Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients

Loupec, Thibault; Frasca, Denis; Rousseau, N.; Faure, Jean‐Pierre; Mimoz, Olivier; Debaene, B.

doi:10.1111/anae.13344

Cited by 43 publications

(33 citation statements)

References 37 publications

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“…At the end of surgery, a moderate NMB was reversed with sugammadex (MSD BV, Haarlem, The Netherlands) 2 mg/kg ideal body weight, while a deep NMB was reversed with sugammadex 4 mg/kg ideal body weight [5]. The endotracheal tube was removed when the TOF-ratio > 0.9 and the patient breathed spontaneously and was fully awake.…”

Section: Methodsmentioning

confidence: 99%

Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

et al. 2016

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BackgroundIt remains unknown whether the administration of a deep neuromuscular block (NMB) during bariatric surgery improves surgical conditions and patient outcome. The authors studied the effect of deep versus moderate NMB in laparoscopic bariatric surgery on surgical conditions and postoperative pain.Methods and ResultsOne hundred patients scheduled to undergo elective bariatric surgery were randomized to a deep NMB (post-tetanic-count 2–3) or a moderate NMB (train-of-four 1–2). The quality of the surgical field was scored using the Leiden-Surgical Rating Scale (L-SRS), a 5-point scale ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Three surgeons scored the L-SRS at 10-min intervals during surgery; postoperative pain scores were obtained in the postanesthesia-care-unit (PACU) and on the ward. Mean (95% confidence interval) L-SRS scores in moderate NMB 4.2 (4.0–4.4) versus 4.8 (4.7–4.9) in deep NMB (p < 0.001). Moderate NMB resulted in 17% of scores at L-SRS scores of 1–3, while deep NMB resulted in 100% scores at the high end of the L-SRS (4–5). Deep NMB led to improved pain scores in the PACU (4.6 (4.2–4.9) versus 3.9 (3.6–4.4), p = 0.03) and reduced shoulder pain on the ward (1.8 (1.5–2.1) versus 1.3 (1.1–1.5), p = 0.03). A composite score of pain and opioid use in the PACU favoured deep NMB (p = 0.001).ConclusionsIn bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to moderate NMB, deep NMB produced stable and improved surgical conditions with less postoperative pain.

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Section: Methodsmentioning

confidence: 99%

Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

et al. 2016

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“…We thank Dr. Carron for his interest in our paper . Among studies that reported a mean reversal time following sugammadex shorter than our results, two were undertaken in non‐obese patients.…”

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confidence: 74%

Dose of sugammadex in morbidly obese patients - a reply

2016

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-581 (154) seconds using ideal body weight doses between 4 mg.kg -1 -1 mg.kg -1 , respectively, much longer than the mean reversal time of approximately 180 seconds reported in other studies [2][3][4]. Would the authors agree that their results suggest ideal body weight doses result in delayed reversal? Secondly, the authors evaluated the reversal from neuromuscular block to a train-of-four ratio of 0.9, which is indicative sufficient but not complete recovery of neuromuscular function [5,6], rendering particiapants susceptible to postoperative recurarisation and so postoperative complications [7], particularly in obese patients [4]. Given the reversal failure rates they report (7-78%), in hindsight do the authors consider that reversal from neuromuscular block to a train-offour ratio of 1.0 might better indicate safe recovery of neuromuscular function when ideal body weight is used to calculate sugammadex dose in obese patients?Thirdly, the authors recommend postoperative monitoring after ideal body weight sugammadex reversal, to detect possible recurarisation. However, evidence suggests this is unnecessary [6]. Could the authors elaborate on why they think continued monitoring is necessary, if they are confident that their dosing strategy is safe?

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“…This substance is used in adults of normal weight at 2mg/kg to promote reversion of moderate NMB, measured by the train-of-four (TOF) stimulus sequence (T4/T1 ≥0.9); at 4mg/kg for reversal of deep NMB; and at a dose of 16mg/kg for immediate reversal of rocuronium-induced NMB [9][10][11][12][13] . Previous studies have suggested that reversal of NMB in morbidly obese patients could be achieved at 4mg/kg for deep blockade considering the ideal body weight, or 2mg/kg, regardless of which body weight is considered, ideal or actual 18,19 .…”

Section: Introductionmentioning

confidence: 99%

Sugammadex ED90 dose to reverse the rocuronium neuromuscular blockade in obese patients

Silva

Matsui

Kim

et al. 2017

Rev. Col. Bras. Cir.

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Objective: to determine the ED90 (minimum effective dose in 90% of patients) of sugammadex for the reversal of rocuronium-induced moderate neuromuscular blockade (NMB) in patients with grade III obesity undergoing bariatric surgery. Methods: we conducted a prospective study with the biased coin up-and-down sequential design. We chosen the following doses: 2.0mg/Kg, 2.2mg/Kg, 2.4mg/Kg, 2.6mg/Kg, 2.8mg/Kg. The complete reversal of rocuronium-induced NMB considered a T4/T1 ratio ≥0.9 as measured by TOF. After induction of general anesthesia and calibration of the peripheral nerve stimulator and accelerometer, we injected rocuronium 0.6mg/kg. We administered propofol and remifentanil by continuous infusion, and intermittent boluses of rocuronium throughout the procedure. Results: we evaluated 31 patients, of whom 26 had displayed successful reversal of the NMB with sugammadex, and failure in five. The mean time to complete moderate NMB reversal was 213 seconds (172-300, median 25-75%). The ED90 of sugammadex calculated by regression was 2.39mg/kg, with a 95% confidence interval of 2.27-2.46 mg/kg. Conclusion: the ED90 of sugammadex in patients with grade III obesity or higher was 2.39mg/kg.

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Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients

Cited by 43 publications

References 37 publications

Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

Dose of sugammadex in morbidly obese patients - a reply

Sugammadex ED90 dose to reverse the rocuronium neuromuscular blockade in obese patients

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