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Wang A, Tsivitis A, Ma S, Jin Z, Al Bizri E, Moore R. The safety and efficacy of sugammadex for reversing neuromuscular blockade in younger children and infants. Expert Opin Drug Saf 2024; 23:845-853. [PMID: 38938223 DOI: 10.1080/14740338.2024.2373906] [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: 11/26/2023] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Sugammadex, a novel selective antagonist of non-depolarizing neuromuscular blocking agents, has been shown to rapidly and effectively reverse moderate and deep paralysis in adults and pediatric patients over age 2, improving patient recovery and reducing the risk of postoperative complications. AREAS COVERED Since the use of sugammadex in patients under age 2 is not widely studied, we aim to provide an overview on the drug's application and potential use in infants and neonates. There is a limited but growing body of evidence for the safe, efficacious use of sugammadex in children under age 2. Relevant studies were identified from the most updated data including case reports, clinical trials, systematic reviews, and meta analyses. EXPERT OPINION The results suggest that at a dose of 2 to 4 mg/kg of sugammadex can be safely used to rapidly and effectively reverse neuromuscular blockade in neonates and infants; it is non-inferior based on incidence of adverse events compared to neostigmine. Additionally, sugammadex doses between 8 and 16 mg/kg may be used as a rescue agent for infants during 'can't intubate, can't ventilate' crisis. Overall, sugammadex offers new value in the perioperative care of patients under age 2, with further studies warranted to better understand its application and full effect in the pediatric population.
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Affiliation(s)
- Ashley Wang
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Alexandra Tsivitis
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Sijia Ma
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Ehab Al Bizri
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Robert Moore
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
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Blum FE, Locke AR, Nathan N, Katz J, Bissing D, Minhaj M, Greenberg SB. Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review. J Clin Med 2024; 13:861. [PMID: 38337560 PMCID: PMC10856567 DOI: 10.3390/jcm13030861] [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: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.
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Affiliation(s)
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Naveen Nathan
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Jeffrey Katz
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - David Bissing
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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Ayhan A, Efe E, Fidan PA, Efe OE, Ates EG, Sahinturk F, Ayhan S. The influence of different sugammadex doses on neural tube development in early-stage chick embryos. Birth Defects Res 2023; 115:1598-1607. [PMID: 37565787 DOI: 10.1002/bdr2.2237] [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: 06/08/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Sugammadex is a modified gamma-cyclodextrin that has been developed with the goal of reversing the steroidal neuromuscular blocking agents. The aim of the present study is to investigate the effects of different sugammadex doses on embryologic and neural tube development in an early-stage chick embryo model. METHODS A total of 100 specific pathogen-free, fertilized domestic chicken eggs were randomly divided into five groups (n = 20, each), and placed in an automatic cycle incubator. The eggs in the "control (C)" group were incubated without administration of any drug till the end of the experiment. Sub-blastodermic administration of 0.9% NaCl as vehicle control (VC) and different doses of sugammadex solutions prepared with the latter [2 mg/mL (LD), 4 mg/mL (MD), 16 mg/mL (HD)] were performed at 30 hr of incubation. All embryos were removed from the eggs at 72 hr when they were expected to reach Hamburger-Hamilton (HH) stages 19-20, then they were fixed, and evaluated histo-morphologically. RESULTS Embryonic development was not observed in 11 eggs (1 in C, 1 in VC; 3 in LD, 3 in MD, and 3 in HD). All the developed embryos were compatible with the HH stages 19-20. A neural tube closure defect was detected in one embryo in the HD group. No statistically significant difference was found between the groups in terms of embryonic and neural tube developments. CONCLUSIONS No significant association was found between the drug and adverse outcomes; however, a trend with dosing was seen. Further studies are required before conclude on safety and extrapolate these results to human beings.
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Affiliation(s)
- Asude Ayhan
- Department of Anaesthesiology and Reanimation, Baskent University School of Medicine, Ankara, Turkey
| | - Ekin Efe
- Department of Histology and Embryology, Baskent University School of Medicine, Ankara, Turkey
| | - Pinar A Fidan
- Department of Histology and Embryology, Baskent University School of Medicine, Ankara, Turkey
| | - Oguzhan E Efe
- Department of Pharmacology, Baskent University School of Medicine, Ankara, Turkey
| | - Eylem Gul Ates
- Department of Biostatistics, Baskent University School of Medicine, Ankara, Turkey
- Institutional Big Data Management Unit, Middle East Technical University, Ankara, Turkey
| | - Fikret Sahinturk
- Department of Neurological Surgery, Baskent University School of Medicine, Ankara, Turkey
| | - Selim Ayhan
- Department of Neurological Surgery, Baskent University School of Medicine, Ankara, Turkey
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Pirinç Şaşıoğlu G, Kendigelen P, Tütüncü AÇ, Kaya G. Reversal of Rocuronium-Induced Neuromuscular Blockade by Sugammadex Under Sevoflurane and Desflurane Anesthesia in Children. Eurasian J Med 2023; 55:173-177. [PMID: 37909186 PMCID: PMC10724797 DOI: 10.5152/eurasianjmed.2022.22090] [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: 09/12/2022] [Accepted: 12/14/2022] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE In children, neuromuscular blockers may have different effects with various inhalation agents and incomplete reversal of the blockade continues to be a problem. The aim of the study is to observe the effects of sugammadex on reversing the blockade by a single dose of rocuronium, the peak inspiratory pressure, hemodynamic parameters in children under sevoflurane and desflurane anesthesia. MATERIALS AND METHODS One hundred forty-eight children aged 2-10 years old, to be operated under shortterm general anesthesia, were enrolled in this prospective randomized controlled trial. After induction, the patients were intubated at the end of TOF (Train-of-four) ratio of 1.0-0. The time taken until TOF reached 0.25 was recorded, and 2 mg/kg sugammadex was administered to the patients. The period until the TOF was at least 0.9 and in the first 10 minutes after sugammadex injection, peak inspiratory pressure, the systolic-diastolic arterial pressure, and the heart rate were monitored and possible side effects were observed in the recovery room. RESULTS Following the injection of sugammadex, the time taken for TOF of 0.25 to reach >0.9 was significantly shorter in the 2-4-year-old age group under sevoflurane anesthesia. After sugammadex injection, a small but statistically significant increase in peak inspiratory pressure values was observed in Group D at the 2nd, 5th, and 10th minutes. CONCLUSION Rapid and complete recovery was achieved from the block induced by a single dose of 0.6 mg/ kg rocuronium by the use of sugammadex which did not give rise to any side effects.
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Affiliation(s)
- Gamze Pirinç Şaşıoğlu
- Department of Anesthesiology and Intensive Care, Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Pınar Kendigelen
- Department of Anesthesiology and Intensive Care, Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Ayşe Çiğdem Tütüncü
- Department of Anesthesiology and Intensive Care, Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Güner Kaya
- Department of Anesthesiology and Intensive Care, Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Istanbul, Turkey
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Ji SH, Huh KY, Oh J, Jeong HJ, Jang YE, Kim EH, Lee JH, Kim JT, Kim HS. Conventional reversal of rocuronium-induced neuromuscular blockade by sugammadex in Korean children: pharmacokinetics, efficacy, and safety analyses. Front Pharmacol 2023; 14:1127932. [PMID: 37124204 PMCID: PMC10133539 DOI: 10.3389/fphar.2023.1127932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/05/2023] [Indexed: 05/02/2023] Open
Abstract
Background: Sugammadex is known to reverse neuromuscular blockade induced by non-depolarizing agents. In children, the recommended dose for reversal of moderate neuromuscular blockade is 2 mg/kg. We investigated the pharmacokinetics and pharmacodynamics of sugammadex in Korean children. Methods: Children (2-17 years of age) undergoing brain or spine surgery were enrolled and randomly assigned to control (neostigmine) and 2, 4, or 8 mg/kg sugammadex groups. Following induction of anesthesia and monitoring of the response to train-of-four stimulation, 1 mg/kg rocuronium was intravenously administered. Upon reappearance of the second twitch to train-of-four stimulation, the study drug was administered according to group allocation. The plasma concentrations of rocuronium and sugammadex were serially measured at nine predefined time points following study drug administration. To determine efficacy, we measured the time elapsed from drug administration to recovery of T4/T1 ≥ 0.9. For pharmacokinetics, non-compartmental analysis was performed and we monitored adverse event occurrence from the time of study drug administration until 24 h post-surgery. Results: Among the 29 enrolled participants, the sugammadex (2 mg/kg) and control groups showed recovery times [median (interquartile range)] of 1.3 (1.0-1.9) and 7.7 (5.3-21.0) min, respectively (p = 0.002). There were no significant differences in recovery time among the participants in sugammadex groups. The pharmacokinetics of sugammadex were comparable to those of literature findings. Although two hypotensive events related to sugammadex were observed, no intervention was necessary. Conclusion: The findings of this pharmacokinetic analysis and efficacy study of sugammadex in Korean children indicated that sugammadex (2 mg/kg) may be safely administered for reversing moderate neuromuscular blockade. Some differences in pharmacokinetics of sugammadex were observed according to age. Clinical Trial Registration: http://clinicaltrials.gov (NCT04347486).
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Affiliation(s)
- Sang-Hwan Ji
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Young Huh
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jaeseong Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Jeong Jeong
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- *Correspondence: Hee-Soo Kim,
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Paredes S, Torres VH, Chaves-Cardona H, Matus M, Porter SB, Renew JR. An appraisal of neostigmine versus sugammadex for neuromuscular blockade reversal in patients with a prior heart transplant. Anaesthesiol Intensive Ther 2023; 55:46-51. [PMID: 37306271 PMCID: PMC10156568 DOI: 10.5114/ait.2023.125337] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/05/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Heart transplant recipients present unique perioperative challenges for surgery. Specifically, autonomic system denervation has significant implications for commonly used perioperative drugs. This study investigates neuromuscular blocking antagonists in this population when undergoing subsequent non-cardiac surgery. MATERIAL AND METHODS A retrospective review was performed for the period 2015-2019 across our health care enterprise. Patients with previous orthotopic heart transplant and subsequent non-cardiac surgery were identified. A total of 185 patients were found, 67 receiving neostigmine (NEO) and 118 receiving sugammadex (SGX). Information of patient characteristics, prior heart transplant, and subsequent non-cardiac surgery was collected. Our primary outcome was the incidence of bradycardia (heart rate < 60 bpm) and/or hypotension (mean blood pressure (MAP) < 65 mmHg) following neuromuscular blockade reversal. Secondary outcomes included need of intra-operative inotropic agents, arrhythmia, cardiac arrest, hospital length of stay (hLOS), ICU admission, and death within 30 postoperative days. RESULTS In unadjusted analysis, no significant differences were found between the two groups in change in heart rate [0 (-26, 14) vs. 1 (-19, 10), P = 0.59], change in MAP [0 (-22, 28) vs. 0 (-40, 47), P = 0.96], hLOS [2 days (1, 72) vs. 2 (0, 161), P = 0.92], or intraoperative hypotension [4 (6.0%) vs. 5 (4.2%), OR = 0.70, P = 0.60] for NEO and SGX respectively. After multivariable analysis, the results were similar for change in heart rate ( P = 0.59) and MAP ( P = 0.90). CONCLUSIONS No significant differences in the incidence of bradycardia and hypotension were found in the NEO versus SGX groups. NEO and SGX may have similar safety profiles in patients with prior heart transplant undergoing non-cardiac surgery.
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Affiliation(s)
- Stephania Paredes
- Departments of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Harold Chaves-Cardona
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Mark Matus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Steven B. Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Johnathan Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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Ji S, Huh KY, Oh J, Jeong H, Jang Y, Kim E, Lee J, Kim J, Kim H. Reversal of rocuronium-induced intense neuromuscular blockade by sugammadex in Korean children: A pharmacokinetic and pharmacodynamic analysis. Clin Transl Sci 2022; 16:92-103. [PMID: 36181377 PMCID: PMC9841294 DOI: 10.1111/cts.13429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/09/2022] [Accepted: 09/21/2022] [Indexed: 02/06/2023] Open
Abstract
Sugammadex, a selective antagonist of steroidal non-depolarizing neuromuscular blocking agents, has been used in children in limited circumstances. However, neither pharmacokinetics (PKs) nor recovery profile of sugammadex for intense neuromuscular blockade reversal in children have been reported. This prospective study aimed to obtain a PK model of sugammadex and evaluate its efficacy and safety for intense neuromuscular blockade reversal in children. Forty children (age, 2-17 years) who underwent surgery that required early neuromuscular blockade reversal were enrolled. After neuromuscular blockade with 1 mg∙kg-1 of rocuronium, sugammadex (2, 4, and 8 mg∙kg-1 ) or a conventional dose of neostigmine (0.03 mg∙kg-1 ) was administered randomly after confirmation of zero post-tetanic count. The plasma concentrations of rocuronium and sugammadex were measured 2 min after rocuronium injection; immediately before, 2, 5, 15, 60, 120, 240, and 480 min after the study drug injection. Response to train-of-four stimulation was continuously recorded. Noncompartmental analysis and population PK modeling were performed. For pharmacodynamics, the recovery profile was measured. Three-compartment PK model was established for sugammadex. The median (interquartile range [IQR]) time from injection of 8 mg∙kg-1 of sugammadex to recovery of T4 /T1 greater than or equal to 0.9 at train-of-four stimulation was 1.1 (IQR: 0.88-1.8) min. No adverse events related to sugammadex were observed. We present a PK analysis of sugammadex for rocuronium-induced intense neuromuscular blockade reversal in children with its recovery profile. The time to recover T4 /T1 greater than or equal to 0.9 at train-of-four stimulation with 8 mg∙kg-1 of sugammadex was less than 3 min and comparable to that in adults.
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Affiliation(s)
- Sang‐Hwan Ji
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Ki Young Huh
- Seoul National University College of MedicineSeoulKorea,Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulKorea
| | - Jaeseong Oh
- Seoul National University College of MedicineSeoulKorea,Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulKorea
| | - Hee‐Jeong Jeong
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Young‐Eun Jang
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Eun‐Hee Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Ji‐Hyun Lee
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Jin‐Tae Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Hee‐Soo Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
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Vishneski SR, Saha AK, Fram MR, Templeton LB, Lee LK, Ririe DG, Goenaga‐Diaz EJ, Smith LD, Templeton TW. Risk factors for administration of additional reversal following neuromuscular blockade with rocuronium in children: A retrospective case-control study. Paediatr Anaesth 2022; 32:916-925. [PMID: 35438816 PMCID: PMC9544061 DOI: 10.1111/pan.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prevalence and risk factors for residual neuromuscular blockade in children remain poorly characterized. We hypothesize that specific patient and anesthetic risk factors may be associated with the administration of additional reversal in children following initial reversal of rocuronium with neostigmine. METHODS Our electronic health record was queried for patients <18 years of age who received rocuronium and reversal with neostigmine from 2017 through 2020. Patients receiving other nondepolarizing neuromuscular blocking drugs were excluded. The outcome of interest was defined as the administration of additional neostigmine or sugammadex following primary reversal with neostigmine. Time between the last dose of rocuronium and initial dose of neostigmine, and the cumulative dose of rocuronium were dichotomized. These were combined with other covariates including age, weight, sex, racial group, procedure type, ASA physical status, >1 rocuronium dose administered during the procedure, initial neostigmine dose <0.05 mg kg-1 , use of train-of-four monitoring, duration of anesthesia, inpatient or outpatient, emergency case, neuromuscular disease, and extremes of weight, to assess possible associations with the primary outcome. RESULTS During the study period, 101/6373 (1.58%) patients received rocuronium and additional reversal. Dichotomization of time between last dose of rocuronium and neostigmine yielded <28 min since the last dose of rocuronium and cumulative dose of rocuronium >0.45 mg kg-1 hr-1 . These were associated with the administration of additional reversal with an OR 1.52 (95% CI, 1.08-2.35) and OR 1.71 (95% CI, 1.10-2.67), respectively. Other risk factors included an initial neostigmine dose <0.05 mg kg-1 , OR 4.98 (95% CI, 2.84-6.49), and African American race, OR 1.78 (95% CI, 1.07-2.87). CONCLUSION Risk factors associated with the administration of additional reversal included time <28 min from the last dose of rocuronium to initial dose of neostigmine, cumulative dose of rocuronium >0.45 mg kg-1 hr-1 , initial neostigmine dose <0.05 mg kg-1 , and African American race.
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Affiliation(s)
- Susan R. Vishneski
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Amit K. Saha
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | - Leah B. Templeton
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Lisa K. Lee
- Department of AnesthesiologyUCLALos AngelesCaliforniaUSA
| | - Douglas G. Ririe
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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9
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Lang B, Han L, Zeng L, Zhang Q, Chen S, Huang L, Jia Z, Yu Q, Zhang L. Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis. BMC Pediatr 2022; 22:295. [PMID: 35590273 PMCID: PMC9118813 DOI: 10.1186/s12887-022-03288-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 04/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent survey revealed that extensive off-label use of sugammadex in pediatric anesthesia deserved particular attention. The present study with trial sequential analysis (TSA) aimed to evaluate the effects of sugammadex for antagonizing neuromuscular blockade (NMB) in pediatric patients, and to investigate whether the findings achieved the required information size to draw conclusions. METHODS PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to April 2021. All randomized controlled trials used sugammadex as reversal agent in pediatric patients were enrolled. Time from NMB reversal to recovery of the train-of-four ratio (TOFr) to 0.9 and extubation time were considered as co-primary outcomes, and incidences of adverse events were considered as secondary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of evidences. RESULTS Data from 18 studies involving 1,065 pediatric patients were acquired. The results revealed that use of sugammadex was associated with shorter duration from administration of reversal agents to TOFr > 0.9 (MD = -14.42, with 95% CI [-17.08, -11.75]) and shorter interval from reversal from NMB to extubation (MD = -13.98, with 95% CI [-16.70, -11.26]) compared to control groups. TSA also indicated that the current sample sizes were sufficient with unnecessary further trials. Analysis of secondary outcomes indicated that administration of sugammadex was associated with less incidence of postoperative nausea and vomiting (PONV), bradycardia, and dry mouth compared to control groups. CONCLUSION Considering of satisfactory and rapid neuromuscular blockade reversal with low incidences of adverse events, sugammadex might be considered as the preferred option for children in clinical anesthesia practice compared to acetylcholinesterase inhibitors. However, overall low-quality evidences in present study rated by GRADE system indicated that superiority of sugammadex employed in pediatric patients needs to be confirmed by more studies with high quality and large sample size in future.
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Affiliation(s)
- Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Lu Han
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Qianqian Zhang
- Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Zhijun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Biopharmaceutics, West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
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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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11
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Voss T, Wang A, DeAngelis M, Speek M, Saldien V, Hammer GB, Wrishko R, Herring WJ. Sugammadex for reversal of neuromuscular blockade in pediatric patients: Results from a phase IV randomized study. Paediatr Anaesth 2022; 32:436-445. [PMID: 34878707 DOI: 10.1111/pan.14370] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few randomized studies have assessed recovery from rocuronium- or vecuronium-induced moderate or deep neuromuscular blockade with sugammadex in pediatric participants. AIM To assess sugammadex for reversal of neuromuscular blockade in pediatric participants. METHODS This was a randomized, phase IV, active comparator-controlled, double-blind study. Participants aged 2 to <17 years, under moderate or deep neuromuscular blockade, were administered sugammadex (2 or 4 mg/kg) or neostigmine (50 µg/kg; for moderate neuromuscular blockade only). Predefined adverse events of clinical interest, including clinically relevant bradycardia, hypersensitivity, and anaphylaxis, were monitored. The primary efficacy endpoint was time to recovery to a train-of-four ratio of ≥0.9 in participants receiving sugammadex 2 mg/kg versus neostigmine for reversal of moderate neuromuscular blockade, analyzed by analysis of variance adjusted for neuromuscular blocking agent and age. RESULTS Of 288 randomized participants, 272 completed the study and 276 were included in the analyses. Clinically relevant bradycardia was experienced by 2.0%, 1.6%, and 5.9% of participants in the sugammadex 2 mg/kg, sugammadex 4 mg/kg, and neostigmine groups, respectively. No hypersensitivity or anaphylaxis events were observed. Recovery to a train-of-four ratio of ≥0.9 with sugammadex 2 mg/kg was faster than neostigmine (1.6 min, 95% CI 1.3 to 2.0 vs. 7.5 min, 95% CI 5.6 to 10.0; p < .0001) and was comparable to sugammadex 4 mg/kg (2.0 min, 95% CI 1.8 to 2.3). CONCLUSIONS Pediatric participants recovered from rocuronium- or vecuronium-induced moderate neuromuscular blockade significantly faster with sugammadex 2 mg/kg than with neostigmine. Time to reversal of deep neuromuscular blockade with sugammadex 4 mg/kg was consistent with that of moderate neuromuscular blockade reversal. No meaningful differences in clinically relevant bradycardia, hypersensitivity, or anaphylaxis were seen with sugammadex vs neostigmine. These results support the use of sugammadex for reversal of moderate and deep rocuronium- and vecuronium-induced neuromuscular blockade in patients aged 2 to <17 years. CLINICAL TRIAL REGISTRATION NCT03351608/EudraCT 2017-000692-92.
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Affiliation(s)
- Tiffini Voss
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Aobo Wang
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Matthew DeAngelis
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Marcel Speek
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Vera Saldien
- Department of Anesthesiology, Antwerp University Hospital, Edegem and University of Antwerp, Antwerp, Belgium
| | - Gregory B Hammer
- Departments of Pediatrics and Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca Wrishko
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - W Joseph Herring
- Department of Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
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12
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Zhong W, Liu X, Bash LD, Bortnichak E, Horrow J, Koro C. Neuromuscular Blocking Agents and Reversal Agents Among Hospitalized Children: A Cerner Database Study. Hosp Pharm 2021; 56:424-429. [PMID: 34720141 DOI: 10.1177/0018578720918332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Sugammadex (Bridion) was approved by the US Food and Drug Administration (FDA) in December 2015 for the reversal of neuromuscular block (NMB) induced by rocuronium and vecuronium bromide in adults undergoing surgery and approved for use in both adults and children in the European Union in 2008. Sugammadex use in children has been reported in the United States, but to what extent is not clear. Aims: The aim was to describe the utilization pattern of NMB agents and factors associated with the use of reversal agents (neostigmine and sugammadex) in US children. Methods: Cross-sectional study of children with exposure to NMB agents between 2015 and 2017 in the Cerner Health Facts® database, which is an electronic health record (EHR) database across 600 facilities in the United States. Logistic regression estimated factors associated with the use of sugammadex vs neostigmine. Results: A total of 27 094 pediatric clinical encounters were exposed to neuromuscular blocking agents (NMBAs), in which 21 845 were exposed to rocuronium (76%), vecuronium (18%), or both (6%). Among children with exposure to rocuronium and vecuronium, the use of sugammadex was 1.7% in 2016 and 7.6% in 2017. The multivariable logistic model suggested that children who were older (age 12-17 years vs 0-1 year; odds ratio [OR] 1.96; 95% confidence interval [CI], 1.36-2.83), Hispanic or Latino ethnicity and other ethnicities (vs non-Hispanic or Latino; OR 2.03 and 1.56; 95% CI, 1.55-2.67 and 1.15-2.13, respectively), in teaching facilities (OR 1.26; 95% CI, 1.00-1.59), or admitted through emergency departments (OR 1.65; 95% CI, 1.06-2.58) were independently more likely to receive sugammadex than neostigmine after controlling for other covariates. Conclusions: In Cerner Health Facts database 2015 to 2017, among children, rocuronium was more commonly used than vecuronium, and sugammadex use was observed since 2016. Sugammadex and neostigmine users varied by demographic, clinical, and site-level characteristics.
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13
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Lamoshi A, Lerman J, Dughayli J, Elberson V, Towle-Miller L, Wilding GE, Rothstein DH. Association of anesthesia type with prolonged postoperative intubation in neonates undergoing inguinal hernia repair. J Perinatol 2021; 41:571-576. [PMID: 32499596 PMCID: PMC7270742 DOI: 10.1038/s41372-020-0703-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/06/2020] [Accepted: 05/22/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study is to determine factors associated with prolonged intubation after inguinal herniorrhaphy in neonates. METHODS Retrospective, single institution review of neonates undergoing inguinal herniorrhaphy between 2010 and 2018. Variables recorded included demographics, comorbidities, ventilation status at time of hernia repair, and anesthetic technique. RESULTS We identified 97 neonates (median corrected gestational age 39.9 weeks, IQR 6.6). The majority (87.6%) received general anesthesia (GA); the remainder received caudal anesthesia (CA). Among the GA subjects, 25.8% remained intubated for at least 6 h after surgery, whereas none of the CA patients required intubation postoperatively (p = 0.03). Two risk factors associated with prolonged postoperative intubation: a history of intubation before surgery (p = 0.04) and a diagnosis of bronchopulmonary dysplasia (p = 0.03). CONCLUSIONS Neonates undergoing inguinal herniorrhaphy under GA have a greater rate of prolonged postoperative intubation compared with those undergoing CA. A history of previous intubation and bronchopulmonary dysplasia were significant risk factors for prolonged postoperative intubation.
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Affiliation(s)
| | - Jerrold Lerman
- grid.413993.50000 0000 9958 7286John R. Oishei Children’s Hospital, Buffalo, NY USA ,Great Lakes Anesthesiology, Buffalo, NY USA
| | - Jad Dughayli
- grid.413993.50000 0000 9958 7286John R. Oishei Children’s Hospital, Buffalo, NY USA ,Great Lakes Anesthesiology, Buffalo, NY USA
| | - Valerie Elberson
- grid.273335.30000 0004 1936 9887Division of Neonatology and Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Lorin Towle-Miller
- grid.273335.30000 0004 1936 9887Department of Biostatistics, University at Buffalo School of Public Health, Buffalo, NY USA
| | - Gregory E Wilding
- grid.273335.30000 0004 1936 9887Department of Biostatistics, University at Buffalo School of Public Health, Buffalo, NY USA
| | - David H Rothstein
- grid.413993.50000 0000 9958 7286John R. Oishei Children’s Hospital, Buffalo, NY USA ,grid.273335.30000 0004 1936 9887Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY USA
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14
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Bray JP, Adams DR, Phadke AS, Adams PS. Sugammadex Neuromuscular Blockade Reversal Associated With Lower Postoperative Arterial Carbon Dioxide Levels After Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:154-161. [PMID: 32768253 DOI: 10.1053/j.jvca.2020.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery. DESIGN Retrospective, cross-sectional study. SETTING Single-center, university-based, tertiary care hospital. PARTICIPANTS Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass. INTERVENTIONS Chart review. MEASUREMENTS AND MAIN RESULTS The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO2) values (coefficient -3.1, 95% confidence interval [CI] -5.9 to -0.4; p = 0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1-0.8; p = 0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p = 0.01) and lower PaCO2 values (coefficient -5.2, 95% CI -9.6 to -0.8; p = 0.021). CONCLUSION Sugammadex reversal was associated with lower postoperative PaCO2 values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal.
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Affiliation(s)
- Jacob P Bray
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas R Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Aparna S Phadke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phillip S Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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15
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Egbuta C, Mason KP. Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient. J Clin Med 2020; 9:jcm9061942. [PMID: 32580323 PMCID: PMC7355459 DOI: 10.3390/jcm9061942] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022] Open
Abstract
There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.
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16
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Lorinc AN, Lawson KC, Niconchuk JA, Modes KB, Moore JD, Brenn BR. Residual Weakness and Recurarization After Sugammadex Administration in Pediatric Patients: A Case Series. A A Pract 2020; 14:e01225. [PMID: 32539277 DOI: 10.1213/xaa.0000000000001225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While shown to be safe for administration in pediatric patients, sugammadex has recently been associated with residual weakness or recurarization. We describe 4 additional cases of pediatric patients with residual or recurrent weakness following rocuronium reversal with sugammadex. Two infant patients developed postoperative ventilatory distress, which was possibly related to recurarization after sugammadex reversal. A third patient received sugammadex with apparent waning of clinical effect and subsequently required neostigmine reversal. A fourth patient was observed to have residual weakness, which led to prolonged intubation despite appropriate train-of-four results after reversal with sugammadex.
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Affiliation(s)
- Amanda N Lorinc
- From the Department of Anesthesiology/Division of Pediatric Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katheryne C Lawson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan A Niconchuk
- From the Department of Anesthesiology/Division of Pediatric Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katharina B Modes
- From the Department of Anesthesiology/Division of Pediatric Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - John D Moore
- From the Department of Anesthesiology/Division of Pediatric Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Bruce R Brenn
- From the Department of Anesthesiology/Division of Pediatric Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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17
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Grigg E. Sugammadex and neuromuscular reversal: special focus on neonatal and infant populations. Curr Opin Anaesthesiol 2020; 33:374-380. [DOI: 10.1097/aco.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Sugammadex reverses neuromuscular blockade by the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. In 2015, it was approved in the United States by the Food and Drug Administration for adult use. However, there are ongoing clinical trials investigating its use in the pediatric population. Before approval in adult use in the United States, several adverse effects were noted to occur in patients receiving sugammadex in clinical trials including prolonged QT interval, bradycardia, hypersensitivity reactions, and prolongation of coagulation parameters. Additional investigations further elucidated the risks of these adverse events. Sugammadex is approved for use in children older than 2 years in other countries in Europe and Asia. Investigations suggest that the efficacy, safety, and pharmacokinetic profile is similar in children when compared with adults. Published pediatric data favor the use of sugammadex in children older than 2 years, but there are some data in young children younger than 2 years. Case reports discuss the use of sugammadex in pediatric patients with neuromuscular diseases. Although sugammadex is typically used in the operating room for reversing neuromuscular blockade for surgical procedures, there is a small but important role for sugammadex use in the emergency department. In cases where rapid neurological examination is required after neuromuscular blockage with rocuronium or vecuronium, sugammadex can assist in facilitating a timely comprehensive neurological examination where pharmacologic or surgical management may depend on examination findings such as in the case of cerebral vascular accident, status epilepticus, or traumatic brain injury. Some clinicians have advocated for the use of sugammadex in the cannot intubate, cannot ventilate scenario. However, caution should be exercised in this situation as reversal of paralysis can take up to 22 minutes to occur.
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19
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Kim WY, Kim YH, Lee JY, Kim JH, Min TJ. Evaluation of the Toxicity of Sugammadex in Zebrafish Larvae. J Korean Med Sci 2020; 35:e51. [PMID: 32141248 PMCID: PMC7061149 DOI: 10.3346/jkms.2020.35.e51] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/12/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Sugammadex is a new neuromuscular blockade reversal agent. Recently, it has been used in patients under general anesthesia. However, sugammadex could be toxic to fetuses and pediatric patients under 3 years of age. In this study, we demonstrated the safety of sugammadex in fetuses, using zebrafish larvae. Furthermore, its neurotoxicity was evaluated using neuronal cell lines. METHODS We used SH-SY5Y cells to determine the viability of neuronal cells treated with sugammadex. Zebrafish larvae were used to determine the teratogenic effects of sugammadex. RESULTS Sugammadex showed no adverse effects on neuronal cells and zebrafish larvae. The survival rates of neuronal cells were not different in all concentrations. In addition, the heart formation of zebrafish embryos, which were exposed to various concentrations of sugammadex, were not different. CONCLUSION This study demonstrated the feasibility of using sugammadex during pregnancy. However, further clinical studies will be required to extrapolate these results to humans.
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Affiliation(s)
- Woon Young Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Yeon Hwa Kim
- Department of Translational Research Institute for Intractable Diseases, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Ji Yoon Lee
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jae Hwan Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Too Jae Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.
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20
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Gadade DD, Pekamwar SS. Cyclodextrin Based Nanoparticles for Drug Delivery and Theranostics. Adv Pharm Bull 2020; 10:166-183. [PMID: 32373486 PMCID: PMC7191229 DOI: 10.34172/apb.2020.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/29/2019] [Accepted: 10/01/2019] [Indexed: 12/18/2022] Open
Abstract
Colloidal nanoparticulate technology has been described in the literature as a versatile drug delivery system. But it possesses some inherent lacunae in their formulation. Cyclodextrins (CDs) have been extensively reported for the solubility enhancement of poorly water-soluble drugs. The CDs can cause intervention in aspects related to nanoparticles (NPs) that include improving drug loading in nano-system, improving stability, site-specific/targeted drug delivery, improving solubility profile and absorption of the drug in nanosystem with consequent improvement in bioavailability, with the possibility of controlled release, safety and efficacy. They find application in for simultaneous diagnosis and therapeutics for better treatment procedures. The current communication is focused on the application of CDs to overcome troubles in nanoparticulate formulation and enhancement of their performance. It also envisages the theranostic aspects of CDs.
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Affiliation(s)
- Dipak Dilip Gadade
- Department of Pharmaceutics, Shri Bhagwan College of Pharmacy, CIDCO, N-6, Dr. Y.S. Khedkar Marg, Aurangabad-431001, India.,School of Pharmacy, SRTM University,Vishnupuri, Nanded- 431606, India
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21
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An J, Lee JH, Kim E, Woo K, Kim H, Lee D. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: A prospective randomized study. Medicine (Baltimore) 2020; 99:e19130. [PMID: 32049831 PMCID: PMC7035047 DOI: 10.1097/md.0000000000019130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. This study compared efficacy of sugammadex and pyridostigmine for reversal of rocuronium-induced light block or minimal block in children scheduled for elective entropion surgery. METHODS A prospective randomized study was conducted on 60 pediatric patients aged 1 to 11 years and scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using train-of-four (TOF) ulnar nerve stimulation. Patients were randomly assigned to 2 groups receiving sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg plus glycopyrrolate 0.01 mg/kg. Primary outcomes were time from reversal agents administration to TOF ratio 0.9 and time from reversal agent administration to TOF ratio 1.0. Time from TOF ratio 0.9 to extubation, time from TOF ratio 1.0 to extubation, and postoperative adverse events were also recorded. RESULTS There were no substantial differences in demographic variables. Time from reversal agents administration to TOF ratio 0.9 and time from reversal agents to TOF ratio 1.0 were significantly faster in sugammadex group: 1.30 ± 0.84 versus 3.53 ± 2.73 minutes (P < .001) and 2.75 ± 1.00 versus 5.73 ± 2.83 minutes (P < .001). Extubation time was shorter in sugammadex group. Incidence of skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction) was not statistically different between groups. Incidence of patients agitation in recovery room was lower in sugammadex group. CONCLUSION Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery lasting 30 to 60 minutes than did pyridostigmine plus glycopyrrolate, with no differences in incidence of adverse events between groups.
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22
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Cohen JC, Latchford KJ. Sugammadex in Ontario hospitals: Access and institutional policies. J Eval Clin Pract 2020; 26:50-55. [PMID: 31012211 DOI: 10.1111/jep.13151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/26/2019] [Accepted: 03/30/2019] [Indexed: 11/28/2022]
Abstract
RATIONALE AND AIMS Sugammadex is a novel neuromuscular blockade reversal agent which rapidly reverses the effects of rocuronium and vecuronium. Compared with the first-generation neuromuscular blockade reversal agent, neostigmine, sugammadex has a number of superior properties; however, sugammadex is significantly more expensive per dose compared with neostigmine (~CAD$95 vs $4). Given the high cost of sugammadex, many Ontario hospitals either do not stock the drug or have specific policies on when the drug can be administered. This study was designed to determine access to sugammadex in Ontario hospitals, as well as the prevalence and content of institutional policies on its use. METHODS We designed a survey assessing the availability of sugammadex and institutional policies on its use. We identified 60 Ontario hospitals with surgical services and obtained contact information for 45 of the anaesthesia departments. Surveys were sent to each department chief, and results were collected from July to October 2018. RESULTS Thirty-four (75.6%) hospitals responded to the survey. Twenty-seven (79.4%) of the 34 respondent hospitals had sugammadex. Of the seven hospitals that did not have sugammadex, six were group B hospitals, and one was a paediatric hospital. Of the 27 hospitals with sugammadex, 16 (59.3%) hospitals had specific policies on when sugammadex may be used. Based on policies, sugammadex was most frequently allowed to be used in emergency situations, especially failed intubations or "can't intubate, can't ventilate" situations where 100% of policies allowed its use. Policies on specific patient populations for sugammadex use were uncommon, with 43.8% of existing hospital policies not specifying any patient populations. CONCLUSIONS Though most hospitals have sugammadex available, there is a marked heterogeneity in hospital policies on its use. Given the high cost of sugammadex use, it is worthwhile to have evidence-based policies on its use. Judicious use of sugammadex may also have secondary cost-saving benefits, through improved operating room efficiency and decreased complication rates.
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Affiliation(s)
- Jared C Cohen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kevin J Latchford
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Anesthesia, Grand River Hospital and St. Mary's General Hospital, Kitchener, ON, Canada
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Yuki K, Scholl R. Should we Routinely Reverse Neuromuscular Blockade with Sugammadex in Patients with a History of Heart Transplantation? TRANSLATIONAL PERIOPERATIVE AND PAIN MEDICINE 2020; 7:185-189. [PMID: 32039284 PMCID: PMC7007180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cases of cardiac arrest after administration of neostigmine as a neuromuscular reversal agent have been reported in the literature. Sugammadex is a new neuromuscular reversal agent that acts via a different mechanism than acetylcholinesterase inhibitors. Here we reviewed the currently available literature on the use of sugammadex and potential considerations of using sugammadex in patients with a history of heart transplantation. Based on our currently available information, sugammadex administration in heart transplant patients should warrant similar caution and preparation for cardiovascular collapse as acetylcholinesterase inhibitors.
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Affiliation(s)
- Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Massachusetts, USA,Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Scholl
- Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Massachusetts, USA,Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
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24
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Retrospective Analysis of the Safety and Efficacy of Sugammadex Versus Neostigmine for the Reversal of Neuromuscular Blockade in Children. Anesth Analg 2019; 129:1124-1129. [DOI: 10.1213/ane.0000000000004207] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Honing G, Martini CH, Bom A, van Velzen M, Niesters M, Aarts L, Dahan A, Boon M. Safety of sugammadex for reversal of neuromuscular block. Expert Opin Drug Saf 2019; 18:883-891. [PMID: 31359807 DOI: 10.1080/14740338.2019.1649393] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Sugammadex is a modified cyclodextrin that is able to reverse neuromuscular block induced by aminosteroidal neuromuscular blocking drugs. Compared to reversal with neostigmine, it reverses neuromuscular block quicker and more predictable and without cholinergic side effects. However, there have been concerns about sugammadex ability to bind other drugs and its effects on QT interval and clotting times. In addition, sugammadex might induce hypersensitivity reactions more frequently than initially anticipated. This review summarizes current evidence with regard to these and other safety aspects of sugammadex. Areas covered: This review provides an overview of the efficacy of sugammadex in various patient populations, evaluates potential interactions with other drugs and discusses adverse effects and reactions that have been reported in the literature. Expert opinion: Sugammadex quickly reverses aminosteroid neuromuscular block with less side effects compared to neostigmine. As such, it has the potential to significantly reduce the incidence of residual neuromuscular block and to improve postoperative pulmonary outcome. Current safety concerns mainly focus on hypersensitivity reactions and cardiac arrhythmias. Although the absolute risk for these events is low, ongoing vigilance and research in this area are needed.
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Affiliation(s)
- Ghm Honing
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - C H Martini
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | | | - M van Velzen
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - M Niesters
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - Lphj Aarts
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - M Boon
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
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26
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An J, Kim E, Lee J, Kim H, Son J, Huh J, Woo K. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: a prospective randomized study. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.3.288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jihyun An
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eunju Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jihyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyun Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jongcheol Son
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Joonyoung Huh
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Kyeongyoon Woo
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
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27
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Affiliation(s)
- Wonjin Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Busan, Korea
- Paik Institute for Clinical Research, Inje University College of Medicine, Busan, Korea
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28
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Simonini A, Brogi E, Calevo MG, Carron M. Sugammadex for reversal of neuromuscular blockade in paediatric patients: A two-year single-centre retrospective study. Anaesth Crit Care Pain Med 2019; 38:529-531. [PMID: 30818070 DOI: 10.1016/j.accpm.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Affiliation(s)
- A Simonini
- Department of Anaesthesiology and Intensive Care, IRCCS Istituto Giannina Gaslini, L.go G. Gaslini 5, 16147 Genova, Italy
| | - E Brogi
- Department of Anaesthesiology and Intensive Care, University of Pisa, via Paradisa 2, 56124 Pisa, Italy
| | - M G Calevo
- Department of Epidemiology and Biostatistic, IRCCS Istituto Giannina Gaslini, L.go G. Gaslini 5, 16147 Genova, Italy
| | - M Carron
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padova, via V. Gallucci 13, 35121 Padova, Italy.
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29
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González AM. About congenital myopathies and neuromuscular monitorization. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:601-602. [PMID: 30413284 DOI: 10.1016/j.redar.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A M González
- Servicio de Anestesia, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
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