Background Prolong effects of non-depolarizing neuromuscular blocking agents after rapid sequence intubation may prevent meaningful neurological examination, delaying appropriate diagnosis and neurosurgical intervention. Sugammadex is indicated for the reversal of neuromuscular blockade induced by rocuronium. Objective The objective of this study was to evaluate low- (2 mg/kg) vs standard-dose (4 mg/kg) sugammadex for rocuronium-induced deep neuromuscular blockade reversal in the emergency department (ED) by achieving a post-treatment train-of-four (TOF) of 4 to facilitate neurological examination. Methods This was a single-center, retrospective, cohort study evaluating low-vs standard-dose sugammadex for neuromuscular blockade reversal in the ED. Results 34 patients were identified within the designated time period, 24 of which were included in the final analysis ([n = 9 low-dose], [n = 15 standard-dose]). Median sugammadex doses were 2.3 mg/kg and 4.1 mg/kg for low- and standard-dose, respectively. The majority of patients presented for intraparenchymal hemorrhage (54.2%). No significant difference in success rate of NMBA reversal was found between low- and standard-dose sugammadex ([100.0% vs 93.3%], P = 1.000). A total of 9 patients had a neurosurgical procedure performed after sugammadex administration. Low-dose sugammadex was associated with significantly less acquisition cost compared to the standard dose ( P < .001). Conclusion Low- (2 mg/kg) and standard-dose (4 mg/kg) sugammadex successfully reversed rocuronium-induced deep neuromuscular blockade in the ED by achieving a post-treatment TOF of 4 to facilitate neurologic examination. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED and is associated with decreased institutional cost.
INTRODUCTION:Patients often present to the emergency department with acute agitation and may escalate to becoming a threat to self and medical staff. Physical and/ or chemical restraint may be warranted for safety and facilitation of patient care. Currently, the mainstays of acute agitation management include benzodiazepines and antipsychotics which may precipitate unwanted adverse events such as extrapyramidal symptoms and over-sedation. Ketamine is a desirable medication, as it has a short halflife and lacks clinically significant respiratory depression. University Hospitals Cleveland Medical Center implemented a behavioral decision tree for appropriate management of patients with acute agitation in the emergency department in June 2021. With evidence to support the use of ketamine for violently agitated patients, this decision tree recommends ketamine 5mg/kg IM (max 500mg) or 1mg/kg IV.
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