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Chia PA, Wolfe MW. Sugammadex-Associated Anaphylaxis: Summary and Proposed Management. Anesth Analg 2024; 139:273-277. [PMID: 38446697 DOI: 10.1213/ane.0000000000006759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Affiliation(s)
- Pamela A Chia
- From the Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
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2
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An Y, Wang T, Li L, Li Z, Liang C, Wang P, Jia X, Song H, Zhao L. Impact of neuromuscular block on myocardial injury after non-cardiac surgery (MINS) incidence in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection: a randomized controlled study. BMC Geriatr 2024; 24:509. [PMID: 38862916 PMCID: PMC11167868 DOI: 10.1186/s12877-024-05125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a common and serious complication in older patients. This study investigates the impact of neuromuscular block on the MINS incidence and other cardiovascular complications in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection. METHODS 70 older patients who underwent laparoscopic colorectal cancer resection were separated into the deep neuromuscular block group and moderate neuromuscular block group for 35 cases in each group (n = 1:1). The deep neuromuscular block group maintained train of four (TOF) = 0, post-tetanic count (PTC) 1-2, and the moderate neuromuscular block group maintained TOF = 1-2 during the operation. Sugammadex sodium was used at 2 mg/kg or 4 mg/kg for muscle relaxation antagonism at the end of surgery. The MINS incidence was the primary outcome and compared with Fisher's exact test. About the secondary outcomes, the postoperative pain was analyzed with Man-Whitney U test, the postoperative nausea and vomiting (PONV) and the incidence of cardiovascular complications were analyzed with Chi-square test, intraoperative mean artery pressure (MAP) and cardiac output (CO) ratio to baseline, length of stay and dosage of anesthetics were compared by two independent samples t-test. RESULTS MINS was not observed in both groups. The highest incidence of postoperative cardiovascular complications was lower limbs deep vein thrombosis (14.3% in deep neuromuscular block group and 8.6% in moderate neuromuscular group). The numeric rating scale (NRS) score in the deep neuromuscular block group was lower than the moderate neuromuscular block group 72 h after surgery (0(1,2) vs 0(1,2), P = 0.018). The operation time in the deep neuromuscular block group was longer (356.7(107.6) vs 294.8 (80.0), min, P = 0.008), the dosage of propofol and remifentanil was less (3.4 (0.7) vs 3.8 (1.0), mg·kg-1·h-1, P = 0.043; 0.2 (0.06) vs 0.3 (0.07), μg·kg-1·min-1, P < 0.001), and the length of hospital stay was shorter than the moderate neuromuscular block group (18.4 (4.9) vs 22.0 (8.3), day, P = 0.028). The differences of other outcomes were not statistically significant. CONCLUSIONS Maintaining different degrees of the neuromuscular block under TOF guidance did not change the MINS incidence within 7 days after surgery in older patients who underwent laparoscopic colorectal cancer resection. TRIAL REGISTRATION The present study was registered in the Chinese Clinical Trial Registry (10/02/2021, ChiCTR2100043323).
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Affiliation(s)
- Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Chuanyu Liang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Pei Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Xuefei Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hongyi Song
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
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3
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Oh MW, Mohapatra SG, Pak T, Hermawan A, Chen CA, Thota B, Chen J, Siu E, Park J, Moon TS. Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study. Anesth Analg 2024; 138:1043-1051. [PMID: 38190344 DOI: 10.1213/ane.0000000000006807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.
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Affiliation(s)
- Matthew W Oh
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shweta G Mohapatra
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taylor Pak
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aundree Hermawan
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chieh-An Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhavana Thota
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joy Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Siu
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Park
- Department of Biostatistics, Southern Methodist University, Dallas, Texas
| | - Tiffany S Moon
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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4
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Subramani Y, Rajarathinam M, Dabirzadeh A, Tawfic Q, Krause S, Avci Y, Nagappa M. Comparison of Different Weight Scalars to Dose Sugammadex for the Reversal of Neuromuscular Blockade in Morbidly Obese Patients: A Systematic Review. Cureus 2024; 16:e57057. [PMID: 38681306 PMCID: PMC11051669 DOI: 10.7759/cureus.57057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
This systematic review was conducted to evaluate the optimal weight scalar to dose sugammadex in a morbidly obese (MO) patient population (BMI≥40 kg/m2). The primary outcome was recovery time from moderate neuromuscular blockade (NMB) or deep NMB. Secondary outcomes included time to extubation and incidence of postoperative residual curarization (PORC). Eight randomized controlled trials (RCTs) involving 645 participants were included. The different dose scalars included were total body weight (TBW), ideal body weight (IBW), 20% corrected body weight (CBW) and 40% CBW). A dose of 2 mg/kg of sugammadex based on 40% CBW and a 4 mg/kg dose of sugammadex based on 40% CBW provide a reliable and timely reversal of moderate and deep NMB respectively in the MO patients.
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Affiliation(s)
- Yamini Subramani
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, Canada
| | - Manikandan Rajarathinam
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Anita Dabirzadeh
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Qutaiba Tawfic
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
| | - Sarah Krause
- Medical Sciences, Western University, London, CAN
| | - Yasin Avci
- Interdisciplinary Arts and Science, Western University, London, CAN
| | - Mahesh Nagappa
- Anesthesiology and Perioperative Medicine, London Health Sciences Centre, Western University, London, CAN
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Bucheery BA, Isa HM, Rafiq O, Almansoori NA, Razaq ZAA, Gawe ZA, Almoosawi JA. Residual Neuromuscular Blockade and Postoperative Pulmonary Complications in the Post-anesthesia Care Unit: A Prospective Observational Study. Cureus 2023; 15:e51013. [PMID: 38264400 PMCID: PMC10803948 DOI: 10.7759/cureus.51013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/25/2024] Open
Abstract
Background Neuromuscular blocking agents (NMBAs) are employed during general anesthesia induction for endotracheal intubation and to facilitate specific surgeries requiring muscle relaxation. However, residual neuromuscular blockade (RNMB) can lead to respiratory complications in post-anesthesia care units (PACUs). This study investigates RNMB incidence in PACUs and its association with postoperative airway and respiratory issues. Methods A prospective observational study on patients undergoing general anesthesia with NMBAs was conducted at the Department of Anesthesia, Salmaniya Medical Complex, Bahrain, over six months (April to September 2023). Train-of-four (TOF) ratios were calculated using an acceleromyograph upon PACU arrival. Data on demographics, perioperative variables, and postoperative complications were recorded. Results Among 82 patients, 30 (36.6%) had RNMB upon PACU arrival. RNMB incidence declined: 17.1% at 10 minutes, 6.1% at 20 minutes, and 2.4% at 30 minutes, resolving by 40 minutes. Demographics and procedure duration showed no correlation with RNMB. Postoperative respiratory complications affected 23.2% of patients, notably higher in those with RNMB (p = 0.001). Among patients with TOF <90% at PACU arrival, 46.7% experienced complications compared to 9.6% with TOF ≥90% (p<0.001). Participants without RNMB had a significantly higher weight (p = 0.046). Airway support was required for 30% of patients, all with TOF <90% (p<0.001). Conclusion This study emphasizes the importance of assessing and monitoring neuromuscular function to detect and prevent RNMB in PACUs. RNMB presence correlated with an increased susceptibility to postoperative respiratory complications. Regular quantitative neuromuscular monitoring is advisable in clinical practice to proactively mitigate RNMB incidence and its complications.
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Affiliation(s)
| | - Hasan M Isa
- Department of Pediatrics, Arabian Gulf University, Manama, BHR
- Department of Pediatrics, Salmaniya Medical Complex, Manama, BHR
| | - Owais Rafiq
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
| | | | | | - Zeana A Gawe
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
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Kim S, Choo H, Jung H, Kim JH. Sugammadex-induced bronchospasm: a case report. J Dent Anesth Pain Med 2023; 23:287-291. [PMID: 37841521 PMCID: PMC10567541 DOI: 10.17245/jdapm.2023.23.5.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 10/17/2023] Open
Abstract
Sugammadex has shown faster reversal of steroidal neuromuscular blockade (NMB) than neostigmine, a traditional reversal agent for NMB, even in the intense block phase. This efficiency is possible because of the unique mechanism of action by encapsulating the NMB molecules. Therefore, with the use of sugammadex, we can also expect to avoid direct interactions with the cholinergic system and its subsequent side effects, which are disadvantages of traditional drugs. However, despite these benefits and US Food and Drug Administration (FDA) approval in 2015, rare adverse events associated with sugammadex have been reported. Herein, we report a case of bronchospasm that developed immediately after sugammadex administration.
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Affiliation(s)
- Saeyoung Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyojun Choo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hoon Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ji Hyun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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8
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Yang J, Crosby T, Chen S, Ezeh UC, Patil S, Kwak PE, Chin WA, Amin MR. Paralysis Versus Non-Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial. Laryngoscope 2023; 133:2654-2664. [PMID: 36715102 DOI: 10.1002/lary.30571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA). METHODS This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected. RESULTS Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0). CONCLUSIONS Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia. LEVEL OF EVIDENCE 2 Laryngoscope, 133:2654-2664, 2023.
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Affiliation(s)
- Jackie Yang
- NYU Grossman School of Medicine, New York, New York, USA
| | - Tyler Crosby
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone, New York, New York, USA
| | - Sophia Chen
- NYU Grossman School of Medicine, New York, New York, USA
| | - Uche C Ezeh
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone, New York, New York, USA
| | - Sachi Patil
- NYU Grossman School of Medicine, New York, New York, USA
| | - Paul E Kwak
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone, New York, New York, USA
| | - Wanda A Chin
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Milan R Amin
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone, New York, New York, USA
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9
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Schmidt M, Rössler J, Brooker J, Lara-Erazo V, Ekrami E, Pu X, Turan A, Sessler DI, Ruetzler K. Postoperative oxygenation assessed by SpO 2/FiO 2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study. J Clin Anesth 2023; 88:111138. [PMID: 37148836 DOI: 10.1016/j.jclinane.2023.111138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/31/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Residual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization. DESIGN Retrospective cohort analysis. SETTING Postoperative recovery area of a tertiary care hospital. PATIENTS Adults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex. INTERVENTIONS None. MEASUREMENTS The primary outcome was the lowest SpO2/FiO2 ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications. MAIN RESULTS Among 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO2/FiO2 ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of -3.5 (95% confidence interval: -5.3, -1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease. CONCLUSIONS Postoperative minimum SpO2/FiO2 ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.
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Affiliation(s)
- Marc Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jack Brooker
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Valentina Lara-Erazo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Xuan Pu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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10
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Carron M, Tamburini E, Ieppariello G, Linassi F. Reversal of neuromuscular block with sugammadex compared with neostigmine and postoperative pulmonary complications in obese patients: meta-analysis and trial sequential analysis. Br J Anaesth 2023; 130:e461-e463. [PMID: 37028987 DOI: 10.1016/j.bja.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023] Open
Affiliation(s)
- Michele Carron
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padova, Padova, Italy.
| | - Enrico Tamburini
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Giovanna Ieppariello
- Institute of Anaesthesia and Intensive Care - Azienda Ospedale Università Padova, Padova, Italy
| | - Federico Linassi
- Department of Anaesthesia and Intensive Care, Ca' Foncello Treviso Regional Hospital, Treviso, Italy
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11
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Lyu Q, Ye P, Zhang H, Ye X, Zheng Y, Xu J, Chen X, Chen C, Guo X. Safety of sugammadex for reversal of neuromuscular block: A postmarketing study based on the World Health Organization pharmacovigilance database. Br J Clin Pharmacol 2023; 89:449-457. [PMID: 35607986 DOI: 10.1111/bcp.15417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 01/18/2023] Open
Abstract
AIM Residual neuromuscular blockade is a common complication after general anaesthesia. Sugammadex can reverse the action of aminosteroid neuromuscular blockers. This study aimed to explore sugammadex safety issues in the real world and determine the spectrum of adverse reactions. METHODS All sugammadex-related adverse events reported in VigiBase between 2010 and 2019 were classified by group queries according to the Medical Dictionary for Regulatory Activities. A disproportionality analysis of data was performed using the information component (IC); positive IC values were deemed significant. RESULTS Overall, 16 219 410 adverse events were reported and 2032 were associated with sugammadex. The frequent reactions were recurrence of neuromuscular blockade (n = 54, IC 6.74, IC025 6.33), laryngospasm (n = 53, IC 6.05, IC025 5.64), bronchospasm (n = 119, IC 5.63, IC025 5.36) and bradycardia (n = 169, IC 5.13, IC025 4.90). Fatal cases were more likely among patients with cardiac disorders, especially those over 65 years. In addition, the common adverse drug reactions (ADRs) differed between different age groups (P < .01). ADRs were higher in the 0-17 years age group than in other age groups. The onset time of common ADRs was typically within 1 day and 68.9% occurred within half an hour after sugammadex administration. CONCLUSIONS Anaesthesiologists should carefully monitor the anaesthesia recovery period to correct the ADRs caused by sugammadex and recommend monitoring neuromuscular function throughout the anaesthesia process. Sugammadex should be used carefully in patients with cardiovascular diseases, and electrocardiography and hemodynamic changes should be monitored after medication.
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Affiliation(s)
- Qiang Lyu
- Basic Medical College, Naval Medical University, Shanghai, China.,92608 Militang Hospital of PLA, Shanghai, China
| | - Pei Ye
- Department of Anaesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Hewei Zhang
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Yi Zheng
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Jinfang Xu
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Xiao Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Chenxin Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
| | - Xiaojing Guo
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, China
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12
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Kadiyala M, Gedulig T, Banik RK. Adverse Effects of Sugammadex on the Cardiovascular System. Cureus 2023; 15:e34728. [PMID: 36909044 PMCID: PMC9997420 DOI: 10.7759/cureus.34728] [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: 02/07/2023] [Indexed: 02/10/2023] Open
Abstract
Perioperative anaphylaxis is rare but potentially life-threatening. Although the most common causative agents are muscle relaxants and antibiotics, there have been several case reports of sugammadex-induced anaphylactic reactions. Though most cases of perioperative anaphylaxis present after induction, sugammadex anaphylaxis presents at the end of the case, sometimes in unmonitored situations such as after extubation or during transport to the recovery unit. Here we report a case of suspected sugammadex-induced anaphylaxis that led to cardiac arrest. We emphasize that vigilance is required when a high dose of sugammadex is used for the reversal of neuromuscular blockade.
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Affiliation(s)
- Mamatha Kadiyala
- Anesthesiology and Reanimation, University of Massachusetts Memorial Medical Center, Worchester, USA
| | - Thomas Gedulig
- Anesthesiology, University of Connecticut, Bloomfield, USA
| | - Ratan K Banik
- Anesthesiology, University of Minnesota, Minneapolis, USA
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13
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Cost-Effectiveness of Sugammadex Versus Neostigmine to Reverse Neuromuscular Blockade in a University Hospital in Taiwan: A Propensity Score-Matched Analysis. Healthcare (Basel) 2023; 11:healthcare11020240. [PMID: 36673608 PMCID: PMC9859243 DOI: 10.3390/healthcare11020240] [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: 12/21/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
Sugammadex has several pharmacological advantages over neostigmine, including faster reversal of neuromuscular blockade and fewer adverse effects. However, the economic impact of sugammadex remains controversial due to the considerable heterogeneity of study designs and clinical settings in previous studies. In a post-hoc analysis of a randomized controlled trial, we evaluated patients who underwent elective surgeries and general anesthesia with endotracheal intubation in a medical center in Taiwan between March 2020 and August 2020. Patients were divided into either the sugammadex or neostigmine group based on the neuromuscular blocking drug used. Propensity score matching was used to balance the baseline patient characteristics between the two groups. The patient’s recovery from anesthesia and the putative cost-effectiveness of sugammadex versus neostigmine was assessed. Derived cost-effectiveness using personnel costs in the operating room and the post-anesthesia care unit was estimated using multiple linear regression models. A total of 2587 and 1784 patients were included before and after matching, respectively. Time to endotracheal extubation was significantly shorter in the sugammadex group (mean 6.0 ± standard deviation 5.3 min) compared with the neostigmine group (6.6 ± 6.3 min; p = 0.0032). In addition, the incidence of bradycardia was significantly lower in the sugammadex group (10.2%) compared with the neostigmine group (16.9%; p < 0.001). However, the total costs were significantly lower in the neostigmine group (50.6 ± 21.4 United States dollars) compared with the sugammadex group (212.0 ± 49.5 United States dollars). Despite improving postoperative recovery, the benefits of sugammadex did not outweigh its higher costs compared with neostigmine, possibly due to the low costs of labor in Taiwan’s healthcare system.
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14
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Díaz-Cambronero O, Serrano A, Abad-Gurumeta A, Garutti Martinez I, Esteve N, Alday E, Ferrando C, Mazzinari G, Vila-Caral P, Errando Oyonarte CL. Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:37-50. [PMID: 36621572 DOI: 10.1016/j.redare.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.
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Affiliation(s)
- O Díaz-Cambronero
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - A Serrano
- Hospital Ramón y Cajal, Madrid, Spain.
| | | | | | - N Esteve
- Hospital Son Espases, Palma de Mallorca, Mallorca, Spain.
| | - E Alday
- Hospital de La Princesa, Madrid, Spain.
| | | | - G Mazzinari
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - P Vila-Caral
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - C L Errando Oyonarte
- Hospital Can Misses, Ibiza, Islas Baleares, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
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15
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Sugammadex-Induced Bradycardia and Anaphylaxis and Proposed Mechanism for Adverse Events. Am J Ther 2023; 30:e72-e76. [PMID: 36608072 DOI: 10.1097/mjt.0000000000001590] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 01/07/2023]
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16
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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].
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Affiliation(s)
- Juan Fiorda Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Juan Fiorda Diaz,
| | | | - 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
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17
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Chang HC, Liu SY, Lee MJ, Lee SO, Wong CS. Sugammadex reversal of muscle relaxant blockade provided less Post-Anesthesia Care Unit adverse effects than neostigmine/glycopyrrolate. J Formos Med Assoc 2022; 121:2639-2643. [PMID: 35577643 DOI: 10.1016/j.jfma.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022] Open
Abstract
Sugammadex is a direct reversal agent of aminosteroid muscle relaxants, particularly rocuronium, with promptly and completely reverse of deep neuromuscular block (NMB), which allows better surgical conditions. Sugammadex exhibits advantages over indirect reversal agent acetylcholinesterase inhibitor neostigmine with less adverse effects. In this retrospective review, we compared the incidence of postoperative vomiting (POV), postoperative urinary retention (POUR), and hemodynamic changes between sugammadex and neostigmine/glycopyrrolate in reversal of muscular blockade. Sugammadex showed superior in all three aspects. The heart rate was 7.253 lower (P < 0.0001) and mean arterial pressure was 5.213 lower (P < 0.0001) in sugammadex group. The POV of neostigmine/glycopyrrolate group was 3.16 times more than sugammadex group (OR = 3.16, p < 0.0001), and POUR of neostigmine/glycopyrrolate group was 4.291 times more than sugammadex group (OR = 4.291, p < 0.0001). Sugammadex showed better hemodynamic stability, and lower incidence of POV and POUR than neostigmine/glycopyrrolate.
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Affiliation(s)
- Hsiao-Cheng Chang
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan
| | - Shih-Yuan Liu
- School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Min-Jia Lee
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan
| | - Sing-Ong Lee
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan
| | - Chih-Shung Wong
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan; School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
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18
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Tesoro S, Gamba P, Bertozzi M, Borgogni R, Caramelli F, Cobellis G, Cortese G, Esposito C, Gargano T, Garra R, Mantovani G, Marchesini L, Mencherini S, Messina M, Neba GR, Pelizzo G, Pizzi S, Riccipetitoni G, Simonini A, Tognon C, Lima M. Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP). Surg Endosc 2022; 36:7877-7897. [PMID: 36121503 PMCID: PMC9613560 DOI: 10.1007/s00464-022-09577-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy.
| | - Mirko Bertozzi
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Fabio Caramelli
- Anesthesia and Intensive Care Unit, IRCCS Sant'Orsola Polyclinic, Bologna, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children's Hospital, Polytechnical University of Marche, Ancona, Italy
| | - Giuseppe Cortese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
| | - Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giulia Mantovani
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Laura Marchesini
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS San Matteo Polyclinic, Pavia, Italy
| | - Mario Messina
- Division of Pediatric Surgery, Santa Maria Alle Scotte Polyclinic, University of Siena, Siena, Italy
| | - Gerald Rogan Neba
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Vittore Buzzi' Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Simone Pizzi
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Alessandro Simonini
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Costanza Tognon
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Mario Lima
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
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19
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Anzai A, Utino A, Tosello G, Katayama H, Spir IAZ, Tristão LS, Nery MM, Anhesini M, Tiezzi OS, Spir PRN, Otani P, Bernado WM. Sugammadex in awakening from general anesthesia: systematic review and meta-analysis. Rev Assoc Med Bras (1992) 2022; 68:1130-1153. [PMID: 36228244 PMCID: PMC9575014 DOI: 10.1590/1806-9282.2022d687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Adriano Anzai
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Armelin Utino
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Giuliano Tosello
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Haroldo Katayama
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | | | | | - Mary Martins Nery
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Mauricio Anhesini
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | | | | | - Pericles Otani
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Wanderley Marques Bernado
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil.,Corresponding author:
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20
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Liao JQ, Shih D, Lin TY, Lee M, Lu CW. Appropriate dosing of sugammadex for reversal of rocuronium-/vecuronium-induced muscle relaxation in morbidly obese patients: a meta-analysis of randomized controlled trials. J Int Med Res 2022; 50:3000605221116760. [PMID: 35983671 PMCID: PMC9393676 DOI: 10.1177/03000605221116760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To conduct a meta-analysis to compare different dosing scalars of sugammadex
in a morbidly obese population for reversal of neuromuscular blockade
(NMB). Methods PubMed®, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials
(CENTRAL) and Google Scholar were searched for relevant randomized
controlled trials (RCTs) comparing lower-dose sugammadex using ideal body
weight (IBW) or corrected body weight (CBW) as dosing scalars with
standard-dose sugammadex based on total body weight (TBW) among morbidly
obese people after NMB. Mean difference with SD was used to estimate the
results. Results The analysis included five RCT with a total of 444 morbidly obese patients.
The reversal time was significantly longer in patients receiving sugammadex
with dosing scalar based on IBW than in patients receiving sugammadex with
dosing scalar based on TBW (mean difference 55.77 s, 95% confidence interval
[CI] 32.01, 79.53 s), but it was not significantly different between
patients receiving sugammadex with dosing scalars based on CBW versus TBW
(mean difference 2.28 s, 95% CI –10.34, 14.89 s). Conclusion Compared with standard-dose sugammadex based on TBW, lower-dose sugammadex
based on IBW had 56 s longer reversal time whereas lower-dose sugammadex
based on CBW had a comparable reversal time.
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Affiliation(s)
- Jian-Qiang Liao
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City
| | - Darrell Shih
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City
| | - Tzu-Yu Lin
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City.,Department of Mechanical Engineering, Yuan Ze University, Taoyuan City
| | - Meng Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Puzi City
| | - Cheng-Wei Lu
- Department of Anaesthesiology, Far Eastern Memorial Hospital, New Taipei City.,Department of Mechanical Engineering, Yuan Ze University, Taoyuan City
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21
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Haddad D, Hanna AJ, Russo L. Successful Neuromuscular Blockade Reversal Using Sugammadex and Neostigmine Failed to Prevent Myasthenic Crisis After Emergency Surgery: A Case Report. Cureus 2022; 14:e27366. [PMID: 36046312 PMCID: PMC9417863 DOI: 10.7759/cureus.27366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1. A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure. Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.
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22
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Ebert TJ, Cumming CE, Roberts CJ, Anglin MF, Gandhi S, Anderson CJ, Stekiel TA, Gliniecki R, Dugan SM, Abdelrahim MT, Klinewski VB, Sherman K. Characterizing the Heart Rate Effects From Administration of Sugammadex to Reverse Neuromuscular Blockade: An Observational Study in Patients. Anesth Analg 2022; 135:807-814. [PMID: 35759402 DOI: 10.1213/ane.0000000000006131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reversal of neuromuscular blockade (NMB) with sugammadex can cause marked bradycardia and asystole. Administration of sugammadex typically occurs in a dynamic period when anesthetic adjuvants and gas concentrations are being titrated to achieve emergence. This evaluation examined the heart rate (HR) responses to sugammadex to reverse moderate to deep NMB during a steady-state period and sought mechanisms for HR changes. METHODS Patients with normal sinus rhythm, who were undergoing elective surgery that included rocuronium for NMB, were evaluated. After surgery, while at steady-state surgical depth anesthesia with sevoflurane and mechanical ventilation, patients received either placebo or 2 or 4 mg/kg of sugammadex to reverse moderate to deep NMB. Study personnel involved in data analysis were blinded to treatment. Continuous electrocardiogram (ECG) was recorded from the 5 minutes before and 5 minutes after sugammadex/placebo administration. R-R intervals were converted to HR and averaged in 1-minute increments. The maximum prolongation of an R-R interval after sugammadex was converted to an instantaneous HR. RESULTS A total of 63 patients were evaluated: 8 received placebo, and 38 and 17 received 2 and 4 mg/kg sugammadex. Age, body mass index, and patient factors were similar in groups. Placebo did not elicit HR changes, whereas sugammadex caused maximum instantaneous HR slowing (calculated from the longest R-R interval), ranging from 2 to 19 beats/min. There were 7 patients with maximum HR slowing >10 beats/min. The average HR change and 95% confidence interval (CI) during the 5 minutes after 2 mg/kg sugammadex were 3.1 (CI, 2.3-4.1) beats/min, and this was not different from the 4 mg/kg sugammadex group (4.1 beats/min [CI, 2.5-5.6]). HR variability derived from the standard deviation of consecutive R-R intervals increased after sugammadex. CONCLUSIONS Sugammadex to reverse moderate and deep NMB resulted in a fast onset and variable magnitude of HR slowing in patients. A difference in HR slowing as a function of dose did not achieve statistical significance. The observational nature of the investigation prevented a full understanding of the mechanism(s) of the HR slowing.
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Affiliation(s)
- Thomas J Ebert
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Craig E Cumming
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Christopher J Roberts
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Missy F Anglin
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Sweeta Gandhi
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Christopher J Anderson
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Thomas A Stekiel
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Ross Gliniecki
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Shannon M Dugan
- Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Mohamed T Abdelrahim
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Victoria B Klinewski
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Sherman
- Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
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23
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Sharma A, Campos JH. Influence of Sugammadex in Decreasing Postoperative Pulmonary Complications in Thoracic Surgery, Is There Evidence? J Cardiothorac Vasc Anesth 2022; 36:3634-3636. [DOI: 10.1053/j.jvca.2022.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
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24
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Cho SA, Sung TY. Choice of neuromuscular block reversal agent to reduce postoperative pulmonary complications. Anesth Pain Med (Seoul) 2022; 17:121-131. [PMID: 35538653 PMCID: PMC9091678 DOI: 10.17085/apm.22146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
The definition of postoperative pulmonary complications (PPCs) is inconsistent in literature; however, PPCs include pulmonary abnormalities that adversely affect patient outcomes, such as respiratory failure, atelectasis, pneumonia, pleural effusion, and exacerbation of underlying lung conditions. Furthermore, although the incidence of PPCs varies according to its definition, surgery type, and patient population, they can lead to increased morbidity, mortality, duration of hospitalization, and medical costs; thus, efforts to identify and reduce the risk factors are important to improve patient outcomes. Among the risk factors for PPCs, residual neuromuscular block is a representative and preventable anesthesia-related risk factor that is affected by the choice of the reversal agent. However, it is not clear whether the chosen reversal agent, i.e., sugammadex, reduces PPCs better when compared to anticholinesterases. Additionally, the effects of the reversal agents on PPCs in high-risk patients, such as elderly patients, pediatric patients, those with end-stage renal disease, obesity, obstructive sleep apnea, or those undergoing specific surgeries, are diverse. To reduce the PPCs associated with the use of neuromuscular blocking agents, it is important to confirm complete reversal of the neuromuscular block under neuromuscular monitoring. Additionally, efforts to reduce the incidence of PPCs through interdisciplinary communication are required.
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Affiliation(s)
- Sung-Ae Cho
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
- Corresponding author Tae-Yun Sung, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea -Tel: 82-42-600-9316 -Fax: 82-42-545-2132 -E-mail:
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25
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Sonny A, Bose S. Pro: Sugammadex Should Be Used Routinely for Reversal of Neuromuscular Blockade in Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth 2022; 36:1788-1791. [PMID: 35260324 DOI: 10.1053/j.jvca.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/03/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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26
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Park SH, Huh H, Choi SI, Kim JH, Jang YJ, Park JM, Kwon OK, Jung MR, Jeong O, Lee CM, Min JS, Kim JJ, An L, Yang KS, Park S, Lee IO. Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial. J Am Coll Surg 2022; 234:326-339. [PMID: 35213496 DOI: 10.1097/xcs.0000000000000061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients. STUDY DESIGN We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events. RESULTS Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth. CONCLUSION Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.
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Affiliation(s)
- Shin-Hoo Park
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Anam Hospital, Seoul, Republic of Korea (SH Park, S Park)
| | - Hyub Huh
- Department of Anesthesiology and Pain Medicine (Huh), Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Sung Il Choi
- Department of Surgery (Choi), Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Jong-Han Kim
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea (JH Kim, Jang)
| | - You-Jin Jang
- Division of Foregut Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea (JH Kim, Jang)
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Republic of Korea (JM Park)
| | - Oh Kyoung Kwon
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea (Kyoung Kwon)
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Jeollanam-do, Republic of Korea (Ran Jung, Jeong)
| | - Oh Jeong
- Department of Surgery, Chonnam National University Medical School, Jeollanam-do, Republic of Korea (Ran Jung, Jeong)
| | - Chang Min Lee
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Ansan Hospital, Seoul, Republic of Korea (CM Lee)
| | - Jae Seok Min
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Cancer Center, Busan, Republic of Korea (Seok Min)
| | - Jin-Jo Kim
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Republic of Korea (JJ Kim)
| | - Liang An
- Shaoxing Hospital Zhejiang University School of Medicine, Shaoxing, China (An)
| | - Kyung Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Sook Yang)
| | - Sungsoo Park
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Anam Hospital, Seoul, Republic of Korea (SH Park, S Park)
| | - Il Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Seoul, Republic of Korea (IO Lee)
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27
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Khanna S, Sreedharan R. Con: Sugammadex Should Not Be Used Routinely for Reversal of Neuromuscular Blockade in Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth 2022; 36:1792-1797. [PMID: 35027298 DOI: 10.1053/j.jvca.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sandeep Khanna
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Roshni Sreedharan
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Intensive Care Resuscitation, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
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28
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Carron M, Andreatta G, Pesenti E, De Cassai A, Feltracco P, Linassi F, Sergi M, Di Bella C, Di Bello M, Neri F, Silvestre C, Furian L, Navalesi P. Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study. Perioper Med (Lond) 2022; 11:3. [PMID: 35022076 PMCID: PMC8756660 DOI: 10.1186/s13741-021-00231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. Methods A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. Results No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). Conclusions Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.
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Affiliation(s)
- M Carron
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy.
| | - G Andreatta
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - E Pesenti
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - A De Cassai
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Feltracco
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - F Linassi
- Department of Anesthesia and Intensive Care, Ca' Foncello Treviso Regional Hospital, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - M Sergi
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Di Bella
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - M Di Bello
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - F Neri
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Silvestre
- Kidney and Pancreas Transplantation Unit, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - L Furian
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Navalesi
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
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Ruetzler K, Li K, Chhabada S, Maheshwari K, Chahar P, Khanna S, Schmidt MT, Yang D, Turan A, Sessler DI. Sugammadex Versus Neostigmine for Reversal of Residual Neuromuscular Blocks After Surgery: A Retrospective Cohort Analysis of Postoperative Side Effects. Anesth Analg 2022; 134:1043-1053. [PMID: 35020636 DOI: 10.1213/ane.0000000000005842] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sugammadex and neostigmine given to reverse residual neuromuscular blockade can cause side effects including bradycardia, anaphylaxis, bronchospasm, and even cardiac arrest. We tested the hypothesis that sugammadex is noninferior to neostigmine on a composite of clinically meaningful side effects, or vice versa. METHODS We analyzed medical records of patients who had general, cardiothoracic, or pediatric surgery and were given neostigmine or sugammadex from June 2016 to December 2019. Our primary outcome was a collapsed composite of bradycardia, anaphylaxis, bronchospasm, and cardiac arrest occurring between administration of the reversal agent and departure from the operation room. We a priori restricted our analysis to side effects requiring pharmacologic treatment that were therefore presumably clinically meaningful. Sugammadex would be considered noninferior to neostigmine (or vice versa) if the odds ratio for composite of side effects did not exceed 1.2. RESULTS Among 89,753 surgeries in 70,690 patients, 16,480 (18%) were given sugammadex and 73,273 (82%) were given neostigmine. The incidence of composite outcome was 3.4% in patients given sugammadex and 3.0% in patients given neostigmine. The most common individual side effect was bradycardia (2.4% in the sugammadex group versus 2.2% neostigmine). Noninferiority was not found, with an estimated odds ratio of 1.21 (sugammadex versus neostigmine; 95% confidence interval [CI], 1.09-1.34; noninferiority P = .57), and neostigmine was superior to sugammadex with an estimated odds ratio of 0.83 (0.74-0.92), 1-side superiority P < .001. CONCLUSIONS The composite incidence was less with neostigmine than with sugammadex, but only by 0.4% (a negligible clinical effect). Since 250 patients would need to be given neostigmine rather than sugammadex to avoid 1 episode of a minor complication such as bradycardia or bronchospasm, we conclude that sugammadex and neostigmine are comparably safe.
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Affiliation(s)
- Kurt Ruetzler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kai Li
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Anesthesia, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Surendrasingh Chhabada
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Pediatric Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Praveen Chahar
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sandeep Khanna
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc T Schmidt
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dongsheng Yang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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30
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Carron M, Tessari I, Linassi F. Sugammadex compared with neostigmine in reducing postoperative pulmonary complications in older patients: a meta-analysis. Br J Anaesth 2022; 128:e259-e262. [DOI: 10.1016/j.bja.2021.12.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 12/20/2022] Open
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31
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KUDOH OSAMU, HAYASHIDA MASAKAZU. Historical Changes in Anesthesia Practice for Laparoscopic Gynecological Surgery at Juntendo University Hospital – A Retrospective Observational Study Focusing on Factors Affecting the Incidence of Postoperative Nausea and Vomiting. JUNTENDO MEDICAL JOURNAL 2022. [DOI: 10.14789/jmj.jmj22-0013-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- OSAMU KUDOH
- Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine
| | - MASAKAZU HAYASHIDA
- Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine
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32
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Min KJ, Rabinowitz AL, Hess CJ. Is It Time to Abandon Routine Mask Ventilation Before Intubation? Anesth Analg 2021; 133:1353-1357. [PMID: 34673727 DOI: 10.1213/ane.0000000000005723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Cary J Hess
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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33
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Wong P, Seet E, Kumar CM, Koh KF, Pan TLT, Quah T, Chua NPP. Recommendations for standards of neuromuscular monitoring during anaesthesia. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:852-855. [PMID: 34877589 DOI: 10.47102/annals-acadmedsg.2021159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Patrick Wong
- Department of Anaesthesia, Waikato District Health Board, Hamilton, New Zealand
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34
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Deng J, Balouch M, Albrink M, Camporesi EM. Sugammadex Reduces PACU Recovery Time after Abdominal Surgery Compared with Neostigmine. South Med J 2021; 114:644-648. [PMID: 34599343 DOI: 10.14423/smj.0000000000001304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study blindly evaluated sugammadex compared with neostigmine on length of stay in the postanesthesia care unit (PACU). METHODS Fifty patients undergoing elective laparoscopic cholecystectomy or abdominal wall hernia repair consented to receive either sugammadex (2 mg/kg) or neostigmine (0.07 mg/kg) for the reversal of rocuronium neuromuscular blockade. Reversal agents were administered during surgical closing, and the train of four was measured until a twitch ratio of T4:T1 ≥ 0.9 was obtained to signify a robust reversal. Postreversal outcomes also were measured during PACU stay. Aldrete scores, pain visual analog scale score, and nausea were measured during the PACU stay. RESULTS Patients receiving sugammadex experienced a shorter PACU stay at the time of discharge than patients receiving neostigmine, by an average of 12 minutes (P < 0.05). CONCLUSIONS Sugammadex patients had a significantly shorter PACU stay.
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Affiliation(s)
- Jin Deng
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Maha Balouch
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Michael Albrink
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Enrico M Camporesi
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
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Sun Y, Wu Z, Wang Q, Chen R, Sun S, Lin Y. Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:3893-3901. [PMID: 34548781 PMCID: PMC8449549 DOI: 10.2147/dddt.s328682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022]
Abstract
High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.
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Affiliation(s)
- Yan Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Zhilin Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Qi Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Rui Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
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Wang JF, Zhao ZZ, Jiang ZY, Liu HX, Deng XM. Influence of sugammadex versus neostigmine for neuromuscular block reversal on the incidence of postoperative pulmonary complications: a meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:32. [PMID: 34538277 PMCID: PMC8451127 DOI: 10.1186/s13741-021-00203-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The influence of sugammadex for reversal of neuromuscular block (NMB) on postoperative pulmonary complications (PPCs), compared with neostigmine, remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) to compare the incidence of PPCs between patients who received sugammadex versus neostigmine. METHODS Relevant studies were obtained by searching the PubMed, Embase, and Cochrane Library databases. A random effects model incorporating the potential heterogeneity was used to pool the results. RESULTS Fourteen RCTs including 1478 adult patients who underwent surgeries with general anesthesia were included, and of these, 753 received sugammadex and 725 received neostigmine for reversal of NMB. The pooled results showed that sugammadex was associated with a lower risk of overall PPCs compared to neostigmine (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.43-0.89, p = 0.01; I2 = 0%). This finding remained consistent after exclusion of two studies with potential overlapping events (OR: 0.58, 95% CI: 0.36-0.96, p = 0.03; I2=9%). Stratified analyses according to the categories of PPCs showed that sugammadex was associated with a significantly lower risk of postoperative respiratory failure (OR: 0.60, 95% CI: 0.38-0.97, p = 0.04; I2 = 0%) but not of postoperative pulmonary infection (OR: 0.79, p = 0.71), atelectasis (OR: 0.78, p = 0.33), or pneumothorax (OR: 0.87, p = 0.79). CONCLUSIONS Compared with neostigmine, the use of sugammadex for reversal of NMB was associated with a lower risk of PPCs, mainly due to a lower incidence of postoperative respiratory failure with the use of sugammadex.
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Affiliation(s)
- Jia-Feng Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | | | - Zheng-Yu Jiang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Hui-Xing Liu
- Department of Clinical Epidemiology and Biostatistics, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiao-Ming Deng
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Echeverry G, Polskin L, Tollinche LE, Seier K, Tan KS, McCormick PJ, Fischer GW, Grant FM. ROUTINE USE OF SUGAMMADEX DOES NOT SHORTEN PACU LENGTH OF STAY: A PROSPECTIVE DOUBLE-BLINDED RANDOMIZED CONTROLLED TRIAL. ACTA ACUST UNITED AC 2021; 24. [PMID: 34504958 DOI: 10.1016/j.pcorm.2021.100199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background The reversal agent sugammadex has been shown to be more efficacious at reversal from neuromuscular blockade (NMB) induced by the aminosteroid class of non-depolarizing muscle relaxants than the traditionally used medication neostigmine. However, whether these differences lead to significantly faster PACU discharge readiness remains unknown. Given the increased acquisition cost of sugammadex as compared to neostigmine we compared these two reversal agents in our surgical population to determine if its pharmacokinetic superiority warranted a change in current practice. Methods We conducted a single-center randomized patient and assessor blinded clinical trial. A total of 201 patients presenting for surgery requiring NMB with an estimated duration of ≤ 6 hours were included in the intention-to-treat (ITT) analysis. The primary outcome was time from reversal agent administration to PACU discharge readiness, measured by either the institutional discharge scoring tool or bedside clinical assessment by a PACU physician or advanced practice provider. Secondary outcomes included subjective assessment of recovery by the patient (pain, visual changes, speaking difficulty, swallowing difficulty, PONV, anxiety) and a simple strength assessment. Results Median time from reversal administration to PACU discharge readiness was 3.59 hours (IQR 2.49-5.09) in the neostigmine group and 3.62 hours (IQR 2.70-5.87) in the sugammadex group. Patients who received sugammadex had 8% longer reversal to PACU discharge times (exp(estimate) 1.08, 95% CI [0.87-1.34], p=0.499). Patients age 70 or older had 28% longer reversal to PACU discharge times (exp(estimate) of 1.28, 95% CI [0.91-1.80], P=0.158). In the a modified ITT analysis, sugammadex patients were estimated to be in PACU 13% longer than neostigmine arm patients (exp(estimate) 1.13, 95% CI [0.91-1.40], p=0.265) and patients older than or equal to 70 years 31% longer than patients less than 70 years old (exp(estimate) 1.31, 95% CI [0.93-1.84], p=0.121). Treatment arm was not associated with any of the secondary outcomes. Conclusion There was no significant difference in time to readiness to discharge from PACU, and there were no subjective or objective clinically relevant differences in recovery from neuromuscular blockade between the groups. Findings of this study support continued use of either agent at the anesthesiologist's discretion.
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Affiliation(s)
- Germán Echeverry
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Lily Polskin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Luis E Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10056
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10056
| | - Patrick J McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Florence M Grant
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
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Farag E, Rivas E, Bravo M, Hussain S, Argalious M, Khanna S, Seif J, Pu X, Mao G, Bain M, Elgabaly M, Esa WAS, Sessler DI. Sugammadex Versus Neostigmine for Reversal of Rocuronium Neuromuscular Block in Patients Having Catheter-Based Neurointerventional Procedures: A Randomized Trial. Anesth Analg 2021; 132:1666-1676. [PMID: 34032663 DOI: 10.1213/ane.0000000000005533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Catheter-based endovascular neurointerventions require deep neuromuscular blocks during the procedure and rapid subsequent recovery of strength to facilitate neurological evaluation. We tested the primary hypothesis that sugammadex reverses deep neuromuscular blocks faster than neostigmine reverses moderate neuromuscular blocks. METHODS Patients having catheter-based cerebral neurointerventional procedures were randomized to: (1) deep rocuronium neuromuscular block with posttetanic count 1 to 2 and 4-mg/kg sugammadex as the reversal agent or (2) moderate rocuronium neuromuscular block with train-of-four (TOF) count 1 during the procedure and neuromuscular reversal with 0.07-mg/kg neostigmine to a maximum of 5 mg. Recovery of diaphragmatic function was assessed by ultrasound at baseline before the procedure and 90 minutes thereafter. The primary outcome-time to reach a TOF ratio ≥0.9 after administration of the designated reversal agent-was analyzed with a log-rank test. Secondary outcomes included time to successful tracheal extubation and the difference between postoperative and preoperative diaphragmatic contraction speed and distance. RESULTS Thirty-five patients were randomized to sugammadex and 33 to neostigmine. Baseline characteristics and surgical factors were well balanced. The median time to reach TOF ratio ≥0.9 was 3 minutes (95% confidence interval [CI], 2-3 minutes) in patients given sugammadex versus 8 minutes (95% CI, 6-10 minutes) in patients given neostigmine. Sugammadex was significantly faster by a median of 5 minutes (95% CI, 3-6 minutes; P < .001). However, times to tracheal extubation and diaphragmatic function at 90 minutes did not differ significantly. CONCLUSIONS Sugammadex reversed deep rocuronium neuromuscular blocks considerably faster than neostigmine reversed moderate neuromuscular blocks. However, times to extubation did not differ significantly, apparently because extubation was largely determined by the time required for awaking from general anesthesia and because clinicians were willing to extubate before full neuromuscular recovery. Sugammadex may nonetheless be preferable to procedures that require a deep neuromuscular block and rapid recovery.
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Affiliation(s)
- Ehab Farag
- From the Department of Outcomes Research.,Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Eva Rivas
- From the Department of Outcomes Research.,Department of Anesthesia, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universidad de Barcelona, Barcelona, Spain
| | | | | | - Maged Argalious
- From the Department of Outcomes Research.,Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Sandeep Khanna
- From the Department of Outcomes Research.,Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - John Seif
- From the Department of Outcomes Research.,Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- From the Department of Outcomes Research.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Guangmei Mao
- From the Department of Outcomes Research.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Mark Bain
- Cerebrovascular Center, Neurological Institute and
| | | | - Wael Ali Sakr Esa
- From the Department of Outcomes Research.,Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
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Renew JR, Tobias JD, Brull SJ. The Time to Seriously Reassess the Use and Misuse of Neuromuscular Blockade in Children Is Now. Anesth Analg 2021; 132:1514-1517. [PMID: 34032656 DOI: 10.1213/ane.0000000000005488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- J Ross Renew
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Sorin J Brull
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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40
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The "True" Risk of Postoperative Pulmonary Complications and the Socratic Paradox: "I Know that I Know Nothing". Anesthesiology 2021; 134:828-831. [PMID: 33909882 DOI: 10.1097/aln.0000000000003767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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41
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Postoperative Pulmonary Complications' Association with Sugammadex versus Neostigmine: A Retrospective Registry Analysis. Anesthesiology 2021; 134:862-873. [PMID: 33730169 DOI: 10.1097/aln.0000000000003735] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade related to nondepolarizing neuromuscular blocking agents may be associated with pulmonary complications. In this study, the authors sought to determine whether sugammadex was associated with a lower risk of postoperative pulmonary complications in comparison with neostigmine. METHODS Adult patients from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who underwent general anesthesia procedures between January 2010 and July 2019 were included in an observational cohort study. In early 2017, a wholesale switch from neostigmine to sugammadex occurred at Vanderbilt University Medical Center. The authors therefore identified all patients receiving nondepolarizing neuromuscular blockades and reversal with neostigmine or sugammadex. An inverse probability of treatment weighting propensity score analysis approach was applied to control for measured confounding. The primary outcome was postoperative pulmonary complications, determined by retrospective chart review and defined as the composite of the three postoperative respiratory occurrences: pneumonia, prolonged mechanical ventilation, and unplanned intubation. RESULTS Of 10,491 eligible cases, 7,800 patients received neostigmine, and 2,691 received sugammadex. A total of 575 (5.5%) patients experienced postoperative pulmonary complications (5.9% neostigmine vs. 4.2% sugammadex). Specifically, 306 (2.9%) patients had pneumonia (3.2% vs. 2.1%), 113 (1.1%) prolonged mechanical ventilation (1.1% vs. 1.1%), and 156 (1.5%) unplanned intubation (1.6% vs. 1.0%). After propensity score adjustment, the authors found a lower absolute incidence rate of postoperative pulmonary complications over time (adjusted odds ratio, 0.91 [per year]; 95% CI, 0.87 to 0.96; P < .001). No difference was observed on the odds of postoperative pulmonary complications in patients receiving sugammadex in comparison with neostigmine (adjusted odds ratio, 0.89; 95% CI, 0.65 to 1.22; P = 0.468). CONCLUSIONS Among 10,491 patients at a single academic tertiary care center, the authors found that switching neuromuscular blockade reversal agents was not associated with the occurrence of postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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42
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Samara E, Stamatiou K, Balanika M, Tzimas P. The Effect of Sugammadex on Prothrombin and Activated Partial Thromboplastin Time. Cureus 2021; 13:e14521. [PMID: 34012734 PMCID: PMC8126340 DOI: 10.7759/cureus.14521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 12/03/2022] Open
Abstract
Sugammadex is routinely used as an effective neuromuscular blockade reversal agent. Several studies have indicated that it may prolong the prothrombin time (PT) and the activated partial thromboplastin time (aPTT). This review gathers the relevant in vivo studies to accumulate knowledge on the subject. Nine studies were included. According to the results, sugammadex seems to lead to a transient increase in aPTT and PT values, compared to standard care. However, the clinical impact seems to be trivial. Nevertheless, the trials' findings reveal great heterogeneity, preventing a meta-analysis. Therefore, more well-designed studies are needed to lead to prudent conclusions.
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Affiliation(s)
- Evangelia Samara
- Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, GRC
| | | | - Marina Balanika
- Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, GRC
| | - Petros Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, School of Health Sciences, University of Ioannina, Ioannina, GRC
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43
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Pappy AL, Sirmon CAF, Mukkamala SG. Administration of Sugammadex Intraoperatively in a Patient With a Congenital Myasthenic Syndrome: A Case Report. A A Pract 2021; 15:e01437. [PMID: 33760762 DOI: 10.1213/xaa.0000000000001437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Congenital myasthenic syndromes are a group of genetic neuromuscular disorders caused by mutations that impair synaptic transmission at the neuromuscular junction. Developing an anesthetic plan for patients with this diagnosis is difficult, as they are at risk for prolonged neuromuscular blockade. Sugammadex is an alternative to neostigmine for neuromuscular blockade reversal that does not produce muscarinic side effects, yet there is a little literature assessing sugammadex in congenital myasthenic syndromes. We present the case of a 6-year-old boy with a congenital myasthenic syndrome who received sugammadex without complication. This case provides support for clinicians to consider sugammadex in these patients.
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Affiliation(s)
- Adlai L Pappy
- From the Department of Anesthesiology and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carie Ann F Sirmon
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Shivani G Mukkamala
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
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Hartman E, Funk E, Dear G, Wellman C, Pereira K. Sugammadex Effects on Hormonal Contraception Effectiveness: Implementation of Uniform Postoperative Teaching. J Perianesth Nurs 2021; 36:351-358. [PMID: 33745828 DOI: 10.1016/j.jopan.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this quality improvement project was to improve consistency of discharge teaching in women who used progesterone-containing hormonal contraceptive medications and received sugammadex during general anesthesia, as there is a risk of unintended pregnancy for 1 week after administration of sugammadex. DESIGN This project used a predesign and postdesign using two separate sample groups of patients and postanesthesia care unit (PACU) nurses. METHODS The sample consisted of 31 total women of childbearing age and 59 PACU nurses. Simplification of sugammadex discharge instructions was achieved by incorporating evidence-based recommendations for electronic discharge instructions and nursing education. PACU nurses were educated and surveyed before and after regarding frequency of discharge teaching, clarity, and comprehension of the after-visit summary and knowledge of sugammadex. Patients were called via telephone postoperatively to assess recall of sugammadex discharge teaching. FINDINGS Postoperative patient phone calls identified a small increase in patient recall of discharge instructions from 5 of 14 patients (35.7%) before implementation to 7 of 17 after implementation (41.2%). PACU nurse surveys indicated an increase in self-reported frequency of sugammadex discharge teaching (34.8% vs 64.2%, P = .024) and that new discharge instructions contained more clear, comprehensive information as compared with previous instructions (29.4% vs 75.5%, P = .001). CONCLUSIONS This quality improvement project successfully implemented more consistent and comprehensive discharge instructions for women who receive sugammadex intraoperatively. Limitations of the project included a small sample size and short implementation intervals. As a result of switching to uniform discharge instructions, more patients received important discharge teaching from PACU nurses, and the percentage of patients who recalled this information increased.
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Affiliation(s)
| | | | - Guy Dear
- Duke University Hospital, Durham, NC
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Martinez-Ubieto J, Aragón-Benedí C, de Pedro J, Cea-Calvo L, Morell A, Jiang Y, Cedillo S, Ramírez-Boix P, Pascual-Bellosta AM. Economic impact of improving patient safety using Sugammadex for routine reversal of neuromuscular blockade in Spain. BMC Anesthesiol 2021; 21:55. [PMID: 33593283 PMCID: PMC7888144 DOI: 10.1186/s12871-021-01248-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background Neuromuscular blocking (NMB) agents are often administered to facilitate tracheal intubation and prevent patient movement during surgical procedures requiring the use of general anesthetics. Incomplete reversal of NMB, can lead to residual NMB, which can increase the risk of post-operative pulmonary complications. Sugammadex is indicated to reverse neuromuscular blockade induced by rocuronium or vecuronium in adults. The aim of this study is to estimate the clinical and economic impact of introducing sugammadex to routine reversal of neuromuscular blockade (NMB) with rocuronium in Spain. Methods A decision analytic model was constructed reflecting a set of procedures using rocuronium that resulted in moderate or deep NMB at the end of the procedure. Two scenarios were considered for 537,931 procedures using NMB agents in Spain in 2015: a scenario without sugammadex versus a scenario with sugammadex. Comparators included neostigmine (plus glycopyrrolate) and no reversal agent. The total costs for the healthcare system were estimated from the net of costs of reversal agents and overall cost offsets via reduction in postoperative pneumonias and atelectasis for which incidence rates were based on a Spanish real-world evidence (RWE) study. The model time horizon was assumed to be one year. Costs were expressed in 2019 euros (€) and estimated from the perspective of a healthcare system. One-way sensitivity analysis was carried out by varying each parameter included in the model within a range of +/− 50%. Results The estimated budget impact of the introduction of sugammadex to the routine reversal of neuromuscular blockade in Spanish hospitals was a net saving of €57.1 million annually. An increase in drug acquisition costs was offset by savings in post-operative pulmonary events, including 4806 post-operative pneumonias and 13,996 cases of atelectasis. The total cost of complications avoided was €70.4 million. All parameters included in the model were tested in sensitivity analysis and were favorable to the scenario with sugammadex. Conclusions This economic analysis shows that sugammadex can potentially lead to cost savings for the reversal of rocuronium-induced moderate or profound NMB compared to no reversal and reversal with neostigmine in the Spanish health care setting. The economic model was based on data obtained from Spain and from assumptions from clinical practice and may not be valid for other countries.
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Affiliation(s)
| | | | | | | | - A Morell
- Hospital Universitario de la Princesa, Madrid, Spain
| | - Y Jiang
- MSD Ltd., Hoddesdon, Hertfordshire, UK
| | - S Cedillo
- Covance Clinical Development, Madrid, Spain
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46
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Serrano AB, DÍaz-Cambronero Ó, Melchor-RipollÉs J, Abad-Gurumeta A, Ramirez-Rodriguez JM, MartÍnez-Ubieto J, SÁnchez-Merchante M, Rodriguez R, JordÁ L, Gil-Trujillo S, Cabellos-Olivares M, Bordonaba-Bosque D, Aldecoa C. Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial. Minerva Anestesiol 2021; 87:13-25. [PMID: 33538417 DOI: 10.23736/s0375-9393.20.14589-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program. METHODS We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated. RESULTS Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048). CONCLUSIONS Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.
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Affiliation(s)
- Ana B Serrano
- Department of Anesthesiology, Ramón y Cajal University Hospital, Madrid, Spain - .,Instituto de Investigación Sanitaria Hospital Ramón y Cajal (IRYCIS), Madrid, Spain -
| | - Óscar DÍaz-Cambronero
- Department of Anesthesiology, The University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
| | | | | | | | | | | | - Rita Rodriguez
- Department of Anesthesiology, University Clinical Hospital of Valladolid, Valladolid, Spain
| | - Laura JordÁ
- Department of Anesthesiology, University General Hospital of Castellón, Castellón, Spain
| | - Silvia Gil-Trujillo
- Department of Anesthesiology, Hospital General Universitario de Ciudad Real (HGUCR), Ciudad Real, Spain
| | | | - Daniel Bordonaba-Bosque
- Institute for Health Sciences in Aragon (IACS), Centro de Investigación Biomédica de Aragón (CIBA), Zaragoza, Spain
| | - César Aldecoa
- Department of Anesthesiology, University General Hospital of Castellón, Castellón, Spain
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Sims T, Peterson J, Hakim M, Roth C, Tumin D, Tobias JD, Hansen JK. Decrease in heart rate following the administration of sugammadex in adults. J Anaesthesiol Clin Pharmacol 2021; 36:465-469. [PMID: 33840924 PMCID: PMC8022043 DOI: 10.4103/joacp.joacp_346_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/14/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults. Material and Methods: Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was <70 bpm. Results: The study cohort included 200 patients. Bradycardia was observed in 13 cases (7%; 95% confidence interval: 4, 11), occurring a median of 4 minutes after sugammadex administration (IQR: 4, 9, range: 2-25). Among patients developing bradycardia, two (15%) had cardiac comorbid conditions. One patient received treatment for bradycardia with ephedrine. No clinically significant blood pressure changes were noted. On bivariate analysis, patients receiving a higher initial sugammadex dose were more likely to develop bradycardia. On multivariable logistic regression, initial sugammadex dose was not associated with the risk of bradycardia. Conclusion: The incidence of bradycardia after administration of sugammadex in our study was low and not associated with significant hemodynamic changes.
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Affiliation(s)
- Trent Sims
- Department of Anesthesiology, The University of Kansas, Kansas City, Kansas, USA
| | - Joshua Peterson
- Department of Anesthesiology, The University of Kansas, Kansas City, Kansas, USA
| | - Mohammed Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Catherine Roth
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jennifer K Hansen
- Department of Anesthesiology, The University of Kansas, Kansas City, Kansas, USA
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Postoperative Recurarization in a Pediatric Patient After Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Case Report. A A Pract 2020; 13:204-205. [PMID: 30985317 DOI: 10.1213/xaa.0000000000001023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a case of a pediatric patient who developed recurarization after a cardiac catheterization procedure. Intraoperative neuromuscular blockade was achieved with 2 doses of rocuronium, and the blockade was reversed with a bolus dose of sugammadex at the end of the procedure. While recovering in the pediatric cardiac intensive care unit, the patient developed respiratory failure and a decline in the train-of-four response. The patient fully recovered after receiving a second dose of sugammadex.
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Murphy GS, Avram MJ, Greenberg SB, Bilimoria S, Benson J, Maher CE, Teister KJ, Szokol JW. Neuromuscular and Clinical Recovery in Thoracic Surgical Patients Reversed With Neostigmine or Sugammadex. Anesth Analg 2020; 133:435-444. [PMID: 33323787 DOI: 10.1213/ane.0000000000005294] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients undergoing thoracoscopic procedures may be at high-risk for incomplete neuromuscular recovery and associated complications. The aim of this clinical investigation was to assess the incidence of postoperative residual neuromuscular blockade in adult thoracic surgical patients administered neostigmine or sugammadex when optimal dosing and reversal strategies for these agents were used. The effect of choice of reversal agent on hypoxemic events and signs and symptoms of muscle weakness were also determined. Additionally, operative conditions in each group were graded by surgeons performing the procedures. METHODS Two hundred patients undergoing thoracoscopic surgical procedures were enrolled in this nonrandomized controlled trial. One hundred consecutive patients maintained at moderate levels of neuromuscular blockade were reversed with neostigmine (neostigmine group) followed by 100 consecutive patients given sugammadex to antagonize deeper levels of neuromuscular blockade (sugammadex group). Anesthetic and neuromuscular management were standardized. Surgeons rated operative conditions at the conclusion of the procedure on a 4-point scale (grade 1 = excellent to grade 4 = poor). Train-of-four ratios were measured immediately before extubation and at PACU admission (primary outcomes). Postoperatively, patients were assessed for adverse respiratory events and 11 signs and 16 symptoms of muscle weakness. RESULTS The 2 groups were similar in intraoperative management characteristics. The percentage of patients with residual neuromuscular blockade, defined as a normalized train-of-four ratio <0.9, was significantly greater in the neostigmine group than the sugammadex group at both tracheal extubation (80% vs 6%, respectively, P < .0001) and PACU admission (61% vs 1%, respectively, P < .0001). Patients in the neostigmine group had less optimal operative conditions (median score 2 [good] versus 1 [excellent] in the sugammadex group; P < .0001), and more symptoms of muscle weakness were present in these subjects (median number [interquartile range] 4 [1-8] vs 1 [0-2] in the sugammadex group, P < .0001). No differences between groups in adverse airway events were observed. CONCLUSIONS Despite the application of strategies documented to reduce the risk of residual neuromuscular blockade, a high percentage of thoracoscopic patients whose neuromuscular blockade was reversed with neostigmine were admitted to the PACU with clinical evidence of residual paralysis. In contrast, muscle weakness was rarely observed in patients whose neuromuscular blockade was antagonized with sugammadex.
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Affiliation(s)
- Glenn S Murphy
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Michael J Avram
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Steven B Greenberg
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Sara Bilimoria
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Jessica Benson
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Colleen E Maher
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Kevin J Teister
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Joseph W Szokol
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
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50
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Sugammadex use in patients with end-stage renal disease: a historical cohort study. Can J Anaesth 2020; 67:1789-1797. [PMID: 32949009 DOI: 10.1007/s12630-020-01812-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE While sugammadex (SGX) is not approved for use in patients with end-stage renal disease (ESRD), its administration in this patient population has been reported. We designed the current study to review all instances of patients with ESRD receiving SGX and to describe their clinical outcomes. METHODS This is a historical cohort study of 219 patients with chronic kidney disease stage 5 who received SGX in one of three hospital locations within the same academic health system. Data were collected between 7 March 2016 and 1 August 2019 and included demographics, notable events from the anesthesia records, and postoperative complications. The primary outcome included any complication possibly related to SGX such as hypersensitivity reactions, need for reintubation, hypoxemia, pneumonia, and residual neuromuscular blockade. Secondary outcomes included any other complication not included in the primary outcome and/or patient mortality within 30 days after the procedure. RESULTS No patient experienced a hypersensitivity reaction. Three patients required reintubation while two patients developed hypoxemia that did not require reintubation. One patient developed hospital-acquired pneumonia. Fifty (23%) patients developed other postoperative complications (different from our primary outcome) and nine patients (4%) died during the subsequent 30 postoperative days. None of the primary or secondary outcomes appeared to be related to SGX use. CONCLUSIONS We provide incremental evidence that SGX could be considered as an alternative neuromuscular blockade reversal agent in patients with ESRD.
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