Earlier and lower dose administration of sugammadex

Abstract

BACKGROUND Sugammadex allows for rapid reversal of muscle relaxation after the use of rocuronium or vecuronium. The lowest recommended dose is 2 mg kg−1 intravenously when there are two twitches during the train-of-four stimulation. OBJECTIVE To study the efficacy and risks of a lower dose of sugammadex administered earlier. DESIGN Monocentric randomised controlled double-blind study. SETTING Academic hospital. PATIENTS Eighty patients were enrolled and randomised in 8 groups of 10 patients, 56 were finally evaluated. INTERVENTIONS Patients were distributed in two clusters constituting four groups each. In the first cluster, injections were administered after the return of one twitch with the train-of-four (TOF1). In the second cluster, injections were delivered after the return of two twitches with the TOF (TOF2). We created four groups in each cluster for different dosages: placebo, 0.5, 1 or 2 mg kg−1. MAIN OUTCOME MEASURES Time between the injection of sugammadex and full recovery (TOF ratio > 0.9) that is expressed in minutes. RESULTS Fifty-six successive patients were assessed between February and August 2018. The difference to TOF greater than 0.9 was not statistically significant between groups with the same dose administered at different times (F value = 0.001, P value = 0.975). There was a significant difference between groups with a different dosage administered at the same time (F ratio = 28.34; P value <0.0001). Concerning the time to TOF greater than 0.9 from the time point of TOF1, the timing of the dosages were statistically significant using log rank test (P < 0.0001). No patient presented a reparalysis. CONCLUSION No difference between injecting sugammadex at TOF1 or TOF2 was found regarding time to full recovery. Difference regarding sugammadex quantity was found and compatible with other studies. TRIAL REGISTRATION clinicaltrials.gov: ‘BRIDION_ERASME’, EudraCT: 2017-005074-19.

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

“…The body of evidence enrolling adults included 191 studies (133 randomized controlled trials, 4,59–90,92,95,98–104,110–114,118–127,132–141,145–148,155–157,163,173–181,206–254 11 nonrandomized trials, 17,128,142,182–184,191,255–258 45 cohort studies, 15,42,86,91,93,94,96,97,105–109,116,117,129–131,143,144,186–190,227,259–277 and 2 before–after designs 115,168 ) evaluating efficacy and safety of antagonist drugs for neuromuscular blockade. The randomized controlled trials enrolling only adults had a median of 88 participants (range, 16 to 350).…”

Reply to: Earlier and lower dose administration of sugammadex. A randomized placebo-controlled trial

“…The recommended dose of sugammadex for reversal of a moderate block, after the appearance of the second response with train of four (TOF) stimulation (TOF2), is 2 mg kg À1 . 3 The data provided by Duranteau et al 1 not only support the use of lower doses of this reversal but also the possibility of administering it at a slightly deeper muscular blockade level, after the appearance of the first TOF response (TOF1). Recovery times to a TOFr >0.9 when the reversal was administered with the appearance of TOF1 were 6.8 AE 6.2, 2.5 AE 0.7 and 1.8 AE 1.0 min in the 0.5 mg kg À1 , 1 mg kg À1 and 2 mg kg À1 groups, respectively.…”

“…We read with much interest the article ‘Earlier and lower dose administration of sugammadex. A randomized placebo-controlled trial’, by Duranteau et al , 1 as well as the reply provided by Timko et al , 2 about which we would like to share some ideas.…”

Appropriate dosing of sugammadex for reversal of rocuronium-/vecuronium-induced muscle relaxation in morbidly obese patients: a meta-analysis of randomized controlled trials

“…As sugammadex is expensive, there have been several reports investigating the use of reduced doses in otherwise healthy adult patients with favourable clinical outcomes. 18 , 19 In contrast, studies on the appropriate dosing in patients with morbid obesity are scarce. Although a guideline published in 2020 suggested using IBW or CBW for obese patients, the evidence level was low, and the strength of the recommendation had limited support.…”