate-type hypersensitivity to the drugs used for anesthesia, including rocuronium. However, rocuronium induced an irritative reaction in skin tests in all 3 patients and in 3 healthy individuals. This reaction was specifically suppressed by adding sugammadex at a 1:1 molecular proportion to rocuronium before the skin tests. This observation suggests that the patients suffered from a pseudoallergic reaction, and indicates that sugammadex might act via the inhibition of non-IgE mediated MRGPRX2 (Mas-related G-protein-coupled receptor member X2)-triggered mast cell degranulation induced by rocuronium.
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Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, Geneva University Hospital, Geneva, Switzerland
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A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports? Can J Anaesth 2014; 61:511-8. [DOI: 10.1007/s12630-014-0150-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/13/2014] [Indexed: 12/17/2022] Open
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Conte B, Zoric L, Bonada G, Debaene B, Ripart J. Reversal of a rocuronium-induced grade IV anaphylaxis via early injection of a large dose of sugammadex. Can J Anaesth 2014; 61:558-62. [PMID: 24844201 DOI: 10.1007/s12630-014-0148-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 03/12/2014] [Indexed: 12/19/2022] Open
Abstract
AIM To report rapid recovery from grade IV rocuronium-induced anaphylaxis with a large dose of sugammadex administered early after the onset of symptoms. CLINICAL FEATURES A 22-yr-old female without relevant medical history developed an anaphylactic reaction within three minutes of rocuronium injection at induction of anesthesia for a routine cholecystectomy. During the first six minutes, she was unresponsive to usual treatment and her condition evolved to a grade IV anaphylaxis reaction despite a cumulated dose of epinephrine 0.7 mg. Sugammadex 14 mg·kg(-1), injected six minutes after rocuronium, resulted in total resolution of all manifestations of anaphylaxis within three minutes. The patient was discharged from hospital the next day. Allergy investigations confirmed rocuronium as the cause of anaphylaxis. CONCLUSION Very early administration of a large dose of sugammadex may be an effective treatment for rocuronium-induced anaphylaxis.
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Affiliation(s)
- Benjamin Conte
- Département « Anesthésie -Douleur », Centre Hospitalier Régional Universitaire de Caremeau, Nîmes, Faculté de Médecine Montpellier-Nîmes, Université Montpellier I, Montpellier, France
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Baldo BA, McDonnell NJ. Sugammadex and anaphylaxis in the operating theater. ACTA ACUST UNITED AC 2014; 61:239-45. [PMID: 24666509 DOI: 10.1016/j.redar.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- B A Baldo
- Retired. Formerly, Head, Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - N J McDonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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Lobaz S, Clymer M, Sammut M. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. ACTA ACUST UNITED AC 2014. [DOI: 10.4137/cmt.s10241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.
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Affiliation(s)
- Steven Lobaz
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mark Clymer
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mario Sammut
- Department of Anaesthetics and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. CORE EVIDENCE 2013; 8:57-67. [PMID: 24098155 PMCID: PMC3789633 DOI: 10.2147/ce.s35675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
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Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Un nouveau cas de choc anaphylactique induit par le rocuronium amélioré par le sugammadex. Can J Anaesth 2012; 59:909-10. [DOI: 10.1007/s12630-012-9740-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 05/17/2012] [Indexed: 12/19/2022] Open
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Abad Gurumeta A, Gutiérrez García R. [Sugammadex: the last shot for anaphylactic shock due to rocuronium?]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:177-179. [PMID: 22575774 DOI: 10.1016/j.redar.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/21/2012] [Indexed: 05/31/2023]
Affiliation(s)
- A Abad Gurumeta
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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