Ultra-Rapid Reversal of Rocuronium-Induced Paralysis with Sugammadex in the Emergency Department

Evaluation of Sugammadex Dosing for Neurological Examination in the Emergency Department

Background: Prolong effects of non-depolarizing neuromuscular blocking agents after rapid sequence intubation may prevent meaningful neurological examination, delaying appropriate diagnosis and neurosurgical intervention. Sugammadex is indicated for the reversal of neuromuscular blockade induced by rocuronium. Objective: The objective of this study was to evaluate low- (2 mg/kg) vs standard-dose (4 mg/kg) sugammadex for rocuronium-induced deep neuromuscular blockade reversal in the emergency department (ED) by achieving a post-treatment train-of-four (TOF) of 4 to facilitate neurological examination. Methods: This was a single-center, retrospective, cohort study evaluating low-vs standard-dose sugammadex for neuromuscular blockade reversal in the ED. Results: 34 patients were identified within the designated time period, 24 of which were included in the final analysis ([n = 9 low-dose], [n = 15 standard-dose]). Median sugammadex doses were 2.3 mg/kg and 4.1 mg/kg for low- and standard-dose, respectively. The majority of patients presented for intraparenchymal hemorrhage (54.2%). No significant difference in success rate of NMBA reversal was found between low- and standard-dose sugammadex ([100.0% vs 93.3%], P = 1.000). A total of 9 patients had a neurosurgical procedure performed after sugammadex administration. Low-dose sugammadex was associated with significantly less acquisition cost compared to the standard dose (P < .001). Conclusion: Low- (2 mg/kg) and standard-dose (4 mg/kg) sugammadex successfully reversed rocuronium-induced deep neuromuscular blockade in the ED by achieving a post-treatment TOF of 4 to facilitate neurologic examination. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED and is associated with decreased institutional cost.

What is the Role of Sugammadex in the Emergency Department?

BACKGROUND

Sugammadex is a medication newly available to many emergency physicians. It effectively, and within minutes, reverses neuromuscular blockade in patients who have received rocuronium or vecuronium. The role of sugammadex for the reversal of neuromuscular blockade after rapid sequence intubation in the emergency department (ED) is evolving, and limited emergency medicine-specific literature exists.

OBJECTIVE

This narrative review evaluates the role of sugammadex for the reversal of neuromuscular blockade in the ED.

DISCUSSION

The basic pharmacology, duration of action, adverse effects, and important medication and disease interactions specific to sugammadex are well described. Case reports suggest sugammadex can reverse neuromuscular blockade to facilitate an urgent, neurologic examination by an emergency physician or consultant. Multiple case reports of failure to improve airway patency with the use of sugammadex, even when neuromuscular blockade is completely reversed, and concern for added difficulty of definitive airway management in a patient with spontaneous movement suggest that sugammadex should largely be omitted from failed or difficult airway management strategies. Instead, it is important to focus on the ability to oxygenate and ventilate, including progression to surgical airway or jet ventilation if needed.

CONCLUSION

Sugammadex is an effective, rapid reversal agent for rocuronium and has the potential use to facilitate an urgent neurologic examination shortly after administration of rocuronium. Its routine inclusion in a failed or difficult emergency airway is not supported by available literature.