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Rubio-Baines I, Honorato-Cia C, Valencia M, Panadero A, Cacho-Asenjo E, Manzanilla O, Alegre M, Nuñez-Cordoba JM, Martinez-Simon A. Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy. Br J Anaesth 2023; 131:523-530. [PMID: 37422414 DOI: 10.1016/j.bja.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Sugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. METHODS We performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg-1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. RESULTS Twenty-five patients were included in this study. Compared with baseline, BIS increased at 4-6 min (β coefficient: 3.63; 95% confidence interval [CI]: 2.22-5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2-4 min (β coefficient: 0.29; 95% CI: 0.05-0.52; P=0.016) and 4-6 min (β coefficient: 0.71; 95% CI: 0.47-0.94; P<0.001), and EMG increased at 4-6 min (β coefficient: 1.91; 95% CI: 1.00-2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2-4 min (β coefficient: 93; 95% CI: 1-185; P=0.046) and 4-6 min (β coefficient: 208; 95% CI: 116-300; P<0.001), and decreased delta power was observed at 4-6 min (β coefficient: -526.72; 95% CI: -778 to -276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. CONCLUSIONS After neuromuscular block reversal with 2 mg kg-1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.
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Affiliation(s)
- Iñigo Rubio-Baines
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain.
| | - Cristina Honorato-Cia
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, 31080, Pamplona, Spain.
| | - Miguel Valencia
- IdiSNA, Navarra Institute for Health Research, 31080, Pamplona, Spain; University of Navarra, CIMA, Systems Neuroscience Laboratory, Pamplona, Spain
| | - Alfredo Panadero
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Elena Cacho-Asenjo
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Oscar Manzanilla
- University of Navarra, CIMA, Systems Neuroscience Laboratory, Pamplona, Spain; Clinical Neurophysiology Section, Clínica Universidad de Navarra, Pamplona, Spain
| | - Manuel Alegre
- IdiSNA, Navarra Institute for Health Research, 31080, Pamplona, Spain; University of Navarra, CIMA, Systems Neuroscience Laboratory, Pamplona, Spain; Clinical Neurophysiology Section, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Antonio Martinez-Simon
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, 31080, Pamplona, Spain
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Abdelrahim MT, Kassels AC, Stark CW, Roberts CJ, Vogt JA, Ebert TJ. A Case Report of Acute Onset and Rapid Resolution of Atrioventricular Block After Sugammadex: Is the Autonomic System Involved? A A Pract 2023; 17:e01683. [PMID: 37146215 DOI: 10.1213/xaa.0000000000001683] [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: 05/07/2023]
Abstract
Administering sugammadex to reverse neuromuscular blockade can cause marked bradycardia and rarely asystole. In this case, a rapid onset, biphasic heart rate response; slowing then speeding, after administering sugammadex was noted while at steady state, 1.3% end-tidal sevoflurane. On review of the electrocardiogram (ECG), the heart rate slowing coincided with the onset of a second-degree, Mobitz type I block that lasted 45 seconds. No other events, drugs, or stimuli coincided with the event. The acute onset and transient nature of the atrioventricular block without evidence of ischemia implies a brief parasympathetic effect on the atrioventricular node after sugammadex administration.
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Affiliation(s)
- Mohamed T Abdelrahim
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Austin C Kassels
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cain W Stark
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher J Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Julia A Vogt
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Thomas J Ebert
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
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Azimaraghi O, Ahrens E, Wongtangman K, Witt AS, Rupp S, Suleiman A, Tartler TM, Wachtendorf LJ, Fassbender P, Choice C, Houle TT, Eikermann M, Schaefer MS. Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study. Br J Anaesth 2023; 130:296-304. [PMID: 36535827 DOI: 10.1016/j.bja.2022.10.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/09/2022] [Accepted: 10/20/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery. METHODS We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs. RESULTS Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay. CONCLUSIONS Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care.
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Affiliation(s)
- Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Annika S Witt
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samuel Rupp
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luca J Wachtendorf
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Curtis Choice
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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Abstract
BACKGROUND The clinical actions of sugammadex have been well studied, but the detailed molecular mechanism of the drug encapsulation process has not been systematically documented. The hypothesis was that sugammadex would attract rocuronium and vecuronium via interaction with the sugammadex side-chain "tentacles," as previously suggested. METHODS Computational molecular dynamics simulations were done to investigate docking of sugammadex with rocuronium and vecuronium. To validate these methods, strength of binding was assessed between sugammadex and a heterogeneous group of nine other drugs, the binding affinities of which have been experimentally determined. These observations hinted that high concentrations of unbound sugammadex could bind to propofol, potentially altering its pharmacokinetic profile. This was tested experimentally in in vitro cortical slices. RESULTS Sugammadex encapsulation of rocuronium involved a sequential progression down a series of metastable states. After initially binding beside the sugammadex molecule (mean ± SD center-of-mass distance = 1.17 ± 0.13 nm), rocuronium then moved to the opposite side to that hypothesized, where it optimally aligned with the 16 hydroxyl groups (distance, 0.82 ± 0.04 nm) before entering the sugammadex cavity to achieve energetically stable encapsulation by approximately 120 ns (distance, 0.35 ± 0.12 nm). Vecuronium formed fewer hydrogen bonds with sugammadex than did rocuronium; hence, it was less avidly bound. For the other molecules, the computational results showed good agreement with the available experimental data, showing a clear bilogarithmic relation between the relative binding free energy and the association constant (R2 = 0.98). Weaker binding was manifest by periodic unbinding. The brain slice results confirmed the presence of a weak propofol-sugammadex interaction. CONCLUSIONS Computational simulations demonstrate the dynamics of neuromuscular blocking drug encapsulation by sugammadex occurring from the opposite direction to that hypothesized and also how high concentrations of unbound sugammadex can potentially weakly bind to other drugs given during general anesthesia. EDITOR’S PERSPECTIVE
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5
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Motamed C. Sugammadex in Emergency Situations. J Pers Med 2023; 13:jpm13010159. [PMID: 36675820 PMCID: PMC9867288 DOI: 10.3390/jpm13010159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Sugammadex may be required or used in multiple emergency situations. Moderate and high doses of this compound can be used inside and outside the operating room setting. In this communication, recent developments in the use of sugammadex for the immediate reversal of rocuronium-induced neuromuscular blockade were assessed. In emergency surgery and other clinical situations necessitating rapid sequence intubation, the tendency to use rocuronium followed by sugammadex instead of succinylcholine has been increasing. In other emergency situations such as anaphylactic shock caused by rocuronium or if intubation or ventilation is not possible, priority should be given to resuming ventilation maintaining hemodynamic stability, in accordance with the traditional guidelines. If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion.
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Affiliation(s)
- Cyrus Motamed
- Departement of Anesthesia, Gustave Roussy Cancer Campus, 94080 Villejuif, France
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Ebert TJ, Cumming CE, Roberts CJ, Anglin MF, Gandhi S, Anderson CJ, Stekiel TA, Gliniecki R, Dugan SM, Abdelrahim MT, Klinewski VB, Sherman K. Characterizing the Heart Rate Effects From Administration of Sugammadex to Reverse Neuromuscular Blockade: An Observational Study in Patients. Anesth Analg 2022; 135:807-814. [PMID: 35759402 DOI: 10.1213/ane.0000000000006131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reversal of neuromuscular blockade (NMB) with sugammadex can cause marked bradycardia and asystole. Administration of sugammadex typically occurs in a dynamic period when anesthetic adjuvants and gas concentrations are being titrated to achieve emergence. This evaluation examined the heart rate (HR) responses to sugammadex to reverse moderate to deep NMB during a steady-state period and sought mechanisms for HR changes. METHODS Patients with normal sinus rhythm, who were undergoing elective surgery that included rocuronium for NMB, were evaluated. After surgery, while at steady-state surgical depth anesthesia with sevoflurane and mechanical ventilation, patients received either placebo or 2 or 4 mg/kg of sugammadex to reverse moderate to deep NMB. Study personnel involved in data analysis were blinded to treatment. Continuous electrocardiogram (ECG) was recorded from the 5 minutes before and 5 minutes after sugammadex/placebo administration. R-R intervals were converted to HR and averaged in 1-minute increments. The maximum prolongation of an R-R interval after sugammadex was converted to an instantaneous HR. RESULTS A total of 63 patients were evaluated: 8 received placebo, and 38 and 17 received 2 and 4 mg/kg sugammadex. Age, body mass index, and patient factors were similar in groups. Placebo did not elicit HR changes, whereas sugammadex caused maximum instantaneous HR slowing (calculated from the longest R-R interval), ranging from 2 to 19 beats/min. There were 7 patients with maximum HR slowing >10 beats/min. The average HR change and 95% confidence interval (CI) during the 5 minutes after 2 mg/kg sugammadex were 3.1 (CI, 2.3-4.1) beats/min, and this was not different from the 4 mg/kg sugammadex group (4.1 beats/min [CI, 2.5-5.6]). HR variability derived from the standard deviation of consecutive R-R intervals increased after sugammadex. CONCLUSIONS Sugammadex to reverse moderate and deep NMB resulted in a fast onset and variable magnitude of HR slowing in patients. A difference in HR slowing as a function of dose did not achieve statistical significance. The observational nature of the investigation prevented a full understanding of the mechanism(s) of the HR slowing.
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Affiliation(s)
- Thomas J Ebert
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Craig E Cumming
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Christopher J Roberts
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Missy F Anglin
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Sweeta Gandhi
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Christopher J Anderson
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Thomas A Stekiel
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Ross Gliniecki
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Shannon M Dugan
- Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
| | - Mohamed T Abdelrahim
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Victoria B Klinewski
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Sherman
- Department of Anesthesiology, Zablocki Veterans' Administration Medical Center, Milwaukee, Wisconsin
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