Sugammadex is associated with better respiratory recovery than neostigmine following reversal of anaesthesia-associated neuromuscular blockade in the morbidly obese patients following elective laparoscopic surgery
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Abstract:
Complete and reliable neuromuscular reversal is important to successful anaesthetic recovery in the morbidly obese patient undergoing laparoscopic surgery. Our goal was to determine whether sugammadex, a selective reversal agent is associated with better respiratory recovery than neostigmine following the reversal of anaesthesia-associated neuromuscular blockade by rocuronium in the morbidly obese. Peak Expiratory Flow Rate a surrogate marker for respiratory function, was the primary outcome measured and secondary outcome measures included post-operative nausea and vomiting, pain and head lifting. We found that patients reversed with sugammadex had a significantly higher post-operative PEFR as compared to those reversed with neostigmine and glycopyrrolate group.Keywords:
Sugammadex
Glycopyrrolate
The primary outcome of sugammadex reversal for rocuronium-induced neuromuscular block (NMB) is a train-of-four ratio (TOFR) of 0.9, not first twitch (T1) height. We investigated whether the recovery of TOFR or T1 differs based on the reversal of NMB with neostigmine or sugammadex.The acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in 80 patients after induction of anesthesia. The TOFR and T1 height were recorded, and saved in a personal computer using TOF-Watch SX Monitor software in all patients. Patients were randomly assigned to 2 groups to receive either neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg (neostigmine group, n = 40) or sugammadex 2.0 mg/kg (sugammadex group, n = 40). The primary objective was to determine the difference of recovery time between TOFR to 0.9 and T1 to 0.9 after sugammadex or neostigmine administration during moderate rocuronium-induced NMB.The recovery pattern of the TOFR 2 min after sugammadex administration was 1.0 or more, but that of T1 was less than 90% (T1 / control value) up to 6 min after drug was injected. The recovery pattern of TOFR and T1 was similar during the 20 min after reversal with neostigmine.If you have not performed the T1 monitoring, both TOFR and T1 should be considered to confirm suitable recovery during the 6 min after reversal with sugammadex during rocuronium-induced moderate NMB.
Sugammadex
Neuromuscular monitoring
Glycopyrrolate
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Sugammadex
Neuromuscular monitoring
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Sugammadex
Neuromuscular Blocking Agents
Reversing
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Rapid and complete reversal of neuromuscular blockade (NMB) is desirable at the end of surgery. Sugammadex reverses rocuronium-induced NMB by encapsulation. It is well tolerated in Caucasian patients, providing rapid reversal of moderate (reappearance of T2) rocuronium-induced NMB. We investigated the efficacy and safety of sugammadex versus neostigmine in Korean patients.This randomized, safety assessor-blinded trial (NCT01050543) included Korean patients undergoing general anesthesia. Rocuronium 0.6 mg/kg was given prior to intubation with maintenance doses of 0.1-0.2 mg/kg as required. Patients received sugammadex 2.0 mg/kg or neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg to reverse the NMB at the reappearance of T2, after the last rocuronium dose. The primary efficacy endpoint was the time from sugammadex or neostigmine administration to recovery of the train-of-four (TOF) ratio to 0.9. The safety of these medications was also assessed.Of 128 randomized patients, 118 had evaluable data (n = 59 in each group). The geometric mean (95% confidence interval) time to recovery of the TOF ratio to 0.9 was 1.8 (1.6, 2.0) minutes in the sugammadex group and 14.8 (12.4, 17.6) minutes in the neostigmine group (P < 0.0001). Sugammadex was generally well tolerated, with no evidence of residual or recurrence of NMB; four patients in the neostigmine group reported adverse events possibly indicative of inadequate NMB reversal.Sugammadex was well tolerated and provided rapid reversal of moderate rocuronium-induced NMB in Korean patients, with a recovery time 8.1 times faster than neostigmine. These results are consistent with those reported for Caucasian patients.
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Neostigmine has been traditionally used as the agent of choice to reverse Neuromuscular Blockade (NMB) after muscle paralysis during general anesthesia. However, the use of neostigmine has not been without untoward events. Sugammadex is a novel drug that selectively binds to aminosteroid nondepolarizing muscle relaxants and reverses even a deep level of NMB. Controversy exists regarding the optimal dose of sugammadex that is effective in reversing the NMB after the incomplete reversal with neostigmine and glycopyrrolate. We discuss a case where sugammadex reduced the time of the recovery from NMB in a patient who had incomplete antagonisms following adequate treatment with neostigmine, aiding timely extubation without persistent residual NMB, and hence prevented the requirement of postoperative ventilation and the improvement in patient care. More randomized control studies are needed in order to conclude the appropriate dose of sugammadex in cases of incomplete reversal.
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Neuromuscular monitoring
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Background: Residual neuromuscular blockade (NMB) is associated with increased risk of post-operative critical respiratory events. We compared incidence of residual NMB at tracheal extubation after reversal of rocuroniuminduced NMB with sugammadex versus neostigmine.
Methods: Adult patients of American Society of Anesthesiologists Class 1-3, scheduled to undergo open abdominal surgery were included. Patients were randomized to receive sugammadex 4.0 mg/kg at ≥1-2 posttetanic counts after last rocuronium dose, or neostigmine 50mg/kg + glycopyrrolate 10mg/kg, according to usual care practices at each institution. Neuromuscular function was assessed using TOF-Watch® SX. Anesthesiologists were blinded to the TOF-Watch recording, except to ask the TOF-Watch operator whether ≥1 PTC had been reached before administering reversal. Use of a peripheral nerve stimulator was permitted. Clinical criteria defined by the institution were used to determine when to perform extubation. Primary efficacy variable was incidence of residual NMB (train-of-four [TOF] ratio <0.9) at extubation. Safety parameters were assessed by a blinded safety assessor.
Results: The intent-to-treat group comprised 97 patients (sugammadex, n=51; neostigmine, n=46). Among patients with valid TOF data, a TOF ratio of ≥0.9 was reached at or before extubation in 48 of 50 (96.0%) sugammadex and 17 of 43 (39.5%) neostigmine patients (P<0.0001). One sugammadex (2.0%) and 15 neostigmine patients (34.9%) were extubated at TOF ratios ≤0.7. Median (95% CI) time from study drug administration to recovery to a TOF ratio ≥0.9 was 2.0 (1.8-2.5) minutes for sugammadex (n=49) versus 8.0 (3.8-16.5) minutes for neostigmine (n=18) (P<0.0001). Safety was comparable between groups, with no clinical evidence of recurrence of NMB.
Conclusions: Significantly more sugammadex-treated patients recovered to a TOF ratio ≥0.9 at extubation and did so significantly faster than neostigmine-treated patients. This study confirms that sugammadex is more effective than neostigmine in reducing potential for residual blockade in the absence of objective NMB monitoring.
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Background: Sugammadex is a new reversal agent for nondepolarizing neuromuscular blockade. We conducted the randomized clinical study to compare the recovery between sugammadex alone and combined use of sugammadex and neostigmine.
Methods: Forty adult patients were randomly allocated to Group S (n=20) or Group SN (n=20). General anesthesia was induced and maintained with propofol and remifentanil. The patients were intubated without neuromuscular blockers. After the stabilization of TOF Watch SX® acceleromyography as control, rocuronium 0.6 mg/kg was administered to patients in both groups. The patients in Group S received sugammadex 1.0 mg/kg and those in Group SN received sugammadex 0.5 mg/kg, neostigmine 0.04 mg/kg and atropine 0.02 mg/kg five minutes after rocuronium administration. The cost of reversal and recovery time were measured in both groups.
Results: We analyzed the data of 36 patients (n=18 in each group). The T1/control ratios were significantly higher in Group SN than in group S at 5, 10 and 15minutes after administration of reversal agents. The TOF ratios were significantly higher in Group SN than in group S at 10 and 15minutes after administration of reversal agents. The 90% recovery time of TOF ratio in Group SN was significantly shorter than that in Group S. The cost of reversal was significantly smaller in Group SN than in Group S.
Conclusions: By partially substituting sugammadex with neostigmine, we can attain faster recovery from rocuronium-induced profound neuromuscular blockade.
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Rocuronium Bromide
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Background Traditionally, reversal of nondepolarizing neuromuscular blocking agents was achieved using acetylcholinesterase inhibitors, but these are unable to adequately reverse profound blockade. Sugammadex is a novel reversal agent, reversing the effects of rocuronium by encapsulation. This study assessed the efficacy and safety of sugammadex versus neostigmine for reversal of profound rocuronium-induced neuromuscular blockade. Methods This phase III, randomized study enrolled surgical patients, aged 18 yr or older with American Society of Anesthesiologists physical status I-IV. Patients were randomized to receive sugammadex (4.0 mg/kg) or neostigmine (70 microg/kg) plus glycopyrrolate (14 microg/kg). Anesthetized patients received an intubating dose of rocuronium (0.6 mg/kg), with maintenance doses (0.15 mg/kg) as required. Neuromuscular monitoring was performed by acceleromyography. Sugammadex or neostigmine was administered at reappearance of 1-2 posttetanic counts (profound neuromuscular blockade). The primary efficacy parameter was the time from sugammadex or neostigmine-glycopyrrolate administration to return of the train-of-four ratio to 0.9. Results In the intent-to-treat population (n = 37 in each group), geometric mean time to recovery to a train-of-four ratio of 0.9 with sugammadex was 2.9 min versus 50.4 min with neostigmine-glycopyrrolate (P < 0.0001) (median, 2.7 min vs. 49.0 min). Most sugammadex patients (97%) recovered to a train-of-four ratio of 0.9 within 5 min after administration. In contrast, most neostigmine patients (73%) recovered between 30 and 60 min after administration, with 23% requiring more than 60 min to recover to a train-of-four ratio of 0.9. Conclusions Recovery from profound rocuronium-induced neuromuscular blockade was significantly faster with sugammadex versus with neostigmine, suggesting that sugammadex has a unique ability to rapidly reverse profound rocuronium neuromuscular blockade.
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Glycopyrrolate
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