Sugammadex to rescue a 'can't ventilate' scenario in an anticipated difficult intubation: is it the answer?

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.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Anaesthetic management of acute airway obstruction

The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom's 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists' difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.

Sugammadex: An Update

The purpose of this update is to provide recent knowledge and debates regarding the use of sugammadex in the fields of anesthesia and critical care. The review is not intended to provide a comprehensive description of sugammadex and its clinical use.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Sugammadex: Role in current anaesthetic practice and its safety benefits for patients

Sugammadex has revolutionized anaesthetic management of reversal of neuromuscular block (NMB) by way of its unique mechanism of action encapsulating the amino steroid neuromuscular blocking drugs rocuronium and vecuronium. The cholinesterase inhibitors have significant pharmacological and clinical limitations whereas sugammadex allows predictable, safe and rapid reversal from any depth of blockade. The financial cost of sugammadex is significant. Many hospitals in the United Kingdom use clinical guidelines to direct best use of sugammadex in their institutions. Auditing the use of sugammadex provides useful information on which patients are benefiting from sugammadex. The clinical benefits of sugammadex are well understood. No patient should now be subjected to the danger of post-operative residual curarization. Versatility in the ability to reverse NMB has brought opportunities to the anaesthetist in the management of rapid sequence induction using high dose rocuronium with the knowledge that safe reversal of NMB is now possible in the unlikely event of a “can’t intubate can’t ventilate” situation. Do we still need suxamethonium to be available? The nature of surgery continues to evolve with ever-increasing enthusiasm for minimally invasive laparoscopic techniques. There is evidence to support using a deeper level of NMB to improve the working space and operating conditions in laparoscopic surgery. It is now possible to maintain a deep level of NMB right up until the end of surgery with no concerns about the ability to effect safe reversal of NMB. Vigilance about the possibility of allergic sensitivity to sugammadex needs to be maintained. The increased usage of rocuronium has the potential for rocuronium-induced anaphylaxis. Conversely, there is a potential role for sugammadex in the treatment of rocuronium anaphylaxis. Clinicians who have used sugammadex are struck with the quality of recovery seen in their patients. It is important that the economic implications of the use of sugammadex are fully understood. This article considers the current role of sugammadex in clinical practice outside of routine reversal of NMB and discusses how the addition of sugammadex to the anaesthetic armamentarium brings safety benefits for patients.

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.