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Anderson A, García-Fandiño R, Piñeiro Á, O'Connor MS. Unraveling the molecular dynamics of sugammadex-rocuronium complexation: A blueprint for cyclodextrin drug design. Carbohydr Polym 2024; 334:122018. [PMID: 38553217 DOI: 10.1016/j.carbpol.2024.122018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
Sugammadex, marketed as Bridion™, is an approved cyclodextrin (CD) based drug for the reversal of neuromuscular blockade in adults undergoing surgery. Sugammadex forms an inclusion complex with the neuromuscular blocking agent (NMBA) rocuronium, allowing rapid reversal of muscle paralysis. In silico methods have been developed for studying CD inclusion complexes, aimed at accurately predicting their structural, energetic, dynamic, and kinetic properties, as well as binding constants. Here, a computational study aimed at characterizing the sugammadex-rocuronium system from the perspective of docking calculations, free molecular dynamics (MD) simulations, and biased metadynamics simulations with potential of mean force (PMF) calculations is presented. The aim is to provide detailed information about this system, as well as to use it as a model system for validation of the methods. This method predicts results in line with experimental evidence for both the optimal structure and the quantitative value for the binding constant. Interestingly, there is a less profound preference for the orientation than might be assumed based on electrostatic interactions, suggesting that both orientations may exist in solution. These results show that this technology can efficiently analyze CD inclusion complexes and could be used to facilitate the development and optimization of novel applications for CDs.
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Affiliation(s)
- Amelia Anderson
- Cyclarity Therapeutics, 8001 Redwood Blvd Novato, CA 94945, USA; Department of Organic Chemistry, Center for Research in Biological Chemistry and Molecular Materials, Santiago de Compostela University, CIQUS, Spain; Soft Matter & Molecular Biophysics Group, Department of Applied Physics, Faculty of Physics, University of Santiago de Compostela, Spain.
| | - Rebeca García-Fandiño
- Department of Organic Chemistry, Center for Research in Biological Chemistry and Molecular Materials, Santiago de Compostela University, CIQUS, Spain
| | - Ángel Piñeiro
- Soft Matter & Molecular Biophysics Group, Department of Applied Physics, Faculty of Physics, University of Santiago de Compostela, Spain
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Wachtendorf LJ, Tartler TM, Ahrens E, Witt AS, Azimaraghi O, Fassbender P, Suleiman A, Linhardt FC, Blank M, Nabel SY, Chao JY, Goriacko P, Mirhaji P, Houle TT, Schaefer MS, Eikermann M. Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care. Br J Anaesth 2023; 130:133-141. [PMID: 36564246 DOI: 10.1016/j.bja.2022.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/23/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care. METHODS We analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation). RESULTS Based on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (-1.3% lower costs; 95% confidence interval [CI], -0.5 to -2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, -US$376 to -US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, -US$1198 to -US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation). CONCLUSIONS The effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities.
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Affiliation(s)
- Luca J Wachtendorf
- Department of Anesthesiology, Montefiore Medical Center, 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
| | - 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
| | - 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
| | - Annika S Witt
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, 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
| | - 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 and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Felix C Linhardt
- Department of Anesthesiology, Montefiore Medical Center, 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
| | - Michael Blank
- Department of Anesthesiology, Montefiore Medical Center, 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
| | - Sarah Y Nabel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pavel Goriacko
- Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Parsa Mirhaji
- Department of Systems and Computational Biology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Clinical Research Informatics at Einstein and Montefiore Medical Center, Montefiore Medical Center, 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
| | - 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, Duesseldorf, Germany
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
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Yu Y, Wang H, Bao Q, Zhang T, Chen B, Ding J. Sugammadex Versus Neostigmine for Neuromuscular Block Reversal and Postoperative Pulmonary Complications in Patients Undergoing Resection of Lung Cancer. J Cardiothorac Vasc Anesth 2022; 36:3626-3633. [DOI: 10.1053/j.jvca.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 12/24/2022]
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Wang JF, Zhao ZZ, Jiang ZY, Liu HX, Deng XM. Influence of sugammadex versus neostigmine for neuromuscular block reversal on the incidence of postoperative pulmonary complications: a meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:32. [PMID: 34538277 PMCID: PMC8451127 DOI: 10.1186/s13741-021-00203-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The influence of sugammadex for reversal of neuromuscular block (NMB) on postoperative pulmonary complications (PPCs), compared with neostigmine, remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) to compare the incidence of PPCs between patients who received sugammadex versus neostigmine. METHODS Relevant studies were obtained by searching the PubMed, Embase, and Cochrane Library databases. A random effects model incorporating the potential heterogeneity was used to pool the results. RESULTS Fourteen RCTs including 1478 adult patients who underwent surgeries with general anesthesia were included, and of these, 753 received sugammadex and 725 received neostigmine for reversal of NMB. The pooled results showed that sugammadex was associated with a lower risk of overall PPCs compared to neostigmine (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.43-0.89, p = 0.01; I2 = 0%). This finding remained consistent after exclusion of two studies with potential overlapping events (OR: 0.58, 95% CI: 0.36-0.96, p = 0.03; I2=9%). Stratified analyses according to the categories of PPCs showed that sugammadex was associated with a significantly lower risk of postoperative respiratory failure (OR: 0.60, 95% CI: 0.38-0.97, p = 0.04; I2 = 0%) but not of postoperative pulmonary infection (OR: 0.79, p = 0.71), atelectasis (OR: 0.78, p = 0.33), or pneumothorax (OR: 0.87, p = 0.79). CONCLUSIONS Compared with neostigmine, the use of sugammadex for reversal of NMB was associated with a lower risk of PPCs, mainly due to a lower incidence of postoperative respiratory failure with the use of sugammadex.
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Affiliation(s)
- Jia-Feng Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | | | - Zheng-Yu Jiang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Hui-Xing Liu
- Department of Clinical Epidemiology and Biostatistics, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiao-Ming Deng
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Jiang Y, Bash LD, Saager L. A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US. Adv Ther 2021; 38:2689-2708. [PMID: 33871823 PMCID: PMC8107065 DOI: 10.1007/s12325-021-01701-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer's budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery. METHODS A 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared. RESULTS A total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of -$3,079,703 (-$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses. CONCLUSIONS The additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.
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Affiliation(s)
- Yiling Jiang
- Center for Observational and Real-world Evidence (CORE), Merck Sharp & Dohme (UK) Ltd., 120 Moorgate, London, EC2Y 9AL, UK.
| | - Lori D Bash
- Center for Observational and Real-world Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ, USA
| | - Leif Saager
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Klinik fuer Anaesthesiologie Universitaetsmedizin Goettingen, Goettingen, Germany
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Oliveira RS, Borges BT, Leal AP, Lailowski MM, Bordon KDCF, de Souza VQ, Vinadé L, dos Santos TG, Hyslop S, Moura S, Arantes EC, Corrado AP, Dal Belo CA. Chemical and Pharmacological Screening of Rhinella icterica (Spix 1824) Toad Parotoid Secretion in Avian Preparations. Toxins (Basel) 2020; 12:toxins12060396. [PMID: 32549266 PMCID: PMC7354542 DOI: 10.3390/toxins12060396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/12/2020] [Accepted: 05/22/2020] [Indexed: 12/15/2022] Open
Abstract
The biological activity of Rhinella icterica parotoid secretion (RIPS) and some of its chromatographic fractions (RI18, RI19, RI23, and RI24) was evaluated in the current study. Mass spectrometry of these fractions indicated the presence of sarmentogenin, argentinogenin, (5β,12β)-12,14-dihydroxy-11-oxobufa-3,20,22-trienolide, marinobufagin, bufogenin B, 11α,19-dihydroxy-telocinobufagin, bufotalin, monohydroxylbufotalin, 19-oxo-cinobufagin, 3α,12β,25,26-tetrahydroxy-7-oxo-5β-cholestane-26-O-sulfate, and cinobufagin-3-hemisuberate that were identified as alkaloid and steroid compounds, in addition to marinoic acid and N-methyl-5-hydroxy-tryptamine. In chick brain slices, all fractions caused a slight decrease in cell viability, as also seen with the highest concentration of RIPS tested. In chick biventer cervicis neuromuscular preparations, RIPS and all four fractions significantly inhibited junctional acetylcholinesterase (AChE) activity. In this preparation, only fraction RI23 completely mimicked the pharmacological profile of RIPS, which included a transient facilitation in the amplitude of muscle twitches followed by progressive and complete neuromuscular blockade. Mass spectrometric analysis showed that RI23 consisted predominantly of bufogenins, a class of steroidal compounds known for their cardiotonic activity mediated by a digoxin- or ouabain-like action and the blockade of voltage-dependent L-type calcium channels. These findings indicate that the pharmacological activities of RI23 (and RIPS) are probably mediated by: (1) inhibition of AChE activity that increases the junctional content of Ach; (2) inhibition of neuronal Na+/K+-ATPase, leading to facilitation followed by neuromuscular blockade; and (3) blockade of voltage-dependent Ca2+ channels, leading to stabilization of the motor endplate membrane.
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Affiliation(s)
- Raquel Soares Oliveira
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
| | - Bruna Trindade Borges
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
| | - Allan Pinto Leal
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica Toxicológica (PPGBTox), Universidade Federal de Santa Maria (UFSM), Avenida Roraima 1000, Santa Maria RS 97105-900, Brazil
| | - Manuela Merlin Lailowski
- Laboratório de Biotecnologia de Produtos Naturais e Sintéticos, Instituto de Biotecnologia, Universidade de Caxias do Sul (UCS), Rua Francisco Getúlio Vargas 1130, Caxias do Sul RS 95070-560, Brazil; (M.M.L.); (S.M.)
| | - Karla de Castro Figueiredo Bordon
- Departamento de Ciências BioMoleculares, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo (USP), Avenida do Café, s/n, Ribeirão Preto SP 14.040-903, Brazil; (K.d.C.F.B.); (E.C.A.)
| | - Velci Queiróz de Souza
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
| | - Lúcia Vinadé
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
- Correspondence: (L.V.); (C.A.D.B.); Tel.: +55-55-3237-0850 (C.A.D.B.)
| | - Tiago Gomes dos Santos
- Laboratório de Estudos em Biodiversidade Pampiana, Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil;
| | - Stephen Hyslop
- Departamento de Farmacologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz, Campinas SP 13083-887, Brazil;
| | - Sidnei Moura
- Laboratório de Biotecnologia de Produtos Naturais e Sintéticos, Instituto de Biotecnologia, Universidade de Caxias do Sul (UCS), Rua Francisco Getúlio Vargas 1130, Caxias do Sul RS 95070-560, Brazil; (M.M.L.); (S.M.)
| | - Eliane Candiani Arantes
- Departamento de Ciências BioMoleculares, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo (USP), Avenida do Café, s/n, Ribeirão Preto SP 14.040-903, Brazil; (K.d.C.F.B.); (E.C.A.)
| | - Alexandre Pinto Corrado
- Departamento de Farmacologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Avenida Bandeirantes 3900, Ribeirão Preto SP 14040-030, Brazil;
| | - Cháriston A. Dal Belo
- Laboratório de Neurobiologia e Toxinologia, Programa de Pós-Graduação em Ciências Biológicas (PPGCB), Universidade Federal do Pampa (UNIPAMPA), Avenida Antônio Trilha 1847, São Gabriel RS 97300-000, Brazil; (R.S.O.); (B.T.B.); (A.P.L.); (V.Q.d.S.)
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica Toxicológica (PPGBTox), Universidade Federal de Santa Maria (UFSM), Avenida Roraima 1000, Santa Maria RS 97105-900, Brazil
- Correspondence: (L.V.); (C.A.D.B.); Tel.: +55-55-3237-0850 (C.A.D.B.)
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Kim JS, Han JW, Lee JH, Choi JM, Kim HJ, Sung TY, Kim YB, Shin YS, Yang HS. Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey. Anesth Pain Med (Seoul) 2019; 14:441-448. [PMID: 33329775 PMCID: PMC7713803 DOI: 10.17085/apm.2019.14.4.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/28/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background Neuromuscular blocking agents (NMBAs) and neuromuscular monitoring in anesthetic management are integral for endotracheal intubation, better visualization of the surgical field, and prevention of residual neuromuscular blockade and pulmonary complications. Sugammadex is a drug that reduces risk of residual neuromuscular blockade, with more rapid recovery compared to anticholinesterase. The purpose of this study was to investigate current usage status of NMBAs and antagonist with neuromuscular monitoring, among anesthesiologists in Korea. Methods Anesthesiologists working in Korea were invited to participate in an online survey via email January 2–February 28, 2018. The questionnaire consisted of 45 items, including preferred NMBAs, antagonists, neuromuscular monitoring, and complications related to the use sugammadex. A total of 174 responses were analyzed. Results Rocuronium was a commonly used NMBA for endotracheal intubation (98%) of hospitals, and maintenance of anesthesia (83.3%) in of hospitals. Sugammadex, pyridostigmine, and neostigmine were used in 89.1%, 87.9%, and 45.4% of hospitals. Neuromuscular monitoring was employed in 79.3% of hospitals; however only 39.7% of hospitals used neuromuscular monitoring before antagonist administration. Usual dosage range of sugammadex was 2.1–4 mg/kg in 35.1% of hospitals, within 2 mg/kg in 34.5% of hospitals, and 1 vial regardless of body weight in 22.4% of hospitals. Sugammadexrelated complications were encountered by 14.9% of respondents. Conclusions This survey indicates several minor problems associated with the use of antagonists and neuromuscular monitoring. However, most anesthesiologists appear to have appropriate information regarding the usage of NMBAs and sugammadex.
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Affiliation(s)
- Jin Sun Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jung Woo Han
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Ho Lee
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hopsital, Konyang University College of Medicine, Daejeon, Korea
| | - Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Yong Seop Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Sun General Hospital, Daejeon, Korea
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Lin XF, Yong CYK, Mok MUS, Ruban P, Wong P. Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit. Singapore Med J 2019; 61:591-597. [PMID: 31535154 DOI: 10.11622/smedj.2019118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU). METHODS An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed. RESULTS A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB. CONCLUSION PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.
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Affiliation(s)
- Xu Feng Lin
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | | | - May Un Sam Mok
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | | | - Patrick Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Abstract
Residual neuromuscular blockade is a widespread challenge for providers in the acute care setting that, if left unrecognized or untreated, places patients at higher risk for morbidity and mortality. The condition is estimated to occur in 26% to 88% of patients undergoing general anesthesia. The role of the advanced practice nurse in the acute care setting is to facilitate a safe recovery process by identifying early signs of deterioration and supporting the patient until full muscular strength has returned. This article discusses the prevalence of residual neuromuscular blockade and associated complications and patient risk factors. A review is included of the current uses for neuromuscular blockade, pathophysiology of the neuromuscular junction, pharmacologic characteristics of neuromuscular blocking agents (including drug-drug interactions), monitoring modalities, and effectiveness of reversal agents. Treatment recommendations pertinent to residual neuromuscular blockade are outlined.
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Affiliation(s)
- Nicole Stawicki
- Nicole Stawicki is an Acute Care Nurse Practitioner, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, Chicago, IL 60612 . Patty Gessner is a Critical Care Nurse Practitioner, Suburban Lung Associates, Elk Grove Village, Illinois
| | - Patty Gessner
- Nicole Stawicki is an Acute Care Nurse Practitioner, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, Chicago, IL 60612 . Patty Gessner is a Critical Care Nurse Practitioner, Suburban Lung Associates, Elk Grove Village, Illinois
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New Drug Developments for Neuromuscular Blockade and Reversal: Gantacurium, CW002, CW011, and Calabadion. CURRENT ANESTHESIOLOGY REPORTS 2018; 8:119-124. [PMID: 29904284 PMCID: PMC5988786 DOI: 10.1007/s40140-018-0262-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review The purpose of this chapter is to provide a brief review of the literature on the recent developments in neuromuscular blockade and reversal agents. Recent Findings Novel drug development resulted in pharmacological advancements in neuromuscular management and led to a new series of compounds, chlorofumarates, such as gantacurium, CW002, and CW011. These drugs have a fast onset and rapid to intermediate duration of action and can be rapidly reversed by l-cysteine adduction without side effects that are commonly observed with anticholinesterase reversal drugs. Another new advancement is the development of a new class of reversal drugs, the calabadions. These drugs are able to reverse both steroidal and non-steroidal non-depolarizing neuromuscular blocking drugs rapidly. Summary Recent advancements in neuromuscular blocking agents and reversal drugs have shown promise in improving safety of management of neuromuscular blockade. Preclinical and clinical studies are discussed. However, to date these new drugs are not yet available for clinical use.
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Aldasoro M, Jorda A, Aldasoro C, Marchio P, Guerra-Ojeda S, Gimeno-Raga M, Mauricio MD, Iradi A, Obrador E, Vila JM, Valles SL. Neuronal Effects of Sugammadex in combination with Rocuronium or Vecuronium. Int J Med Sci 2017; 14:224-230. [PMID: 28367082 PMCID: PMC5370284 DOI: 10.7150/ijms.17545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/28/2016] [Indexed: 12/19/2022] Open
Abstract
Rocuronium (ROC) and Vecuronium (VEC) are the most currently used steroidal non-depolarizing neuromuscular blocking (MNB) agents. Sugammadex (SUG) rapidly reverses steroidal NMB agents after anaesthesia. The present study was conducted in order to evaluate neuronal effects of SUG alone and in combination with both ROC and VEC. Using MTT, CASP-3 activity and Western-blot we determined the toxicity of SUG, ROC or VEC in neurons in primary culture. SUG induces apoptosis/necrosis in neurons in primary culture and increases cytochrome C (CytC), apoptosis-inducing factor (AIF), Smac/Diablo and Caspase 3 (CASP-3) protein expression. Our results also demonstrated that both ROC and VEC prevent these SUG effects. The protective role of both ROC and VEC could be explained by the fact that SUG encapsulates NMB drugs. In BBB impaired conditions it would be desirable to control SUG doses to prevent the excess of free SUG in plasma that may induce neuronal damage. A balance between SUG, ROC or VEC would be necessary to prevent the risk of cell damage.
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Affiliation(s)
- Martin Aldasoro
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Adrian Jorda
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Patricia Marchio
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Sol Guerra-Ojeda
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Marc Gimeno-Raga
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Mª Dolores Mauricio
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Antonio Iradi
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Elena Obrador
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Jose Mª Vila
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Soraya L Valles
- Department of Physiology, School of Medicine, University of Valencia, Valencia, Spain
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12
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Schaller SJ, Lewald H. Clinical pharmacology and efficacy of sugammadex in the reversal of neuromuscular blockade. Expert Opin Drug Metab Toxicol 2016; 12:1097-108. [DOI: 10.1080/17425255.2016.1215426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Venkatesan R, Subedi L, Yeo EJ, Kim SY. Lactucopicrin ameliorates oxidative stress mediated by scopolamine-induced neurotoxicity through activation of the NRF2 pathway. Neurochem Int 2016; 99:133-146. [PMID: 27346436 DOI: 10.1016/j.neuint.2016.06.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 12/13/2022]
Abstract
Cholinergic activity plays a vital role in cognitive function, and is reduced in individuals with neurodegenerative diseases. Scopolamine, a muscarinic cholinergic antagonist, has been employed in many studies to understand, identify, and characterize therapeutic targets for Alzheimer's disease (AD). Scopolamine-induced dementia is associated with impairments in memory and cognitive function, as seen in patients with AD. The current study aimed to investigate the molecular mechanisms underlying scopolamine-induced cholinergic neuronal dysfunction and the neuroprotective effect of lactucopicrin, an inhibitor of acetylcholine esterase (AChE). We investigated apoptotic cell death, caspase activation, generation of reactive oxygen species (ROS), mitochondrial dysfunction, and the expression levels of anti- and pro-apoptotic proteins in scopolamine-treated C6 cells. We also analyzed the expression levels of antioxidant enzymes and nuclear factor (erythroid-derived 2)-like 2 (NRF2) in C6 cells and neurite outgrowth in N2a neuroblastoma cells. Our results revealed that 1 h scopolamine pre-treatment induced cytotoxicity by increasing apoptotic cell death via oxidative stress-mediated caspase 3 activation and mitochondrial dysfunction. Scopolamine also downregulated the expression the antioxidant enzymes superoxide dismutase, glutathione peroxidase, and catalase, and the transcription factor NRF2. Lactucopicrin treatment protected C6 cells from scopolamine-induced toxicity by reversing the effects of scopolamine on those markers of toxicity. In addition, scopolamine attenuated the secretion of neurotrophic nerve growth factor (NGF) in C6 cells and neurite outgrowth in N2a cells. As expected, lactucopicrin treatment enhanced NGF secretion and neurite outgrowth. Our study is the first to show that lactucopicrin, a potential neuroprotective agent, ameliorates scopolamine-induced cholinergic dysfunction via NRF2 activation and subsequent expression of antioxidant enzymes.
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Affiliation(s)
- Ramu Venkatesan
- Lab of Pharmacognosy, College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Republic of Korea
| | - Lalita Subedi
- Lab of Pharmacognosy, College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Republic of Korea
| | - Eui-Ju Yeo
- Department of Biochemistry, College of Medicine, Gachon University, #191 Hambakmoero, Yeonsu-gu, Incheon 21936, Republic of Korea
| | - Sun Yeou Kim
- Lab of Pharmacognosy, College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Republic of Korea; Gachon Medical Research Institute, Gil Medical Center, Inchon 21565, Republic of Korea; Gachon Institute of Pharmaceutical Science, Gachon University, #191 Hambakmoe-ro, Yeonsu-gu, Incheon 21936, Republic of Korea.
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