Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy

Comparison between Sugammadex and Neostigmine after Video-Assisted Thoracoscopic Surgery-Thymectomy in Patients with Myasthenia Gravis: A Single-Center Retrospective Exploratory Analysis

This single-center retrospective exploratory analysis evaluated the effects of sugammadex compared with neostigmine on postoperative recovery in patients with myasthenia gravis (MG) who underwent video-assisted thoracoscopic surgery (VATS)-thymectomy. This retrospective study included 180 patients with MG, aged >18 years, who received sugammadex (sugammadex group, n = 83) or neostigmine-glycopyrrolate (neostigmine group, n = 88) after VATS-thymectomy between November 2007 and December 2020. Inverse probability of treatment weighting (IPTW) adjustment was performed to balance the baseline characteristics between the two groups. The primary outcome was the length of postoperative hospital stay, and the secondary outcomes were the incidence of postoperative mortality and complications, as well as the postoperative extubation and reintubation rates, in the operating room after VATS-thymectomy; the outcomes were compared between the two groups. After IPTW adjustment, the sugammadex group showed a significantly shorter median postoperative hospital stay than the neostigmine group (4 (2, 4) vs. 5 (3, 6) days, respectively; p = 0.003). There were no significant differences between the two groups in the incidences of postoperative complications (including postoperative myasthenic crisis, nerve palsy, atelectasis, and pleural effusion). Patients with MG following VATS-thymectomy who received sugammadex showed a significantly shorter postoperative hospital stay than those who received neostigmine.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan

BACKGROUND

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it.

OBJECTIVES

To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex.

DESIGN

A retrospective cohort study.

SETTING

Nationwide acute in-patient care database.

PATIENTS

A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals.

MAIN OUTCOME MEASURES

The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy.

RESULTS

There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035.

CONCLUSIONS

Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Anaesthetic management of myasthenia gravis in coronary artery bypass grafting

Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction causing weakness and fatigability of muscles. Careful perioperative management is required because of the unpredictable susceptibility to muscle relaxants. In this case report, we describe the successful management of a MG patient for normothermic coronary artery bypass graft (CABG) surgery with titrated doses of rocuronium without prolonged postoperative ventilation. We chose rocuronium because full and rapid recovery of neuromuscular blockade is possible with sugammadex. We conclude that using rocuronium is safe during general anaesthesia in MG patients undergoing on-pump CABG when combined with continuous neuromuscular monitoring and careful perioperative management.

[Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis]

Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis

Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.

Incomplete recovery from rocuronium-induced muscle relaxation in patients with amyotrophic lateral sclerosis using sugammadex: A case report

INTRODUCTION

Patients with motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), have higher sensitivity to nondepolarizing neuromuscular blocking agents (NMBAs) and are at higher risk for a residual block. For this reason, the use of NMBAs such as rocuronium has been limited owing to the delayed reversal of muscle relaxation. It was recently reported that rapid and effective reversal of muscle relaxation occurs when sugammadex, a muscle relaxant reversal drug, is administered to patients in ALS with rocuronium-induced muscle relaxation. However, in this paper, we report the incomplete recovery and recurarization of muscle relaxation after sugammadex administration in ALS patients, and delayed recovery of muscle relaxation after additional administration of sugammadex.

PATIENT CONCERNS

A 71-year-old male patient with ALS received general anesthesia for laparoscopic nephroureterectomy.

DIAGNOSIS

The patient was diagnosed with ALS 2 years earlier, and scheduled to undergo laparoscopic nephroureterectomy for ureteral cancer.

INTERVENTION

We used sugammadex for the reversal of deep neuromuscular block. We measured a train-of-four (TOF) count of 4 and a TOF ratio of 54% at about 8 min after administration of 4 mg/kg sugammadex. However, then the TOF count decreased to 1 to 3 and tidal volume (TV) decreased to < 100 mL. Therefore, an additional 50 mg sugammadex was administered intravenously 12 min after the first dose of sugammadex was injected.

OUTCOMES

The patient's vital signs were stable and his recovery from anesthesia was uneventful. Therefore, he was discharged to the intensive care unit. The patient had aspiration pneumonia symptoms owing to dysphagia on the third postoperative day, but after the symptoms improved he was transferred to the hospital for rehabilitation of dysphagia and dyspnea.

CONCLUSION

It is critical to monitor whether muscle relaxation is sufficiently reversed when using sugammadex in ALS patients. Further research is needed to determine the appropriate dose of sugammadex for muscle relaxation reversal.

Comparison of recovery profiles in patients with Parkinson's disease for 2 types of neuromuscular blockade reversal agent following deep brain stimulator implantation

As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.

Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports

Background

Sugammadex is a modified gamma-cyclodextrin that acts by selectively encapsulating free amino-steroidal neuromuscular relaxants. Several case reports have been published on the use of sugammadex in patients with neuromuscular disorders that include neuromuscular junction diseases, myopathies, neuropathies, and motor neurone disorders. The primary aim of this review is to systematically review the evidence on the use of sugammadex in patients with this heterogeneous group of diseases and provide recommendations for clinical practice.

Methods

A systematic electronic search of Medline, Embase and CINAHL databases was done until June 2019, to identify case reports describing the use of sugammadex in adult surgical patients with neuromuscular disorders.

Results

Of the 578 records identified through database searches, 43 articles were finally included for the systematic review. Of these, 17 reports were on patients with myopathy, 15 reports on myasthenia gravis, 9 reports on motor neuron diseases and 2 reports on neuropathies.

Conclusions

Majority of the articles reviewed report successful use of sugammadex to reverse steroidal muscle relaxants, especially rocuronium, in patients with neuromuscular diseases. However, with sugammadex, unpredictability in response and uncertainty regarding optimum dose still remain issues. Quantitative neuromuscular monitoring to ensure complete reversal and adequate postoperative monitoring is strongly recommended in these patients, despite the use of sugammadex.

Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis

Background

Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy.

Methods

Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg^− 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement.

Results

Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg^− 1 and 0.28(0.17) mg.kg^− 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics.

Conclusions

Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy.

Trial registration

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Anesthetic Management of Total Aortic Arch Replacement in a Myasthenia Gravis Patient under Deep Hypothermic Circulatory Arrest

The anesthetic management of myasthenia gravis patients undergoing cardiac or aortic surgery under cardiopulmonary bypass, especially with deep hypothermic circulatory arrest, is challenging. We describe a case of successful anesthetic management of a myasthenia gravis patient undergoing total arch replacement with deep hypothermic circulatory arrest under neuromuscular monitoring and complete reversal of the action of neuromuscular blocking drugs by sugammadex. The present case suggests that patients with well-controlled myasthenia gravis might be safely managed in cardiac or aortic surgery under cardiopulmonary bypass with deep hypothermic circulatory arrest.

Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.

Perianesthetic Implications and Considerations for Myasthenia Gravis

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease in which antibodies against the post-nicotinic acetylcholine receptor at the neuromuscular junction develop. Although the exact cause of MG remains unknown, the thymus is a common factor in many cases. Patients with underlying junctional disease, such as MG, have greater anesthesia-related risks because of their known predisposition toward prolonged muscle weakness. Medications given in the perioperative period, such as anesthetic agents, antibiotics, cardiovascular drugs, and corticosteroids, affect neuromuscular transmission that contributes to muscle weakness. Judicious use of neuromuscular blocking agents for patients with MG must be considered. This patient population is at high risk for respiratory failure, and therefore must be carefully assessed throughout the perioperative period to ensure that a regular spontaneous respiratory pattern is sufficient to provide adequate oxygenation. Perianesthesia providers must consider anesthetic, ventilatory, and pharmacologic implications when proposing, providing, and recovering anesthesia for the patient with MG.

Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department

BACKGROUND

Myasthenia gravis (MG) is an uncommon autoimmune disorder affecting the neuromuscular junction and manifesting as muscle weakness. A multitude of stressors can exacerbate MG. When symptoms are exacerbated, muscle weakness can be severe enough to result in respiratory failure, a condition known as myasthenic crisis (MC).

OBJECTIVE

This review discusses risk factors, diagnosis, management, and iatrogenic avoidance of MC.

DISCUSSION

MC can affect any age, ethnicity, or sex and can be precipitated with any stressor, infection being the most common. MC is a clinical diagnosis defined by respiratory failure caused by exacerbation of MG. Muscle weakness can involve any voluntary muscle. MC can be differentiated from other neuromuscular junction diseases by the presence of normal reflexes, normal sensation, lack of autonomic symptoms, lack of fasciculations, and worsening weakness with repetitive motion. Treatment should target the inciting event and airway support. All acetylcholinesterase inhibitors should be avoided in crisis, including edrophonium testing and corticosteroids initially. Respiratory support can begin with noninvasive positive-pressure ventilation, as this has been successful even in patients with bulbar weakness. If intubation is necessary, consider avoiding paralytics or use a reduced dose of nondepolarizing agents.

CONCLUSIONS

MC should be in the differential of any patient with muscular weakness and respiratory compromise. Emergency department management of MC should focus on ruling out infection and respiratory support. Strong consideration should be given to beginning with noninvasive positive-pressure ventilation for ventilatory support. Corticosteroids, depolarizing paralytics, and acetylcholinesterase inhibitors should be avoided in patients with MC in the emergency department.

Anesthetic Management of a Patient With Antimuscle-Specific Kinase Antibody-Positive Myasthenia Gravis Undergoing an Open Cholecystectomy: A Case Report

Myasthenia gravis (MG) is an autoimmune disease characterized by the production of antibodies against the acetylcholine receptor, muscle-specific kinase (MuSK), or other proteins at the neuromuscular junction. MG with antibodies against MuSK (MuSK-MG) has been described recently. Here, we report the first case of anesthetic management of a patient with MuSK-MG undergoing an open cholecystectomy. In our case, propofol and remifentanil-based anesthesia were used for successful management without using muscle relaxants. Patients with MuSK-MG have predominantly ocular, bulbar, and respiratory symptoms that may increase the risk of aspiration. Anesthesiologists need to pay attention to perioperative respiratory failure and respiratory crisis.

Sugammadex: A Scientific Review Including Safety and Efficacy, Update on Regulatory Issues, and Clinical Use in Europe

Muscle relaxants are used in the perioperative period to aid in endotracheal intubation, facilitate surgical exposure, and in the critical care setting for prolonged relaxation. Until now, the only mechanism to reverse their effect is acetylcholinesterase inhibitors that result in excess parasympathetic activity and require the second drug to prevent this side effect. Additionally, the onset and degree of neuromuscular antagonism are often unpredictable and unreliable. Sugammadex is the first of the cyclodextrins to be used as a therapeutic agent. It quickly, effectively, and safely reverses steroidal neuromuscular blockers by encapsulating the muscle relaxant and rendering it inactive. Sugammadex may be considered the ideal reversal agent and the first drug in its class, which will likely change the practice of anesthesia and clinical neuromuscular pharmacology.

New diagnosis myasthenia gravis and preeclampsia in late pregnancy

Myasthenia gravis is a chronic autoimmune disease of neuromuscular transmission resulting in fatigable skeletal muscle weakness. Preeclampsia is a multisystem disease of pregnancy which is characterised by hypertension and involvement of one or more organ systems. Both diseases are responsible for considerable morbidity and mortality for mother and fetus. The occurrence of both preeclampsia and myasthenia gravis in pregnancy is very rare, and conflicts arise when considering the optimal management of each disease.We present a case of a parturient who was newly diagnosed with both myasthenia gravis and preeclampsia in late pregnancy. Myasthenia treatment was started with prednisolone and pyridostigmine, and delivery was by caesarean section at 37 weeks gestation under spinal anaesthesia. Postnatally, the patient developed worsening of myasthenia and preeclampsia symptoms. We consider the anaesthetic implications for both diseases and describe our approach for the management of this case.

Sugammadex: What do we Know and What do we Still Need to Know? A Review of the Recent (2013 to 2014) Literature

Since its launch in 2008, sugammadex has been considered one of the most significant developments in anaesthesia-related pharmacology. With almost 500 sugammadex-related publications and over nine million patient exposures worldwide, user experience and scientific data have grown exponentially. However, several important questions are yet to be answered. This article reviews the sugammadex-related literature in 2013 and 2014 to determine which of these questions have been answered more fully over the last 18 months and which questions require more information and research.

High-dose rocuronium for rapid-sequence induction and reversal with sugammadex in two myasthenic patients

The anesthetic management of patients affected by myasthenia gravis is usually challenging in elective surgery and even more so in emergency procedures. The difficulties involved are several-fold, ranging from the choice of an appropriate muscle relaxant (i.e. one that enables safe and rapid airway management) to neuromuscular monitoring and normal muscular recovery. Additionally, optimizing patient conditions - either pharmacologically or with plasmapheresis - before intervention is well beyond the realm of possibility. We discuss the anesthetic management of two myasthenic patients undergoing emergency surgery (for sigmoid perforation and upper gastrointestinal bleeding respectively). In both cases, we opted for rapid-sequence induction with high-dose rocuronium to prevent inhalation of gastric contents. We also report on the implication of neuromuscular monitoring. We found that the rocuronium-sugammadex combination was a useful and effective option in the emergency setting.

Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal

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.