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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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2
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Comparison of the Efficacy and Safety of Adamgammadex with Sugammadex for Reversal of Rocuronium-Induced Neuromuscular Block: Results of a Phase II Clinical Trial. J Clin Med 2022; 11:jcm11236951. [PMID: 36498526 PMCID: PMC9738056 DOI: 10.3390/jcm11236951] [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: 11/03/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
This current phase II clinical trial was to compare the effect and safety of adamgammadex, a new cyclodextrin-based selective relaxant binding agent, with sugammadex to reverse rocuronium-induced neuromuscular block. Patients were randomised to receive adamgammadex (4 or 6 mg kg-1) or sugammadex (2 mg kg-1, as a positive control group) at the reappearance of the second twitch (T2) in response to TOF stimulation. The standard safety data were collected. The 4 mg kg-1 (n = 16) and 6 mg kg-1 (n = 20) adamgammadex- and 2 mg kg-1 (n = 20) sugammadex-induced recovery time of TOF ratio to 0.9 were 2.3, 1.6, and 1.5 min, respectively (p = 0.49). The 4 mg kg -1 adamgammadex-induced median recovery time was longer than that of 2 mg kg-1 sugammadex (p = 0.01), and there was no difference between the 6 mg kg -1 adamgammadex group and 2 mg kg-1 sugammadex group (p = 0.32). Then, the number of patients who experienced adverse events (AEs) was 6, 11, and 14 for adamgammadex at 4, 6 mg kg-1 and sugammadex at 2 mg kg-1, respectively. The treatment emergent AEs that occurred more than twice were detailed as follows: incision site pain, hypotension, emesis, fever, throat pain, blood bilirubin increase, abnormal T-wave of ECG, dizziness, incision site swelling, postoperative fever, expectoration, and nausea. For drug-related AEs, the increased urine acetone bodies and first-degree atrioventricular block were observed in two patients from sugammadex group. Then, the previously reported AEs were not observed in this study, including anaphylaxis, haemorrhage, recurarization, abnormal basic vital signs, or lengthened QRS intervals and QT intervals. Adamgammadex was found to be effective for reversal of rocuronium-induced neuromuscular block as sugammadex.
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3
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Hile GB, Healy KJ, Almassalkhi LR. Rocuronium Reversal in the Emergency Department: Retrospective Evaluation of Hemodynamic Instability Following Administration of Sugammadex Versus Neostigmine With Glycopyrrolate. J Pharm Pract 2021; 36:336-341. [PMID: 34601981 DOI: 10.1177/08971900211048747] [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: 12/17/2022]
Abstract
BACKGROUND Rocuronium is an intermediate-acting non-depolarizing neuromuscular blocking agent frequently used in the emergency department for rapid sequence intubation. The prolonged effects of rocuronium may prevent the ability to conduct a meaningful neurological examination, thereby delaying appropriate diagnosis and treatment. Sugammadex and neostigmine are pharmacologic agents commonly used to reverse rocuronium. The safety of sugammadex versus neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department has not been well described. OBJECTIVE Evaluate the occurrence of hemodynamic instability post-administration of sugammadex versus neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium. METHODS A retrospective cohort study conducted among adult patients that received sugammadex or neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium. The primary outcome was occurrence of hemodynamic instability that required escalation of treatment. Secondary outcomes included occurrence of hypotensive, bradycardic, or cardiac arrest events. RESULTS A total of 37 patients met inclusion criteria (n = 10, sugammadex; n = 27, neostigmine). There was no difference between the two groups in regard to hemodynamic instability that required escalation of treatment within 30 minutes after receiving either sugammadex or neostigmine with glycopyrrolate (P = .557). CONCLUSION There was no difference between the two groups in regard to occurrence of hemodynamic instability that required escalation of treatment. Given the small sample size, future studies are warranted to further delineate the safety of sugammadex and neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department.
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Affiliation(s)
- Garrett B Hile
- Department of Pharmacy, 12253University of Kentucky HealthCare, Lexington, KY, USA
| | - Karl J Healy
- Department of Pharmacy, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Lars R Almassalkhi
- Department of Pharmacy, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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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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5
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Extravascular leakage of induction doses of rocuronium: four cases in which both depth of neuromuscular block and plasma concentration of rocuronium were assessed. J Clin Monit Comput 2021; 36:587-592. [PMID: 33745069 DOI: 10.1007/s10877-021-00692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
The duration of action of extravasated rocuronium varies depending on the patient's comorbidities. In patients who receive high doses of non-depolarizing neuromuscular blocking agents subcutaneously, anesthesiologists should be aware of unexpected prolongation of the progress and recovery of neuromuscular block. In such cases, the depth and recovery of neuromuscular block should be objectively monitored to avoid residual neuromuscular block and recurarization.
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6
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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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7
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Lentz S, Morrissette KM, Porter BA, DeWitt KM, Koyfman A, Long B. What is the Role of Sugammadex in the Emergency Department? J Emerg Med 2020; 60:44-53. [PMID: 32962903 DOI: 10.1016/j.jemermed.2020.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Katelin M Morrissette
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Blake A Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, Vermont
| | - Kyle M DeWitt
- Department of Pharmacy, University of Vermont Medical Center, Burlington, Vermont
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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8
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Arends J, Hubbard R, Shafy SZ, Hakim M, Kim SS, Tumin D, Tobias JD. Heart Rate Changes Following the Administration of Sugammadex to Infants and Children With Comorbid Cardiac, Cardiovascular, and Congenital Heart Diseases. Cardiol Res 2020; 11:274-279. [PMID: 32849961 PMCID: PMC7430884 DOI: 10.14740/cr1045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background Sugammadex is a novel, rapidly-acting pharmacologic agent to reverse steroidal neuromuscular blocking agents with demonstrated advantages over acetylcholinesterase inhibitors. However, anecdotal reports have noted rare instances of bradycardia and even cardiac arrest. The current study examined heart rate (HR) changes in infants and children with comorbid cardiac, cardiovascular, and congenital heart diseases. Methods Patients less than 18 years of age, who had a comorbid cardiac, cardiovascular, or congenital heart disease and were to receive sugammadex, were included in this prospective observational study. After sugammadex administration, HR was continuously monitored and recorded every minute for the first 15 min, and then every 5 min for the next 15 min or until the patient was transferred from the operating room. The primary outcome, bradycardia, was defined as HR below the fifth percentile for age. Secondary outcomes included greatest decrease in HR from baseline for each patient and interventions required for bradycardia. Results The study cohort included 99 patients (58 male and 41 female) with a median age of 3 years. Bradycardia was noted in 20 of 99 patients (20%); however, six of these patients were bradycardic prior to the administration of sugammadex. Older patients, male patients, and patients with higher body weight were the most likely to experience bradycardia. None of the patients required treatment for bradycardia. Conclusions The incidence of bradycardia following the administration of sugammadex was low, even in patients with congenital heart disease. Bradycardia was not associated with clinically significant hemodynamic changes and no treatment was required.
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Affiliation(s)
- Jordan Arends
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard Hubbard
- Department of Anesthesiology, University of Texas, Houston, TX, USA
| | - Shabana Z Shafy
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mohammed Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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9
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Kashima Y, Masui K. Individual pharmacometric analysis for sugammadex reversal and re-administration of neuromuscular blockade. J Anesth 2020; 34:786-789. [DOI: 10.1007/s00540-020-02824-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/04/2020] [Indexed: 12/17/2022]
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10
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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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11
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Tobias JD. Sugammadex: Applications in Pediatric Critical Care. J Pediatr Intensive Care 2020; 9:162-171. [PMID: 32685243 DOI: 10.1055/s-0040-1705133] [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: 12/11/2019] [Accepted: 01/27/2020] [Indexed: 10/24/2022] Open
Abstract
Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade with a mechanism that differs from acetylcholinesterase inhibitors such as neostigmine. There is a growing body of literature demonstrating its efficacy in pediatric patients of all ages. Prospective trials have demonstrated a more rapid and more complete reversal of rocuronium-induced neuromuscular blockade than the acetylcholinesterase inhibitor, neostigmine. Unlike the acetylcholinesterase inhibitors, sugammadex effectively reverses intense or complete neuromuscular blockade. It may also be effective in situations where reversal of neuromuscular blockade is problematic including patients with neuromyopathic conditions or when acetylcholinesterase inhibitors are contraindicated. This article reviews the physiology of neuromuscular transmission as well as the published literature, regarding the use of sugammadex in pediatric population including the pediatric intensive care unit population. Clinical applications are reviewed, adverse effects are discussed, and dosing algorithms are presented.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, United States
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12
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Heart rate changes following the administration of sugammadex in children: a prospective, observational study. J Anesth 2020; 34:238-242. [DOI: 10.1007/s00540-019-02729-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 12/21/2019] [Indexed: 12/17/2022]
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13
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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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14
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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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15
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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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16
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Monitoring of Sugammadex Dosing at a Large Tertiary Care Pediatric Hospital. Pediatr Qual Saf 2018; 3:e113. [PMID: 30584640 PMCID: PMC6221600 DOI: 10.1097/pq9.0000000000000113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 08/31/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction: Anesthesiologists use sugammadex to reverse neuromuscular blockade (NMB) produced by rocuronium and vecuronium. Its mechanism involves encapsulation of the neuromuscular blocking agent. Sugammadex dosing is based on the depth of NMB, assessed by measuring the train-of-four (TOF). Methods: We retrospectively reviewed procedures under general anesthesia in patients older than 1 year of age if they included sugammadex reversal of rocuronium-induced NMB. Documentation of TOF monitoring before and after reversal was noted, along with the dose of sugammadex administered. TOF was considered correctly documented if the anesthesia provider recorded the number of twitches before and after NMB reversal, or if they recorded 4 twitches before NMB reversal. We defined appropriate sugammadex dosing if it was within 10% of the recommended dose for the depth of NMB. We repeated this review after staff education and creating a reminder in the electronic health record system. Results: We included 100 patients in the preintervention analysis, of whom 30% had correct TOF documentation. Among patients with TOF assessment before sugammadex administration, the dose was appropriate in 34 of 40 cases. In the postintervention analysis, we reviewed 75 cases and found that correct documentation improved to 45% (P = 0.024). Among postintervention cases with TOF documented before sugammadex administration, sugammadex dosing was appropriate in 62 patients. Conclusion: Documentation of TOF was low (30%) before intervention and improved to only 45% after the interventions, suggesting that additional interventions are needed. Even before the intervention, with or without TOF documentation, the dose of sugammadex was generally consistent with recommendations.
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17
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Hunter J, Naguib M. Sugammadex-induced bradycardia and asystole: how great is the risk? Br J Anaesth 2018; 121:8-12. [DOI: 10.1016/j.bja.2018.03.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/03/2018] [Accepted: 03/05/2018] [Indexed: 12/17/2022] Open
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Abstract
Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade with a mechanism that differs from the commonly used, acetylcholinesterase inhibitors. Although sugammadex has not received approval from the United States Food & Drug administration in children, its use has already been reported to reverse neuromuscular blockade in several clinical scenarios in the pediatric population including the 'cannot intubate-cannot ventilate' scenario. To date, there remains limited data from prospective trials in the pediatric-aged patient. Anecdotal use has been reported for the reversal of neuromuscular blockade in difficult clinical scenarios such as children with neuromuscular diseases including myasthenia gravis, Duchenne muscular dystrophy, and myotonic dystrophy.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Aldasoro M, Jorda A, Aldasoro C, Marchio P, Guerra-Ojeda S, Gimeno-Raga M, Mauricio MD, Iradi A, Obrador E, Vila JM, Valles SL. Neuronal Effects of Sugammadex in combination with Rocuronium or Vecuronium. Int J Med Sci 2017; 14:224-230. [PMID: 28367082 PMCID: PMC5370284 DOI: 10.7150/ijms.17545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/28/2016] [Indexed: 12/19/2022] Open
Abstract
Rocuronium (ROC) and Vecuronium (VEC) are the most currently used steroidal non-depolarizing neuromuscular blocking (MNB) agents. Sugammadex (SUG) rapidly reverses steroidal NMB agents after anaesthesia. The present study was conducted in order to evaluate neuronal effects of SUG alone and in combination with both ROC and VEC. Using MTT, CASP-3 activity and Western-blot we determined the toxicity of SUG, ROC or VEC in neurons in primary culture. SUG induces apoptosis/necrosis in neurons in primary culture and increases cytochrome C (CytC), apoptosis-inducing factor (AIF), Smac/Diablo and Caspase 3 (CASP-3) protein expression. Our results also demonstrated that both ROC and VEC prevent these SUG effects. The protective role of both ROC and VEC could be explained by the fact that SUG encapsulates NMB drugs. In BBB impaired conditions it would be desirable to control SUG doses to prevent the excess of free SUG in plasma that may induce neuronal damage. A balance between SUG, ROC or VEC would be necessary to prevent the risk of cell damage.
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Affiliation(s)
- Martin Aldasoro
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Adrian Jorda
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Patricia Marchio
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Sol Guerra-Ojeda
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Marc Gimeno-Raga
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Mª Dolores Mauricio
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Antonio Iradi
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Elena Obrador
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Jose Mª Vila
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Soraya L Valles
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
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Trifa M, Krishna S, D'Mello A, Hakim M, Tobias JD. Sugammadex to reverse neuromuscular blockade and provide optimal conditions for motor-evoked potential monitoring. Saudi J Anaesth 2017; 11:219-221. [PMID: 28442963 PMCID: PMC5389243 DOI: 10.4103/1658-354x.203024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade (NMB) via a mechanism that differs completely from acetylcholinesterase inhibitors. By encapsulating rocuronium, sugammadex can provide recovery of neuromuscular function even when there is a profound degree of NMB. We report anecdotal experience with the use of sugammadex to reverse NMB to facilitate intraoperative neurophysiological monitoring (motor evoked potentials) in an adolescent with scoliosis during posterior spinal fusion. Its potential application in this unique clinical scenario is discussed, and potential dosing schemes are reviewed.
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Affiliation(s)
- Mehdi Trifa
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Senthil Krishna
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ajay D'Mello
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mumin Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph Drew Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. The July 2016 monograph topics are pimavanserin, venetoclax, defibrotide, lifitegrast ophthalmic solution 5%, and atezolizumab. The Safety MUE is on pimavanserin.
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Schaller SJ, Lewald H. Clinical pharmacology and efficacy of sugammadex in the reversal of neuromuscular blockade. Expert Opin Drug Metab Toxicol 2016; 12:1097-108. [DOI: 10.1080/17425255.2016.1215426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Abstract
Although neuromuscular block (NMB) allows immobility for airway management and surgical exposure, termination of its effect is limited by and associated with side effects of acetylcholinesterase inhibitors. Sugammadex is a selective relaxant binding agent that has been shown to reverse deep NMB, even when administered 3 minutes following a 1.2 mg/kg dose of rocuronium. This novel drug is a modified gamma cyclodextrin, that through encapsulation process terminates the effects of rocuronium and vecuronium (aminosteroid muscle relaxants), and enables the anesthesiologists rapidly to reverse profound NMB induced by rocuronium or vecuronium, in a "can't ventilate, can't intubate" crisis. In this review, data from published phase 1, 2, and 3 clinical trials are reviewed and presented. In addition, clinical trials on special patient populations (patients with pulmonary disease and renal insufficiency) are evaluated. Each article reviewed will conclude with a discussion of relevance, focus on adverse event profile, and clinical usefulness.
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Hakimoğlu S, Tuzcu K, Davarcı I, Karcıoğlu M, Ayhan Tuzcu E, Hancı V, Aydın S, Kahraman H, Elbeyli A, Turhanoğlu S. Comparison of sugammadex and neostigmine–atropine on intraocular pressure and postoperative effects. Kaohsiung J Med Sci 2016; 32:80-5. [DOI: 10.1016/j.kjms.2016.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/30/2015] [Accepted: 01/11/2016] [Indexed: 12/17/2022] Open
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Loupec T, Frasca D, Rousseau N, Faure JP, Mimoz O, Debaene B. Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients. Anaesthesia 2015; 71:265-72. [DOI: 10.1111/anae.13344] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 12/17/2022]
Affiliation(s)
- T. Loupec
- Department of Digestive Surgery; University Hospital; University of Poitiers; Poitiers France
| | - D. Frasca
- Department of Digestive Surgery; University Hospital; University of Poitiers; Poitiers France
| | - N. Rousseau
- Department of Digestive Surgery; University Hospital; University of Poitiers; Poitiers France
| | - J.-P. Faure
- Department of Digestive Surgery; University Hospital; University of Poitiers; Poitiers France
| | - O. Mimoz
- Department of Anaesthesiology and Intensive Care; University Hospital; University of Poitiers; Poitiers France
| | - B. Debaene
- Department of Anaesthesiology and Intensive Care; University Hospital; University of Poitiers; Poitiers France
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Cheong SH, Ki S, Lee J, Lee JH, Kim MH, Hur D, Cho K, Lim SH, Lee KM, Kim YJ, Lee W. The combination of sugammadex and neostigmine can reduce the dosage of sugammadex during recovery from the moderate neuromuscular blockade. Korean J Anesthesiol 2015; 68:547-55. [PMID: 26634077 PMCID: PMC4667139 DOI: 10.4097/kjae.2015.68.6.547] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/29/2015] [Accepted: 08/10/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sugammadex is a novel neuromuscular reversal agent, but its associated hypersensitivity reaction and high cost have been obstacles to its widespread use. In the interest of reducing the necessary dosage of sugammadex, the reversal time of the combined use of sugammadex and neostigmine from moderate neuromuscular blockade were investigated. METHODS The patients enrolled ranged in age from 18 to 65 years old with American Society of Anesthesiologists class 1 or 2. The subjects were randomly assigned into one of the four groups (Group S2, S1, SN, and N; n = 30 per group). The reversal agents of each groups were as follows: S2 - sugammadex 2 mg/kg, S1 - sugammadex 1 mg/kg, SN - sugammadex 1 mg/kg + neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg, N - neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg. The time to recovery of the train-of-four (TOF) ratio was checked in each group. RESULTS The time to 90% recovery of TOF ratio was 182.6 ± 88.9, 371.1 ± 210.4, 204.3 ± 103.2, 953.2 ± 379.7 sec in group S2, S1, SN and N, respectively. Group SN showed a significantly shorter recovery time than did group S1 and N (P < 0.001). However, statistically significant differences between the S2 and SN groups were not be observed (P = 0.291). No hypersensitivity reactions occurred in all groups. CONCLUSIONS For the reversal from rocuronium-induced moderate neuromuscular blockade, the combined use of sugammadex and neostigmine may be helpful to decrease the recovery time and can also reduce the required dosage of sugammadex. However, the increased incidence of systemic muscarinic side effects must be considered.
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Affiliation(s)
- Soon Ho Cheong
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seunghee Ki
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jiyong Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jeong Han Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Myoung-Hun Kim
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dongki Hur
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kwangrae Cho
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Se Hun Lim
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kun Moo Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young-Jae Kim
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Wonjin Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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Erbaş M, Toman H, Şahin H, Kiraz HA, Barutcu A, Simsek T, Yener AU, Uzun M, Altinişik U. Comparison of effects of sugammadex and neostigmine on QTc prolongation in rabbits under general anesthesia. Acta Cir Bras 2015; 29:807-11. [PMID: 25517494 DOI: 10.1590/s0102-86502014001900007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/24/2014] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To compare the effects of sugammadex and neostigmine, used to antagonize the effects of rocuronium, on the QTc interval. METHODS This study used 10 adult New Zealand white rabbits of 2.5-3.5 kg randomly divided into two groups: sugammadex group (Group S, n:5) and neostigmine group (Group N, n:5). For general anesthesia administering 2 mg/kg iv propofol and 1 mcg/kg iv fentanyl, 0.6 mg/kg iv rocuronium was given. Later to provide reliable airway for all experimental animals V-Gel Rabbit was inserted. The rabbits were manually ventilated by the same anesthetist. After the V-Gel Rabbit was inserted at 2, 5, 10, 20, 25, 27, 30 and 40 minutes measurements were repeated and recorded. At 25 minutes after induction Group N rabbits were given 0.05 mg/kg iv neostigmine + 0.01 mg/kg iv atropine. Group S were administered 2 mg/kg iv sugammadex. RESULTS Comparing the QTc interval in the rabbits in Group S and Group N, in the 25th, 27th and 30th minute after muscle relaxant antagonist was administered the QTc interval in the neostigmine group rabbits was significantly increased (p<0.05). CONCLUSION While sugammadex, administered to antagonize the effect of rocuronium, did not significantly affect the QTc interval, neostigmine+atropine proloned the QTc interval.
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Affiliation(s)
- Mesut Erbaş
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Hüseyin Toman
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Hasan Şahin
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Hasan Ali Kiraz
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Ahmet Barutcu
- Department of Cardiology, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Tuncer Simsek
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Ali Umit Yener
- Department of Cardiovascular Surgery, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Metehan Uzun
- Department of Physiology, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Uğur Altinişik
- Department of Anesthesiology and Reanimation, Medical Faculty, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
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Hanamoto H, Boku A, Morimoto Y, Sugimura M, Kudo C, Niwa H. Appropriate sevoflurane concentration to stabilize autonomic activity during intubation with rocuronium in infants: a randomized controlled trial. BMC Anesthesiol 2015; 15:64. [PMID: 25924844 PMCID: PMC4426550 DOI: 10.1186/s12871-015-0047-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/22/2015] [Indexed: 11/26/2022] Open
Abstract
Background In infants, sevoflurane is commonly used for induction of anesthesia, following which a muscle relaxant is administered to facilitate tracheal intubation. When rocuronium is used as the muscle relaxant, intubation may be performed before reaching an adequate depth of anesthesia because of its rapid onset. The purpose of this study was to investigate the optimal sevoflurane concentration that would minimize the impact of intubation on hemodynamics and autonomic nervous system (ANS) activity in infants. Methods Sixty-one infants aged 1–6 months, undergoing cleft lip repair, were enrolled. Patients were randomly assigned to three end-tidal sevoflurane concentration (E’Sevo) groups, 3%, 4% and 5%. Anesthesia was induced with 5% sevoflurane with 100% oxygen, and rocuronium (0.6 mg/kg) was administered. The concentration of sevoflurane was adjusted to the predetermined concentration in each group. Mechanical pressure control ventilation via a face mask was commenced. Five minutes after E’Sevo became stable at the predetermined concentration, tracheal intubation was performed. Immediately after tracheal intubation, ventilation was restarted at the same ventilator settings and continued for 150 seconds. Heart rate (HR) and mean arterial pressure (MAP) were measured 5 times in the 150 seconds after intubation. Normalized units (nu) of high frequency (HF: 0.04-0.15 Hz) and the ratio of low frequency (LF: 0.15-0.4 Hz) to HF components (LF/HF) of HR variability were calculated by MemCalc/Tonam2C™. Normalized units of HF (HFnu) and LF/HF reflect cardiac parasympathetic and sympathetic activity, respectively. Results After intubation, HR increased slightly in all groups and MAP increased by 9.2% in the E’Sevo-3% group. LF/HF increased (p < 0.01) and HFnu decreased (p < 0.01) in all groups 30 seconds after intubation. HFnu was lower (p < 0.001) and LF/HF was higher (p = 0.007) in the E’Sevo-3% group than in E’Sevo-5% group. ANS responses to intubation were reduced in a dose-dependent manner. Conclusions Sympathomimetic and parasympatholytic responses to intubation in the E’Sevo-3% group were much greater than those in the E’Sevo-5% group. During tracheal intubation in infants, 4% or 5% sevoflurane is appropriate for prevention of sympathetic hyperactivation and maintenance of ANS balance as compared to 3% sevoflurane, when a muscle relaxant is co-administered. Trial registration The study was registered at UMIN-CTR (UMIN000009933).
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Affiliation(s)
- Hiroshi Hanamoto
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Aiji Boku
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yoshinari Morimoto
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan. .,Department of Anesthesiology, Graduate School of Dentistry, Kanagawa Dental University, 82, Inaoka-Cho, Yokosuka, Kanagawa, 238-8580, Japan.
| | - Mitsutaka Sugimura
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Chiho Kudo
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hitoshi Niwa
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Lee HJ, Kim KS, Jeong JS, Kim KN, Lee BC. The influence of mild hypothermia on reversal of rocuronium-induced deep neuromuscular block with sugammadex. BMC Anesthesiol 2015; 15:7. [PMID: 25971394 PMCID: PMC4430027 DOI: 10.1186/1471-2253-15-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/15/2015] [Indexed: 12/18/2022] Open
Abstract
Background Mild hypothermia may be frequently induced due to cool environments in the operating room. The study analyzed patient recovery time and response to sugammadex after a prolonged rocuronium-induced deep neuromuscular block (NMB) during mild hypothermia. Methods Sixty patients were randomly (1:1) allocated to the mild hypothermia and normothermia groups, defined as having core temperatures between 34.5 - 35°C and 36.5 - 37°C, respectively. Patients received 0.6 mg/kg of rocuronium, followed by 7 – 10 μg/kg/min to maintain a deep NMB [post-tetanic count (PTC) 1–2]. After surgery, the deep NMB was reversed with sugammadex 4.0 mg/kg. The primary end-point was the time until the train-of-four (TOF) ratio was 0.9. Results The appropriate neuromuscular function (TOF ratio ≥ 0.9) was restored after sugammadex was administered, even after hypothermia. The length of recovery in the hypothermia patients [mean (SD), 171.1 (62.1) seconds (s)] was significantly slower compared with the normothermia patients [124.9 (59.2) s] (p = 0.005). There were no adverse effects from sugammadex. Conclusions Sugammadex safely and securely reversed deep rocuronium-induced NMB during mild hypothermia. An additional 46 s was required for recovery from a deep NMB in hypothermia patients. Based on the results, we think this prolonged recovery time is clinically acceptable. Trial registration ClinicalTrials.gov Identifier: NCT01965067.
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Affiliation(s)
- Hee Jong Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, #17 Haengdang dong, Sungdong gu, Seoul, 133-792, Korea.
| | - Kyo Sang Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, #17 Haengdang dong, Sungdong gu, Seoul, 133-792, Korea.
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Seoul, Korea.
| | - Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, #17 Haengdang dong, Sungdong gu, Seoul, 133-792, Korea.
| | - Byeong Chan Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, #17 Haengdang dong, Sungdong gu, Seoul, 133-792, Korea.
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Takazawa T, Tomita Y, Yoshida N, Tomioka A, Horiuchi T, Nagata C, Orihara M, Yamada MH, Saito S. Three suspected cases of sugammadex-induced anaphylactic shock. BMC Anesthesiol 2014; 14:92. [PMID: 25349529 PMCID: PMC4209027 DOI: 10.1186/1471-2253-14-92] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/30/2014] [Indexed: 02/08/2023] Open
Abstract
Background Sugammadex has a unique mechanism of action and is widely used because of its safety and efficacy. A few recent reports have described allergic reactions to clinical doses of sugammadex. We hereby describe another series of cases of possible anaphylaxis to sugammadex. Case presentation We present three suspected cases of sugammadex-induced anaphylactic shock, including a 13-year-old boy who underwent laparoscopic appendectomy, a 75-year-old woman who underwent left knee arthroplasty, and a 34-year-old man who underwent left pansinectomy for sinobronchitis. All three patients received general anesthesia with rocuronium and their tracheas were intubated. Shortly after injection of sugammadex for reversal of rocuronium, all of them experienced a decrease in blood pressure along with mucocutaneous erythema. In the most severe case, reintubation after extubation was required due to difficulty in manual ventilation. All patients recovered with anti-allergic therapy. On later investigation, all three patients had a positive skin reaction to sugammadex. Conclusion Our results suggest that physicians using sugammadex should be aware of the possibility of sugammadex-induced anaphylaxis.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
| | - Yukinari Tomita
- Department of Anesthesiology, Isesaki Municipal Hospital, 12-1 Tsunatorihoncho, Isesaki, 372-0817 Japan
| | - Nagahide Yoshida
- Department of Anesthesiology, Saiseikai Maebashi Hospital, 564-1 Kamishinden-machi, Maebashi, 971-0821 Japan
| | - Akihiro Tomioka
- Department of Anesthesiology, Gunma Chuo General Hospital, 1-7-13 Kouuncho, Maebashi, 371-0025 Japan
| | - Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
| | - Chie Nagata
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
| | - Masaki Orihara
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
| | - Makiko Hardy Yamada
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511 Japan
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Ağdanlı D, Öztürk T, Ütük O, Keleş GT. Effects of High-Dose Rocuronium on the QTc Interval During Anaesthesia Induction in Patients Undergoing Coronary Artery Bypass Graft Surgery. Turk J Anaesthesiol Reanim 2014; 42:245-50. [PMID: 27366430 DOI: 10.5152/tjar.2014.64326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 10/21/2013] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Existing myocardial damage in coronary artery disease patients causes prolonged QT syndrome. The primary objective of this trial is to explore the effects of different doses of the muscle relaxant agent rocuronium (0.6 mg kg(-1) and 1.2 mg kg(-1)) on QTc following anaesthetic induction. The second objective is to determine the incidence and kinds of arrhythmias. METHODS In this prospective and randomized trial, patients undergoing elective coronary artery revascularization surgery were included in one of two groups. Both groups took the same anaesthetic induction agents: midazolam and fentanyl. Rocuronium was administered in Group 1 (n=20) with dose of 0.6 mg kg(-1) and in Group 2 (n=20) with a dose of 1.2 mg kg(-1) for muscle relaxation. Heart rate, average arterial pressure and QTc were recorded before induction (T0), after induction (T1), after muscle relaxant (T2), and 2 minutes (T3) and 5 minutes after intubation (T4). RESULTS QTc was significantly longer 2 minutes after intubation (in Group 1 and Group 2, respectively, 447.9±28.3 and 466.1±37.8 ms) than at the beginning (respectively, 426.9±25.7, 432.0±35.5 ms) (p<0.01). In the intergroup comparison, average QTc values were similar in all trial periods (p>0.05). The prevalence of arrhythmias in between Group 1 (35%, n=7) and Group 2 (15%, n=3) was similar (p=0.06). Arrhythmias were recorded 2 minutes after intubation in both groups (n=10, 25%). CONCLUSION In patients undergoing coronary artery revascularization surgery, rocuronium doses of 0.6 mg kg(-1) and 1.2 mg kg(-1) prolong the QTc interval after intubation. Cardiac arrhythmias related to long QTc arising after intubation should be taken into consideration.
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Affiliation(s)
- Doğuş Ağdanlı
- Clinic of Anaesthesiology, Van İpekyolu State Hospital, Van, Turkey
| | - Tülün Öztürk
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Ozan Ütük
- Clinic of Cardiology, Grandmedical Hospital, Manisa, Turkey
| | - Gönül Tezcan Keleş
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
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Fujita A, Ishibe N, Yoshihara T, Ohashi J, Makino H, Ikeda M, Setoguchi H. Rapid reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. ACTA ACUST UNITED AC 2014; 52:54-8. [PMID: 25016508 DOI: 10.1016/j.aat.2014.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 03/14/2014] [Accepted: 03/19/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Sugammadex rapidly reverses neuromuscular blockade (NMB) induced by rocuronium. NMB induced by rocuronium is prolonged in patients with liver dysfunction, because the drug is mainly excreted into the bile. However, the efficacy and safety of sugammadex in terms of reversing rocuronium-induced NMB in patients with liver dysfunction undergoing hepatic surgery have not been evaluated. This observational study investigated the efficacy and safety of sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. METHODS Remifentanil/propofol anesthesia was administered to 31 patients: 15 patients in the control group, and 16 patients from a group with liver dysfunction. Rocuronium (0.6 mg/kg) was administered, followed by continuous infusion. The enrolled patients were then subdivided into two groups according to the dose of sugammadex. In the first group a single dose of sugammadex (2.0 mg/kg) was given at the reappearance of the second twitch (T2). In the second group a single dose of sugammadex (4.0 mg/kg) was given at the first twitch response if T2 did not reappear in 15 minutes after stopping rocuronium. The primary outcome was time from administration of sugammadex to recovery of a train-of-four ratio to 0.9. RESULTS The dose of rocuronium required in the liver dysfunction group was lower than that in the control group (6.2 vs. 8.2 μg/kg/min, p = 0.002). The mean time from the administration of sugammadex to recovery of the train-of-four ratio to 0.9 was not significantly different between the liver dysfunction group and the control group (2.2 minutes vs. 2.0 minutes in the 2 mg/kg administration group, p = 0.44 and 1.9 minutes vs. 1.7 minutes in the 4 mg/kg administration group, p = 0.70, respectively). No evidence of recurarization was observed in any of the patients. Most of the adverse events were found to be mild and such events were not related to the use of sugammadex. None of the patients was eliminated from the study because of an adverse event. One patient died due to cholestatic liver cirrhosis because of repeated hepatic surgery. CONCLUSION Sugammadex can rapidly reverse NMB after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. Sugammadex was found to be safe and well tolerated. However, further studies of sugammadex under similar conditions should be conducted involving a large number of patients with liver dysfunction undergoing hepatic surgery.
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Affiliation(s)
- Ai Fujita
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Natsuki Ishibe
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tatsuya Yoshihara
- Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Ohashi
- Doctoral Program in Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | | | - Mizuko Ikeda
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
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Lobaz S, Clymer M, Sammut M. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. ACTA ACUST UNITED AC 2014. [DOI: 10.4137/cmt.s10241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.
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Affiliation(s)
- Steven Lobaz
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mark Clymer
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mario Sammut
- Department of Anaesthetics and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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Naguib M, Brull SJ. Sugammadex: a novel selective relaxant binding agent. Expert Rev Clin Pharmacol 2014; 2:37-53. [DOI: 10.1586/17512433.2.1.37] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Hogg RMG, Mirakhur RK. Sugammadex: a selective relaxant binding agent for reversal of neuromuscular block. Expert Rev Neurother 2014; 9:599-608. [DOI: 10.1586/ern.09.22] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Aniskevich S, Leone BJ, Brull SJ. Sugammadex: a novel approach to reversal of neuromuscular blockade. Expert Rev Neurother 2014; 11:185-98. [DOI: 10.1586/ern.11.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Cucurbit[n]uril type hosts for the reversal of steroidal neuromuscular blocking agents. Future Med Chem 2013; 5:2075-89. [DOI: 10.4155/fmc.13.164] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The ideal neuromuscular blocking agent (NMBA) is regarded as being a non-depolarizing equivalent of succinylcholine, having a rapid onset and short duration of action, with minimal side effects. In the absence of a single drug, the administration of an aminosteroid NMBA, such as rocuronium, followed by reversal using an acetylcholinesterase inhibitor, such as neostigmine, is commonly employed. A different and safer approach to rapidly reversing the action of the NMBA, by encapsulating it with a macrocyclic or acyclic host molecule, such as the cyclodextrin sugammadex or more recently, cucurbituril-type hosts such as cyclic cucurbit[7]uril and the acyclic glycoluril tetramer calabadion 1, is described.
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Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. CORE EVIDENCE 2013; 8:57-67. [PMID: 24098155 PMCID: PMC3789633 DOI: 10.2147/ce.s35675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
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Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Kalkan Y, Tumkaya L, Bostan H, Tomak Y, Altuner D, Yilmaz A, Erdivanli B, Bedir R, Yalcin A, Turan A. Effect of sugammadex on rocuronium induced changes in pancreatic mast cells. Toxicol Ind Health 2013; 31:738-46. [PMID: 23552269 DOI: 10.1177/0748233713484654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mast cells play a vital role in hypersensitivity reactions. Rocuronium is known to cause mast cell mobilization, hypersensitivity, and pancreatitis. The aim of this study was to investigate the effects of sugammadex on pancreatic changes due to rocuronium. A total of 42 Sprague-Dawley male rats were divided into six equal groups to receive either rocuronium 1 mg/kg intravenously (i.v., R group), rocuronium 1 mg/kg + sugammadex 16 mg/kg i.v. (RS16 group), rocuronium 1 mg/kg + sugammadex 96 mg/kg i.v. (RS96 group), sugammadex 16 mg/kg (S16), sugammadex 96 mg/kg i.v. (S96 group), or 0.9% sodium chloride (control group). Sugammadex was administered 5s later following rocuronium. In R group, mast count was higher, and the distribution rate of granules and nuclear changes were different compared with other groups. Distribution rate of granules in groups S16 and S96 were similar to the control group and lower compared with other groups. The amount of mast cells and granule density in groups RS16 and RS96 was lower compared with R group. The amount of mast cells in groups RS16 and RS96 was significantly lower compared with other treatment groups. These results suggest that sugammadex may have an inhibitory effect on mobilization and morphological changes in pancreatic mast cells induced by administration of rocuronium and sugammadex in rats.
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Affiliation(s)
- Yıldıray Kalkan
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Levent Tumkaya
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Habib Bostan
- The Ministry of Justice, Institute of Forensic Medicine, Istanbul, Turkey
| | - Yakup Tomak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Durdu Altuner
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Adnan Yilmaz
- Department of Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Başar Erdivanli
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Recep Bedir
- Department of Pathology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Alper Yalcin
- Department of Histology and Embryology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
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Palanca JM, Aguirre-Rueda D, Granell MV, Aldasoro M, Garcia A, Iradi A, Obrador E, Mauricio MD, Vila J, Gil-Bisquert A, Valles SL. Sugammadex, a neuromuscular blockade reversal agent, causes neuronal apoptosis in primary cultures. Int J Med Sci 2013; 10:1278-85. [PMID: 23983586 PMCID: PMC3752716 DOI: 10.7150/ijms.6254] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/18/2013] [Indexed: 12/20/2022] Open
Abstract
Sugammadex, a γ-cyclodextrin that encapsulates selectively steroidal neuromuscular blocking agents, such as rocuronium or vecuronium, has changed the face of clinical neuromuscular pharmacology. Sugammadex allows a rapid reversal of muscle paralysis. Sugammadex appears to be safe and well tolerated. Its blood-brain barrier penetration is poor (< 3% in rats), and thus no relevant central nervous toxicity is expected. However the blood brain barrier permeability can be altered under different conditions (i.e. neurodegenerative diseases, trauma, ischemia, infections, or immature nervous system). Using MTT, confocal microscopy, caspase-3 activity, cholesterol quantification and Western-blot we determine toxicity of Sugammadex in neurons in primary culture. Here we show that clinically relevant sugammadex concentrations cause apoptotic/necrosis neuron death in primary cultures. Studies on the underlying mechanism revealed that sugammadex-induced activation of mitochondria-dependent apoptosis associates with depletion of neuronal cholesterol levels. Furthermore SUG increase CytC, AIF, Smac/Diablo and CASP-3 protein expression in cells in culture. Potential association of SUG-induced alteration in cholesterol homeostasis with oxidative stress and apoptosis activation occurs. Furthermore, resistance/sensitivity to oxidative stress differs between neuronal cell types.
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Affiliation(s)
- José M Palanca
- Department of Surgery/Anaesthesiology, School of Medicine and Odontology, University of Valencia, Spain
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Asahi Y, Omichi S, Adachi S, Kagamiuchi H, Kotani J. Hypersensitivity reaction probably induced by sugammadex. ACTA ACUST UNITED AC 2012; 50:183-4. [DOI: 10.1016/j.aat.2012.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 08/09/2012] [Accepted: 08/14/2012] [Indexed: 12/20/2022]
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Peeters PAM, van den Heuvel MW, Heumen EV, Passier PCCM, Smeets JMW, van Iersel T, Zwiers A. Safety, Tolerability and Pharmacokinetics of Sugammadex Using Single High Doses (Up to 96 mg/kg) in Healthy Adult Subjects. Clin Drug Investig 2012; 30:867-74. [DOI: 10.1007/bf03256915] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kalkan Y, Bostan H, Tumkaya L, Tomak Y, Bostan M, Yilmaz A, Turut H, Temiz A, Yalçin A, Turan A. The effect of rocuronium, sugammadex, and their combination on cardiac muscle and diaphragmatic skeletal muscle cells. J Anesth 2012; 26:870-7. [DOI: 10.1007/s00540-012-1440-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/13/2012] [Indexed: 12/17/2022]
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Godai K, Hasegawa-Moriyama M, Kuniyoshi T, Kakoi T, Ikoma K, Isowaki S, Matsunaga A, Kanmura Y. Three cases of suspected sugammadex-induced hypersensitivity reactions. Br J Anaesth 2012; 109:216-8. [PMID: 22617091 DOI: 10.1093/bja/aes137] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Neuromuscular blocking agents have been implicated in 60-70% of anaphylactic events associated with anaesthesia. We report two cases of probable hypersensitivity reaction to sugammadex and an additional suspected but less supported case of possible immune-mediated reaction or other adverse reaction. The patients were given a bolus of sugammadex 100 mg immediately before extubation. In all three patients, a possible allergic reaction was suspected within 4 min of sugammadex administration, but with different degrees of severity. Skin testing was positive in two of these patients. Hypersensitivity to sugammadex unaccompanied by cardiovascular or respiratory symptoms might be missed during the course of anaesthesia. Careful monitoring for possible allergic responses is required in patients who have received sugammadex.
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Affiliation(s)
- K Godai
- Department of Anaesthesiology and Critical Care Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
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Orliaguet G. Sédation et analgésie en structure d’urgence. Pédiatrie : quelle sédation et analgésie pour l’intubation trachéale chez l’enfant ? ACTA ACUST UNITED AC 2012; 31:377-83. [DOI: 10.1016/j.annfar.2012.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Freysz M, Orliaguet G. [Sedation and analgesia in emergency structure. Which are the properties and the disadvantages of the products used?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:283-294. [PMID: 22436603 DOI: 10.1016/j.annfar.2012.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- M Freysz
- Departement de medecine d'urgence, universite de Bourgogne, CHU de Dijon, BP 77908, 21079 Dijon cedex, France.
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Menéndez-Ozcoidi L, Ortiz-Gómez JR, Olaguibel-Ribero JM, Salvador-Bravo MJ. Allergy to low dose sugammadex. Anaesthesia 2011; 66:217-9. [DOI: 10.1111/j.1365-2044.2010.06611.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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