1
|
Haberkorn S, Twite M, Klockau K, Whitney G, Faulk DJ. Quantitative Monitoring Maximizes Cost-Saving Strategies When Antagonizing Neuromuscular Block With Sugammadex. Cureus 2024; 16:e68551. [PMID: 39364519 PMCID: PMC11449403 DOI: 10.7759/cureus.68551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Introduction Weight-based dosing combined with variable patient weights in pediatric anesthesia can lead to significant medication excess and waste from single-use medication vials packaged for dosing in adults. Medication aliquots have been proposed as a strategy to decrease waste and therefore expense when using high-cost medications such as sugammadex. Appropriate dosing of sugammadex to antagonize neuromuscular block is based on the results of quantitative monitoring, though the use of these monitors is not routine. In this quality improvement project, we demonstrate cost savings from aliquoting sugammadex from large, single-use vials and using quantitative monitoring to guide accurate and appropriate dosing. Methods After institutional review and approval, patients receiving rocuronium neuromuscular block during their anesthetic care between October 10 and December 9, 2022, were included for analysis. Sugammadex aliquots were prepared under sterile conditions in the operating room pharmacy according to current compounding guidelines. Quantitative neuromuscular monitoring with electromyography-based monitors was used to guide accurate sugammadex dosing. Cost analysis included the actual savings achieved when aliquots were used instead of single-use vials, the potential savings if aliquots had been used as opposed to single-use vials, and the actual savings achieved when quantitative monitoring indicated that adequate spontaneous recovery was reached and sugammadex administration was not needed. Results A total of 200 patients were included in the analysis. In 73 patients, a 200 mg/2 ml vial of sugammadex was utilized, while 86 patients received sugammadex from pre-filled aliquot syringes of 50 mg/0.5 ml. Forty-one patients did not require sugammadex antagonism as they achieved spontaneous recovery to a train-of-four ratio ≥90%. Conclusion Administration of sugammadex from aliquots rather than manufacturer-packaged single-use vials, with dosing guided by quantitative neuromuscular monitoring, produced a net cost savings of approximately $46 per case and projected net annual cost savings of nearly $370,000 in our institution. Forty percent of the net cost savings came from confirmation by quantitative monitoring of adequate spontaneous recovery to a train-of-four ratio ≥90%.
Collapse
Affiliation(s)
- Steve Haberkorn
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | - Mark Twite
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | | | - Gina Whitney
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | - Debra J Faulk
- Department of Anesthesiology, University of Colorado, Aurora, USA
| |
Collapse
|
2
|
Wang HC, Lu CW, Lin TY, Chang YY. Unexpected delayed reversal of rocuronium-induced neuromuscular blockade by sugammadex: A case report and review of literature. World J Clin Cases 2022; 10:13138-13145. [PMID: 36569003 PMCID: PMC9782926 DOI: 10.12998/wjcc.v10.i35.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Rocuronium, a nondepolarizing muscle relaxant, is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery. Sugammadex, the selective reversal agent of rocuronium, fully reverses the neuromuscular blockade (NMB) at the end of surgery. Most reports show that sugammadex rapidly achieves a ratio of train-of-four (TOF), a quantitative method of neuromuscular monitoring, of 0.9 which ensures adequate recovery for safe extubation. However, very rare patients with neuromuscular diseases may respond poorly to sugammadex.
CASE SUMMARY A 69-year-old female presented with abdominal fullness and nausea, and was diagnosed with gastroparesis. She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium (0.7 mg/kg). At the end of surgery, sugammadex 3.6 mg/kg was administered when TOF showed 2 counts. Afterward, the TOF ratio recovered to 0.65 in 30 min. She was awake but could not fully open her eyelids. The tidal volume during spontaneous breathing was low. After additional doses of sugammadex (up to 7.3 mg/kg) in the following 3 h, the TOF ratio was 0.9, and the endotracheal tube was smoothly removed. After excluding possible mechanisms underlying the prolonged recovery course, we speculated our patient may have had an undiagnosed neuromuscular disease, hinted by her involuntary movement of the tongue and mouth. Furthermore, her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.
CONCLUSION In our case, both prolonged rocuronium-induced NMB and poor response to sugammadex were noted. To optimize the dose of rocuronium, perioperative TOF combined with other neuromuscular monitoring is suggested.
Collapse
Affiliation(s)
- Hao-Chen Wang
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
| | - Cheng-Wei Lu
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Chung-Li 320, Taiwan
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Chung-Li 320, Taiwan
| | - Ya-Ying Chang
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- International Program in Engineering for Bachelor, Yuan Ze University, Chung-Li 320, Taiwan
| |
Collapse
|
3
|
Fiorda Diaz J, Echeverria-Villalobos M, Esparza Gutierrez A, Dada O, Stoicea N, Ackermann W, Abdel-Rasoul M, Heard J, Uribe A, Bergese SD. Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center. Front Med (Lausanne) 2022; 9:1072711. [PMID: 36569123 PMCID: PMC9772266 DOI: 10.3389/fmed.2022.1072711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine. Methods We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes. Results Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs. Discussion Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution. Clinical trial registration [https://clinicaltrials.gov/] identifier number [NCT03579589].
Collapse
Affiliation(s)
- Juan Fiorda Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Alan Esparza Gutierrez
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Olufunke Dada
- Department of Anesthesiology, University of Toledo, Toledo, OH, United States
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wiebke Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mahmoud Abdel-Rasoul
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jarrett Heard
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, United States
| |
Collapse
|
4
|
Lee C, Ahsan H, Chae H, Esnard DM, Broussard D, Hart S, Allain A, Bond B, Busch E, Jhita P, Matte M, Stedman R, Lessing J, Koveleskie J, Nossaman BD. Perioperative Efficiency of Sugammadex Following Laparoscopic Cholecystectomy in Clinical Practice. Ochsner J 2022; 22:292-298. [PMID: 36561110 PMCID: PMC9753942 DOI: 10.31486/toj.22.0064] [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] [Indexed: 12/24/2022] Open
Abstract
Background: Studies have proposed that the routine use of the modified gamma-cyclodextrin, sugammadex, could provide perioperative time savings. However, these investigations have been limited to small group analyses. The purpose of this study was to test the effectiveness of sugammadex on perioperative times when compared to neostigmine under general clinical practice conditions following rocuronium-induced neuromuscular blockade for laparoscopic cholecystectomy. Methods: Following institutional review board approval, data from 1,611 consecutive surgical records for laparoscopic cholecystectomy were reviewed. Patient characteristics, type of primary neuromuscular blocking reversal agent, operating room (OR) discharge times, and postanesthesia care unit (PACU) recovery times were the measures of interest. Equivalence testing was used to determine the between-group differences of the reversal agents in the two perioperative time periods of interest. Results: OR discharge times averaged 10.9 (95% CI, 10-11.8) minutes for patients administered sugammadex and 8.9 (95% CI, 8.2-9.7) minutes for patients administered neostigmine. PACU recovery times averaged 77.6 (95% CI, 74.1-81.1) minutes for sugammadex and 68.6 (95% CI, 65.9-71.3) minutes for neostigmine. Equivalence testing demonstrated no improvement in the two perioperative times with sugammadex. Conclusion: These results suggest no perioperative time savings with sugammadex when compared to neostigmine following laparoscopic cholecystectomy under general clinical practice conditions.
Collapse
Affiliation(s)
- Christian Lee
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
| | - Hana Ahsan
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
| | - Hoon Chae
- Department of Internal Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ
| | - Danielle M Esnard
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - David Broussard
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Stuart Hart
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Alex Allain
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Brittany Bond
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Eric Busch
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Preya Jhita
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Melissa Matte
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Robin Stedman
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Jacob Lessing
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Joseph Koveleskie
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Bobby D Nossaman
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
| |
Collapse
|
5
|
Nossaman LE, Nossaman BD. Hawthorne Effect: More Than Just Telephones. Ochsner J 2022; 22:286-289. [PMID: 36561101 PMCID: PMC9753954 DOI: 10.31486/toj.22.5031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Bobby D Nossaman
- Department of Anesthesiology and Perioperative Medicine, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
| |
Collapse
|
6
|
Duranteau O, Fernandez W, Tuna T, Engelman E, Van Obbergh L, Tabolcea I. Earlier and lower dose administration of sugammadex: A randomised placebo-controlled trial. Eur J Anaesthesiol 2021; 38:865-871. [PMID: 33813569 DOI: 10.1097/eja.0000000000001502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sugammadex allows for rapid reversal of muscle relaxation after the use of rocuronium or vecuronium. The lowest recommended dose is 2 mg kg-1 intravenously when there are two twitches during the train-of-four stimulation. OBJECTIVE To study the efficacy and risks of a lower dose of sugammadex administered earlier. DESIGN Monocentric randomised controlled double-blind study. SETTING Academic hospital. PATIENTS Eighty patients were enrolled and randomised in 8 groups of 10 patients, 56 were finally evaluated. INTERVENTIONS Patients were distributed in two clusters constituting four groups each. In the first cluster, injections were administered after the return of one twitch with the train-of-four (TOF1). In the second cluster, injections were delivered after the return of two twitches with the TOF (TOF2). We created four groups in each cluster for different dosages: placebo, 0.5, 1 or 2 mg kg-1. MAIN OUTCOME MEASURES Time between the injection of sugammadex and full recovery (TOF ratio > 0.9) that is expressed in minutes. RESULTS Fifty-six successive patients were assessed between February and August 2018. The difference to TOF greater than 0.9 was not statistically significant between groups with the same dose administered at different times (F value = 0.001, P value = 0.975). There was a significant difference between groups with a different dosage administered at the same time (F ratio = 28.34; P value <0.0001). Concerning the time to TOF greater than 0.9 from the time point of TOF1, the timing of the dosages were statistically significant using log rank test (P < 0.0001). No patient presented a reparalysis. CONCLUSION No difference between injecting sugammadex at TOF1 or TOF2 was found regarding time to full recovery. Difference regarding sugammadex quantity was found and compatible with other studies. TRIAL REGISTRATION clinicaltrials.gov: 'BRIDION_ERASME', EudraCT: 2017-005074-19.
Collapse
Affiliation(s)
- Olivier Duranteau
- From the Anesthesiology Service, CUB-ULB Erasme, Brussels, Belgium (OD, WF, TT, EE, LVO, IT)
| | | | | | | | | | | |
Collapse
|
7
|
Motamed C, Bourgain JL. Comparison of the Time to Extubation and Length of Stay in the PACU after Sugammadex and Neostigmine Use in Two Types of Surgery: A Monocentric Retrospective Analysis. J Clin Med 2021; 10:jcm10040815. [PMID: 33671391 PMCID: PMC7921908 DOI: 10.3390/jcm10040815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
Sugammadex provides a rapid pharmacological reversal of aminosteroid, as well as fewer pulmonary complications, a better physiological recovery, and shorter stays in the postanesthetic recovery unit (PACU). This retrospective analysis of our Centricity anesthesia database in 2017–2019 assessed the efficiency of sugammadex in real-life situations in two groups of surgical cancer patients (breast and abdominal surgery) based on the extubation time, operating room exit time, and length of PACU stay. Overall, 382 anesthesia records (131 breast and 251 abdominal surgeries) were extracted for the pharmacological reversal of neuromuscular blockades by neostigmine or sugammadex. Sugammadex was used for reversal in 91 breast and 204 abdominal surgeries. Sugammadex use did not affect the extubation time, operating room exit time, or length of PACU stay. However, the time to reach a 90% train of four (TOF) recovery was significantly faster in sugammadex patients: 2 min (1.5–8) in breast surgery and 2 min (1.5–7) in abdominal surgery versus 10 (6–20) and 9 min (5–20), respectively, for neostigmine (p < 0.05). Most patients who were reversed with sugammadex (91%) reached a TOF ratio of at least 90%, while 54% of neostigmine patients had a 90% TOF ratio recorded (p < 0.05). Factors other than pharmacological reversal probably influence the extubation time, operating room exit time, or PACU stay; however, sugammadex reliably shortened the time so as to reach a 90% TOF ratio with a better level of reversal.
Collapse
|
8
|
Dubovoy TZ, Saager L, Shah NJ, Colquhoun DA, Mathis MR, Kapeles S, Mentz G, Kheterpal S, Vaughn MT. Utilization Patterns of Perioperative Neuromuscular Blockade Reversal in the United States: A Retrospective Observational Study From the Multicenter Perioperative Outcomes Group. Anesth Analg 2020; 131:1510-1519. [PMID: 33079874 PMCID: PMC7593983 DOI: 10.1213/ane.0000000000005080] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Following the introduction of sugammadex to the US clinical practice, scarce data are available to understand its utilization patterns. This study aimed to characterize patient, procedure, and provider factors associated with sugammadex administration in US patients. METHODS This retrospective observational study was conducted across 24 Multicenter Perioperative Outcomes Group institutions in the United States with sugammadex on formulary at the time of the study. All American Society of Anesthesiologists (ASA) physical status I-IV adults undergoing noncardiac surgery from 2014 to 2018 receiving neuromuscular blockade (NMB) were eligible. The study established 3 periods based on the date of first documented sugammadex use at each institution: the presugammadex period, 0- to 6-month transitional period, and 6+ months postsugammadex period. The primary outcome was reversal using sugammadex during the postsugammadex period-defined as 6 months after sugammadex was first utilized at each institution. A multivariable mixed-effects logistic regression model controlling for institution was developed to assess patient, procedure, and provider factors associated with sugammadex administration. RESULTS A total of 934,798 cases met inclusion criteria. Following the 6-month transitional period, sugammadex was used on average in 40.0% (95% confidence interval [CI], 39.8-40.2) of cases receiving NMB. Multivariable analysis demonstrated sugammadex use to be associated with train-of-four count of 0-1 (adjusted odds ratio = 4.06; 95% CI, 33.83-4.31) or 2 (2.45; 2.29-2.62) vs 3-4 twitches before reversal; the amount of NMB administered (3.01; 2.88-3.16) for the highest effective dose 95 quartile compared to the lowest quartile; advanced age (1.83; 1.71-1.95) compared to age <41; male sex (1.36; 1.32-1.39) compared to female sex; major thoracic surgery (1.26; 1.13-1.39); congestive heart failure (1.17, 1.07-1.28); and ASA III or IV (1.13; 1.10-1.16) versus ASA I or II. CONCLUSIONS Our data demonstrate broad early clinical adoption of sugammadex following Food and Drug Administration approval. Sugammadex is used preferentially in cases with higher degrees of NMB before reversal and in patients with greater burden of comorbidities and known risk factors for residual blockade or pulmonary complications.
Collapse
Affiliation(s)
- Timur Z Dubovoy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Leif Saager
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Nirav J Shah
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Douglas A Colquhoun
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michael R Mathis
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven Kapeles
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Graciela Mentz
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michelle T Vaughn
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
9
|
Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
Collapse
Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| |
Collapse
|
10
|
Luthe SK, Iwasaki H. The Financial and Humanistic Costs Associated with Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00402-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
11
|
Pimentel MP, Billings F, Sivashanker K, Sarin P, Fields K, Cotugno M, Eappen S, Urman RD. Reducing Medication Waste While Improving Access to Sugammadex: A Quality Improvement Project in Medication Stewardship. A A Pract 2020; 14:e01223. [PMID: 32539276 DOI: 10.1213/xaa.0000000000001223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The relatively high cost of sugammadex compared to neostigmine limits its widespread use to reverse neuromuscular blockade, despite its faster onset and more complete clinical effect. While ensuring timely access to sugammadex is important in improving perioperative safety, it is also vital to control unnecessary spending. We describe a quality improvement initiative to reduce excess spending on sugammadex while improving access for anesthesia providers. Monthly spending on sugammadex decreased by 52% ($70,777 vs $33,821), while medication access increased via automated medication dispensers in each operating room. Clinical usage decreased by one-third, with presumed increased adherence to dosing guidelines.
Collapse
Affiliation(s)
- Marc Philip Pimentel
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School.,Quality and Safety
| | - Felicity Billings
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School
| | | | - Pankaj Sarin
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School
| | - Kara Fields
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School
| | - Michael Cotugno
- Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sunil Eappen
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School
| | - Richard D Urman
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School
| |
Collapse
|
12
|
Moon TS, Reznik S, Pak T, Jan K, Pruszynski J, Kim A, Smith KM, Lu R, Chen J, Gasanova I, Fox PE, Ogunnaike B. Sugammadex versus neostigmine for reversal of rocuronium-induced neuromuscular blockade: A randomized, double-blinded study of thoracic surgical patients evaluating hypoxic episodes in the early postoperative period. J Clin Anesth 2020; 64:109804. [PMID: 32353805 DOI: 10.1016/j.jclinane.2020.109804] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE This objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus neostigmine results in a decreased number of hypoxic episodes in the early postoperative period in patients undergoing thoracic surgery with single lung ventilation. DESIGN Single-center, randomized, double-blind, two-arm clinical trial. SETTING Operating room and postanesthesia care unit. PATIENTS 92 subjects aged ≥18, American Society of Anesthesiologists physical status II-IV, and undergoing a thoracic operation necessitating single lung ventilation. INTERVENTIONS Subjects received either 2 mg/kg sugammadex or 50 μg/kg neostigmine with 8 μg/kg glycopyrrolate for reversal of moderate neuromuscular blockade. MEASUREMENTS For the first 90 min postoperatively, all episodes of hypoxia were recorded. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch® SX) and the train of four (TOF) was recorded at 2, 5, 10, and 15 min after administration of the neuromuscular reversal agent. MAIN RESULTS Subjects who received neostigmine had a median of 1 episode (interquartile range IQR: 0-2.2) of hypoxia versus subjects who received sugammadex who had a median of 0 episodes (IQR: 0-1) (p = 0.009). The mean time to recovery of TOF ≥ 0.9 was significantly faster with sugammadex at 10 min (95% confidence interval CI: 5-15) compared with neostigmine at 40 min (95% CI: 15-53) (p < 0.001). CONCLUSIONS In thoracic surgical patients necessitating single lung ventilation, sugammadex provides faster reversal of moderate neuromuscular blockade and results in a decreased number of postoperative hypoxic episodes compared with neostigmine.
Collapse
Affiliation(s)
- Tiffany S Moon
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Scott Reznik
- University of Texas Southwestern Medical Center, Department of Cardiovascular and Thoracic Surgery, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Taylor Pak
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Kathryn Jan
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Jessica Pruszynski
- University of Texas Southwestern Medical Center, Department of Cardiovascular and Thoracic Surgery, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Agnes Kim
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Katelynn M Smith
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Rachael Lu
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Joy Chen
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Irina Gasanova
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Pamela E Fox
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Babatunde Ogunnaike
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| |
Collapse
|
13
|
Kim JS, Han JW, Lee JH, Choi JM, Kim HJ, Sung TY, Kim YB, Shin YS, Yang HS. Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey. Anesth Pain Med (Seoul) 2019; 14:441-448. [PMID: 33329775 PMCID: PMC7713803 DOI: 10.17085/apm.2019.14.4.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/28/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jin Sun Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jung Woo Han
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Ho Lee
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hopsital, Konyang University College of Medicine, Daejeon, Korea
| | - Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Yong Seop Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Sun General Hospital, Daejeon, Korea
| |
Collapse
|
14
|
Hawkins J, Khanna S, Argalious M. Sugammadex for Reversal of Neuromuscular Blockade: Uses and Limitations. Curr Pharm Des 2019; 25:2140-2148. [DOI: 10.2174/1381612825666190704101145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/20/2019] [Indexed: 12/18/2022]
Abstract
Sugammadex is a reversal agent that was engineered to reverse the effects of aminosteroid muscle relaxants. It is a modified gamma-cyclodextrin, i.e. a large glucose molecule bound in a ring-like structure. Sugammadex, when injected intravenously, creates a concentration gradient favoring the movement of aminosteroid muscle relaxants from the neuromuscular junction back into the plasma, and then encapsulates the aminosteroid muscle relaxants within its inner structure by forming tight water-soluble complexes. The dissociation of the aminosteroidal muscle relaxant from the post-synaptic acetylcholine receptors is responsible for the termination of neuromuscular blockade. This review article presents the current indication, mechanism of action, limitations, side effects and contraindications of sugammadex. An overview of monitoring of the adequacy of reversal of aminosteroid muscle relaxants with sugammadex is presented. Moreover, the use of sugammadex in special situations, including “cannot intubate cannot oxygenate” scenarios is also described.
Collapse
|
15
|
Lee YJ, Money K, Elliott A. Sugammadex compared with Neostigmine/Glycopyrrolate: An Analysis of Total PACU Time, Responsiveness, and Potential for Economic Impact. Innov Pharm 2019; 10. [PMID: 34007560 PMCID: PMC8127084 DOI: 10.24926/iip.v10i3.1798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Studies have previously shown sugammadex works faster and more effectively than neostigmine/glycopyrrolate at reversal of neuromuscular blockade by rocuronium and vecuronium. The purpose of this quality improvement study was to evaluate for differences in patient time spent in the operating room (OR), post-anesthesia care unit (PACU), and patient responsiveness between the sugammadex and neostigmine/glycopyrrolate groups at a small surgical center. Additionally, a cost analysis was conducted to assess potential savings associated with sugammadex use, taking into account the differences in OR time, PACU time, and medication acquisition cost. We conducted a prospective analysis of OR time, PACU time, and responsiveness for a total of 152 patients, 76 patients receiving neostigmine/glycopyrrolate and 76 patients receiving sugammadex, undergoing planned surgery over an 8-week period. We identified an average decrease in total OR time of 6 minutes in the sugammadex group (neostigmine/glycopyrrolate [Mean: 86 min, Median: 77 min, Range 32-211 min] vs sugammadex [Mean: 80 min, Median: 77 min, Range 40-150 min]). Furthermore, there was an average decrease in total PACU time of 6 minutes in the sugammadex group (neostigmine/glycopyrrolate [Mean: 60 min, Median: 56 min, Range 32-154 min] vs sugammadex [Mean: 54 min, Median: 51 min, Range: 28-94 min]). Additionally, the percent of patients fully awake at the end of PACU stay was higher in the sugammadex group than the neostigmine/glycopyrrolate group (86% vs 79% respectively). Cost was evaluated for generating hypotheses. The additional cost of using sugammadex was estimated at $77 per person when compared to neostigmine/glycopyrrolate. However, if the use of sugammadex decreased the time in OR and PACU by an average of 12 minutes per patient, it is possible that it could provide a potential savings of $579 per patient after estimating a soft savings of reduced OR, PACU, and staff time. Overall cost saving per patient with sugammadex, which was calculated after subtracting additional medication acquisition cost, is $502. It is possible that if this value is extrapolated to 988 patients, this might suggest a potential cost savings of $495,976 per year. We hope this study provokes future research to determine if Sugammadex is a potentially viable economical option for the routine reversal of neuromuscular blockade.
Collapse
Affiliation(s)
- Yoon Jung Lee
- Department of Pharmacy, BSA Health System, Amarillo, TX
| | - Kayla Money
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center (TTUHSC), Amarillo, TX
| | - Amber Elliott
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center (TTUHSC), Amarillo, TX
| |
Collapse
|