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Cozowicz C, Zhong H, Poeran J, Illescas A, Liu J, Poultsides LA, Athanassoglou V, Memtsoudis SG. Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis. Eur J Anaesthesiol 2024; 41:374-380. [PMID: 38497249 DOI: 10.1097/eja.0000000000001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.
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Affiliation(s)
- Crispiana Cozowicz
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (CC, SGM), Hospital for Special Surgery, Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College, New York, USA (HZ, AI, JL, SGM), Department of Orthopaedic Surgery/Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, USA (JP), Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA (JL, SGM), Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou (LAP), Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece (LAP) and Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, United Kingdom (VA)
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Abstract
Pulmonary atelectasis is common in the perioperative period. Physiologically, it is produced when collapsing forces derived from positive pleural pressure and surface tension overcome expanding forces from alveolar pressure and parenchymal tethering. Atelectasis impairs blood oxygenation and reduces lung compliance. It is increasingly recognized that it can also induce local tissue biologic responses, such as inflammation, local immune dysfunction, and damage of the alveolar-capillary barrier, with potential loss of lung fluid clearance, increased lung protein permeability, and susceptibility to infection, factors that can initiate or exaggerate lung injury. Mechanical ventilation of a heterogeneously aerated lung (e.g., in the presence of atelectatic lung tissue) involves biomechanical processes that may precipitate further lung damage: concentration of mechanical forces, propagation of gas-liquid interfaces, and remote overdistension. Knowledge of such pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should guide optimal clinical management.
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Recovery of lower oesophageal barrier function: a pilot study comparing a mixture of atropine and neostigmine and sugammadex: A randomised controlled pilot study. Eur J Anaesthesiol 2021; 38:856-864. [PMID: 34226418 DOI: 10.1097/eja.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lower oesophageal sphincter (LOS) barrier serves to prevent regurgitation of gastric contents. Although general anaesthesia depresses its function, its recovery process during emergence from anaesthesia has not been systematically examined. OBJECTIVE To explore whether recovery of lower oesophageal barrier function differed between patients receiving a mixture of 1 mg atropine and 2 mg neostigmine and those receiving 2 mg kg-1 sugammadex during emergence from anaesthesia. DESIGN An unblinded randomised controlled pilot study. SETTING A single university hospital from January 2016 to December 2018. PATIENTS A total of 20 non-obese adult females undergoing minor surgery. INTERVENTION The patients were randomly assigned to a group either receiving atropine and neostigmine or sugammadex for reversal of rocuronium. MAIN OUTCOME MEASURES Through use of the high-resolution manometry technique, the lower oesophageal barrier pressure (PBAR: primary variable) defined as a pressure difference between pressures at the LOS and the stomach was measured at five distinguishable time points during emergence from total intravenous anaesthesia. A mixed effects model for repeated measures was used to test the hypothesis. RESULTS In all patients baseline PBAR values were positive even under muscle paralysis and general anaesthesia before administration of reversal agents, and did not differ between the groups (P = 0.299). During recovery from muscle paralysis and general anaesthesia, PBAR (mean ± SD) significantly increased (P = 0.004) from 17.0 ± 2.9 to 21.0 ± 5.0 mmHg in the atropine and neostigmine group (n = 8) and from 19.1 ± 9.0 to 24.5 ± 12.7 mmHg in the sugammadex group (n = 11). PBAR significantly increased immediately after return of consciousness in both groups, whereas return of muscle tone, lightening of anaesthesia and tracheal extubation did not change it. CONCLUSION Recovery of the lower oesophageal barrier function does not differ between patients receiving either atropine and neostigmine or sugammadex and is completed after recovery of consciousness from general anaesthesia. TRIAL REGISTRATION UMIN Clinical Trials Registry: UMIN000020500: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000023594&type=summary&language=E.
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Yu J, Park JY, Lee Y, Hwang JH, Kim YK. Sugammadex versus neostigmine on postoperative pulmonary complications after robot-assisted laparoscopic prostatectomy: a propensity score-matched analysis. J Anesth 2021; 35:262-269. [PMID: 33683444 DOI: 10.1007/s00540-021-02910-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/14/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Robot-assisted laparoscopic prostatectomy (RALP) requires particular surgical conditions, such as carbon dioxide pneumoperitoneum and steep Trendelenburg positioning, which may have adverse effects on the respiratory system. The effect of sugammadex on postoperative pulmonary complications (PPCs) is controversial. Therefore, we evaluated the incidence of PPCs according to the type of neuromuscular blockade reversal agents in RALP. METHODS We retrospectively analyzed RALP patients. We compared the incidence of PPCs between patients receiving neostigmine (neostigmine group) and those receiving sugammadex (sugammadex group) as a neuromuscular blockade reversal agent. Propensity score-matched analysis was performed. Other postoperative outcomes, such as duration of hospital stays, major adverse cardiac events during hospital stays, and death during hospital stays, were also compared between the two groups. RESULTS The incidence of PPCs was 28.9% (137/474) in RALP. The incidence of PPCs was significantly lower in the sugammadex group than in the neostigmine group (18.6% [44/237] vs. 39.2% [93/237], p < 0.001). The incidence of atelectasis was significantly lower in the sugammadex group than in the neostigmine group (18.6% vs. 39.2%, p < 0.001). The incidence of pneumonia was not significantly different between the sugammadex and neostigmine groups after RALP (0.0% vs. 0.4%, p > 0.999). Besides these, other postoperative outcomes were not significantly different between the two groups. CONCLUSIONS The incidence of PPCs after RALP was significantly lower in patients receiving sugammadex than in those receiving neostigmine. These results can provide useful information on the appropriate selection of neuromuscular blockade reversal agents in RALP.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yongsoo Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Quality of Recovery after Laparoscopic Cholecystectomy Following Neuromuscular Blockade Reversal with Neostigmine or Sugammadex: A Prospective, Randomized, Controlled Trial. J Clin Med 2021; 10:jcm10050938. [PMID: 33804329 PMCID: PMC7957716 DOI: 10.3390/jcm10050938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022] Open
Abstract
The risk of neuromuscular blockade is certainly minimized by sugammadex in combination with monitoring. However, the effect of sugammadex-aided recovery on patients’ satisfaction is unclear. This study compared the Quality of Recovery (QoR)-15 score, which is a patient-reported outcome, in patients undergoing laparoscopic cholecystectomy. Eighty patients were randomly assigned to the neostigmine or sugammadex groups. At the end of surgery, neostigmine or sugammadex was administered, and tracheal extubation was performed after confirmation of a train of four ratio ≥ 0.9. The QoR-15 questionnaire was administered at 1 day before surgery and on post-operative days (POD) 1 and 2. The primary outcome was the QoR-15 score on POD 1. The secondary outcomes were the QoR-15 score on POD 2, modified Aldrete score, length of post-anesthetic care unit stay, post-operative pain, administration of anti-emetics, urinary retention, and length of hospital stay. No significant differences were found in QoR-15 scores on POD 1 (94.4 vs. 95.5, p = 0.87) or 2 (116.3 vs. 122, p = 0.33). Secondary outcomes were also comparable, with the exception of urinary retention (15.8% neostigmine vs. 2.6% sugammadex, p = 0.04). This study demonstrated that the quality of recovery was comparable between the neostigmine and sugammadex groups when reversal and tracheal extubation were performed in accordance with the current guidelines.
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Ghanem MA, Nasr M, el Aziz Motawee A, El-kenany S. Half-dose sugammadex with neostigmine versus full-dose sugammadex for reversal of rocuronium in laparoscopic bariatric surgery. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2020; 12:24. [DOI: 10.1186/s42077-020-00067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/23/2020] [Indexed: 09/02/2023]
Abstract
Abstract
Background
Sugammadex reverses rocuronium more effective than neostigmine during deeper neuromuscular blockade levels. Relying upon the high cost of sugammadex we hypothesized that combined neostigmine with half-dose sugammadex (1.2 mg/kg) would be as effective as the full dose (2.4 mg/kg IBW) in reversing rocuronium-induced deep neuromuscular block in obese patients. A multimodal approach would be an effective cost saving strategy, while preserving the advantages of this novel agent.
Patient and methods
A prospective randomized study done on 50 morbid obese patients undergoing elective laparoscopic sleeve gastrectomy operation. Patients were allocated into two groups each of 25. Group NS received sugammadex 1.2 mg/kg and neostigmine 50 μg/kg with atropine 20 μg/kg. Group S received sugammadex 2.4 mg/kg and 10 mL of normal saline.
Primary outcome
Interval between administration of reversal and reaching TOF of 90%.
Secondary outcomes
Total dose of rocuronium (mg), duration between last dose rocuronium and reverse, number of patients reached TOF of 90% within 5 min, duration between IV reversal and extubation, and the number of patients with residual neuromuscular blockade.
Results
Number of patients who reached TOF 90% within 5 min, the interval between reversal and 90% TOF, the interval between reversal and extubation were comparable between the study groups.
Conclusion
As regards neuromuscular blocker reversal in obese patients, the neostigmine 50 μg/kg plus sugammadex half dose (1.2 mg/kg) is as effective as full-dose sugammadex (2.4 mg/kg) alone.
Trial registration
Institutional Research Board: (IRB code number): MS/17.12.195 on 16 January 2018.
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Togioka BM, Yanez D, Aziz MF, Higgins JR, Tekkali P, Treggiari MM. Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery. Br J Anaesth 2020; 124:553-561. [DOI: 10.1016/j.bja.2020.01.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 12/20/2022] Open
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Park S, Oh EJ, Han S, Shin B, Shin SH, Im Y, Son YH, Park HY. Intraoperative Anesthetic Management of Patients with Chronic Obstructive Pulmonary Disease to Decrease the Risk of Postoperative Pulmonary Complications after Abdominal Surgery. J Clin Med 2020; 9:jcm9010150. [PMID: 31935888 PMCID: PMC7019772 DOI: 10.3390/jcm9010150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) exhibit airflow limitation and suboptimal lung function, and they are at high risk of developing postoperative pulmonary complications (PPCs). We aimed to determine the factors that would decrease PPC risk in patients with COPD. We retrospectively analyzed 419 patients with COPD who were registered in our institutional PPC database and had undergone an abdominal surgery under general anesthesia. PPCs comprised respiratory failure, pleural effusion, atelectasis, respiratory infection, and bronchospasm; the presence or type of PPC was diagnosed by respiratory physicians and recorded in the database before this study. Binary logistic regression was used for statistical analysis. Of the 419 patients, 121 patients (28.8%) experienced 200 PPCs. Multivariable analysis showed three modifiable anesthetic factors that could decrease PPC risk: low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced neuromuscular blockade reversal. We found that the 90-day mortality risk was significantly greater in patients with PPC than in those without PPC (5.8% vs. 1.3%; p = 0.016). Therefore, PPC risk in patients with COPD can be decreased if low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced reversal during abdominal surgery are efficiently managed, as these factors result in decreased postoperative mortality.
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Affiliation(s)
- Sukhee Park
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University School of Medicine, Incheon 22711, Korea
| | - Eun Jung Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon 24341, Korea
| | - Sangbin Han
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Beomsu Shin
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Yunjoo Im
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Yong Hoon Son
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
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Schepens T, Janssens K, Maes S, Wildemeersch D, Vellinga J, Jorens PG, Saldien V. Respiratory muscle activity after spontaneous, neostigmine- or sugammadex-enhanced recovery of neuromuscular blockade: a double blind prospective randomized controlled trial. BMC Anesthesiol 2019; 19:187. [PMID: 31629404 PMCID: PMC6800991 DOI: 10.1186/s12871-019-0863-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background The use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. In previous studies, we found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex. It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. In this study, we wanted to assess the effect of commonly used degrees of NMB and their possible reversal strategies on respiratory muscle activity after the return of normal neuromuscular transmission. Methods This is a randomized, controlled, parallel-group, single-centre, double-blind study in patients scheduled for intracranial surgery at a tertiary academic hospital in Belgium. All participants received target controlled propofol/remifentanil anesthesia and were randomized into one of five groups, receiving either a shallow NMB with no reversal (shallow/saline), a shallow NMB with sugammadex reversal (shallow/sugammadex), a moderate NMB with neostigmine reversal (moderate/neostigmine), a moderate NMB with sugammadex reversal (moderate/sugammadex), or a deep NMB with sugammadex reversal (deep/sugammadex). Primary and secondary outcome parameters were diaphragm and intercostal electromyographic (EMG) activity at the moment of resumed spontaneous breathing activity, defined as a maximal interval of 10 min after the first spontaneous breath. Results For the five groups, a total of 55 patients could be included in the final analysis. Median time of spontaneous breathing analyzed was 5 min (IQR 3–9.5 min). Both the moderate/sugammadex and the moderate/neostigmine groups had lower levels of diaphragm EMG compared to the shallow/sugammadex group. The moderate/neostigmine group had lower levels of intercostal EMG activity compared to the shallow/saline group. Conclusions In this study, the depth of neuromuscular blockade and type of reversal strategy impacts respiratory muscle activity at the moment of resumed spontaneous breathing and recovery of neuromuscular blockade. Both groups that received moderate NMB had lower levels of diaphragm EMG, compared to the shallow NMB group with sugammadex reversal. Compared to the shallow NMB group with no reversal, the moderate NMB with neostigmine reversal group had lower intercostal EMG activity. Trial registration Clinicaltrials.gov NCT01962298 on October 9, 2013 and EudraCT 2013–001926-25 on October 10, 2013.
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Affiliation(s)
- Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium.
| | - Koen Janssens
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - Sabine Maes
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | | | | | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Vera Saldien
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
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Kent NB, Liang SS, Phillips S, Smith NA, Khandkar C, Eikermann M, Stewart PA. Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double-blind, placebo-controlled, randomised volunteer study. Anaesthesia 2019; 73:1079-1089. [PMID: 30132821 DOI: 10.1111/anae.14386] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Neostigmine reverses non-depolarising neuromuscular blockade, but may cause muscle weakness when administered after full recovery of neuromuscular function. We hypothesised that neostigmine in therapeutic doses impairs muscle strength and respiratory function in awake healthy volunteers. Twenty-one volunteers were randomised to receive two doses of either intravenous (i.v.) neostigmine 2.5 mg with glycopyrrolate 450 μg (neostigmine group, n = 14) or normal saline 0.9% (placebo group, n = 7). The first dose was administered immediately after obtaining baseline measurements, and the second dose was administered 15 min later. All 14 volunteers in the neostigmine group received the first dose, mean (SD) 35 (5.8) μg.kg-1 , but only nine of these volunteers agreed to receive the second dose, 34 (3.5) ?g.kg-1 . The primary outcome was hand grip strength. Secondary outcomes were train-of-four ratio, single twitch height, forced expiratory volume in 1 s, forced vital capacity, forced expiratory volume in 1 s/forced vital capacity ratio, oxygen saturation, heart rate and mean arterial pressure. The first dose of intravenous neostigmine with glycopyrrolate resulted in reduced grip strength compared with placebo, -20 (20) % vs. +4.3 (9.9) %, p = 0.0016; depolarising neuromuscular blockade with decreased single twitch height, -14 (11) % vs. -3.8 (5.6) %, p = 0.0077; a restrictive spirometry pattern with decreased predicted forced expiratory volume in 1 s, -15 (12) % vs. -0.47 (3.4) %, p = 0.0011; and predicted forced vital capacity, -20 (12) % vs. -0.59 (3.2) %, p < 0.0001 at 5 min after administration. The second dose of neostigmine with glycopyrrolate further decreased grip strength mean (SD) -41 (23) % vs. +1.0 (15) %, p = 0.0004; single twitch height -25 (15) % vs. -2.5 (6.6) %, p = 0.0030; predicted forced expiratory volume in 1 s -23 (24) % vs. -0.7 (4.4) %, p = 0.0063; and predicted forced vital capacity, -27.1 (22.0) % vs. -0.66 (3.9) %, p = 0.0010. Train-of-four ratio remained unchanged (p = 0.22). In healthy volunteers, therapeutic doses of neostigmine induced significant and dose-dependent muscle weakness, demonstrated by a decrease in maximum voluntary hand grip strength and a restrictive spirometry pattern secondary to depolarising neuromuscular blockade.
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Affiliation(s)
- N B Kent
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - S S Liang
- Department of Anaesthesia, Westmead Hospital, Westmead, NSW, Australia
| | - S Phillips
- Department of Anaesthesia, The University of Sydney, Sydney Adventist Hospital Clinical School, Sydney, NSW, Australia
| | - N A Smith
- Department of Anaesthesia, Wollongong Hospital, Wollongong, NSW, Australia
| | - C Khandkar
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - M Eikermann
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.,Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - P A Stewart
- Department of Anaesthesia, The University of Sydney, Sydney Adventist Hospital Clinical School, Sydney, NSW, Australia
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Affiliation(s)
| | - D Bramley
- Western Health, Melbourne, Vic, Australia
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12
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Abstract
Purpose of Review The purpose of this review is to assess how sugammadex impacts postoperative residual curarization using appropriate doses based on neuromuscular transmission monitoring and whether the advantages of sugammadex versus neostigmine outweigh its higher cost. Recent Findings An accurate assessment of neuromuscular blockade with monitoring is necessary before selecting neostigmine versus sugammadex for reversal at the end of surgery to overcome incomplete neuromuscular recovery. The main advantages of sugammadex over neostigmine are its predictability and its ability to extend the range of blockade reversal. The cost of sugammadex is greater when higher doses of sugammadex are required for antagonism of deep block. Sugammadex probably has the potential to be cost-effective compared with neostigmine if its time savings are put to productive use in clinical practice. However, to date, the economic benefits of the drug are unknown. Summary With sugammadex, almost any degree of neuromuscular block can be antagonized within 2–3 min; neostigmine is the only reversal agent effective against benzylisoquinolines and can ideally be used for reversal of lower levels of residual paralysis. The performance of the more expensive sugammadex on improving patient outcomes may depend on several elements of clinical strategy.
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Affiliation(s)
- Guy Cammu
- Anesthesiology and Critical Care Medicine, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
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Abstract
Muscle relaxation is a routine part of anesthesia and has important advantages. However, the lingering effects of muscle relaxants in the postoperative period have historically been associated with postoperative adverse events. Neuromuscular reversal, together with neuromuscular monitoring, is a recognized strategy to reduce the rate of postoperative residual relaxation but has only marginally improved outcome in the past few decades. Sugammadex, a novel reversal agent with unique encapsulating properties, has changed the landscape of neuromuscular reversal and opened up new opportunities to improve patient care. By quickly and completely reversing any depth of neuromuscular block, it may reduce the rate of residual relaxation and improve respiratory recovery. In addition, sugammadex has made the use of deep neuromuscular block possible during surgery. Deep neuromuscular block may improve surgical working conditions and allow for a reduction in insufflation pressures during selected laparoscopic procedures. However, whether and how this may impact outcomes is not well established.
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Affiliation(s)
- Martijn Boon
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
| | - Christian Martini
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
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Aouad MT, Alfahel WS, Kaddoum RN, Siddik-Sayyid SM. Half dose sugammadex combined with neostigmine is non-inferior to full dose sugammadex for reversal of rocuronium-induced deep neuromuscular blockade: a cost-saving strategy. BMC Anesthesiol 2017; 17:57. [PMID: 28399799 PMCID: PMC5387345 DOI: 10.1186/s12871-017-0348-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/03/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sugammadex reverses the effect of rocuronium more rapidly and effectively than neostigmine, at all levels of neuromuscular blockade (NMB). However, its cost is prohibitive. The combination of half dose sugammadex with neostigmine would be non-inferior to full dose sugammadex for the reversal of deep NMB. This approach would reduce the cost of sugammadex while preserving its efficacy. METHODS Patients were randomly allocated to receive sugammadex 4 mg/kg (Group S) or sugammadex 2 mg/kg with neostigmine 50 μg/kg and glycopyrrolate 10 μg/kg (Group NS) for reversal of rocuronium deep NMB. The primary outcome was the percentage of patients who recovered to 90% Train of Four (TOF) ratio within 5 min. The non-inferiority margin was set at 10%. RESULTS Twenty eight patients were enrolled in each group. The number of patients who reached 90% TOF ratio within 5 min was 27 out of 28 (96%) in group S versus 25 out of 28 (89%) in group NS by intention-to-treat (difference: 7%, 95% CI of the difference: -9% to 24%). The number of patients who reached 90% TOF ratio within 5 min was 26 out of 26 (100%) in group S versus 23 out of 25 (92%) in group NS by per-protocol (difference: 8%, 95% CI of the difference: -6% to 25%). CONCLUSIONS Sugammadex 2 mg/kg with neostigmine 50 μg/kg was at worst 9% and 6% less effective than sugammadex 4 mg/kg by intention-to-treat and by per-protocol analysis respectively. Hence, the combination is non-inferior to the recommended dose of sugammadex. TRIAL REGISTRATION Clinicaltrials.gov NCT 02375217 , registered on February 11, 2015.
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Affiliation(s)
- Marie T Aouad
- Department of Anaesthesiology, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon.
| | - Waseem S Alfahel
- Department of Anaesthesiology, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Roland N Kaddoum
- Department of Anaesthesiology, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Sahar M Siddik-Sayyid
- Department of Anaesthesiology, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
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