ORIGINAL ARTICLE: Can sugammadex save a patient in a simulated ‘cannot intubate, cannot ventilate’ situation?

Abstract

SummaryRecent studies have shown that the use of high dose rocuronium followed by sugammadex provides a faster time to recovery from neuromuscular blockade following rapid sequence induction than suxamethonium. In a manikin-based 'cannot intubate, cannot ventilate' simulation, we studied the total time taken for anaesthetic teams to prepare and administer sugammadex from the time of their initial decision to use the drug. The mean (SD) total time to administration of sugammadex was 6.7 (1.5) min, following which a further 2.2 min (giving a total 8.9 min) should be allowed to achieve a train-of-four ratio of 0.9. Four (22%) teams gave the correct dose, 10 (56%) teams gave a dose that was lower than recommended, four (22%) teams gave a dose that was higher than recommended, six (33%) teams administered sugammadex in a single dose, and 12 (67%) teams gave multiple doses. Our simulation highlights that sugammadex might not have saved this patient in a 'cannot intubate, cannot ventilate' situation, and that difficulties and delays were encountered when identifying, preparing and administering the correct drug dose. The first clinical use of sugammadex in humans to reverse neuromuscular blockade induced by rocuronium was reported in 2005 [1]. Since then, sugammadex has been shown to be clinically effective [2] and has become available for clinical use in hospitals throughout Europe [3]. Since its introduction into clinical practice, the role of sugammadex in rapid sequence induction has been investigated. In a recent review, no statistical difference in intubating conditions was found when suxamethonium was compared to high dose (1.2 mg.kg )1 ) rocuronium administration during rapid sequence induction [4]. The main advantage of suxamethonium over rocuronium is the faster spontaneous recovery from neuromuscular blockade that occurs following the former's use; this characteristic has been a main indication for using suxamethonium despite its possible severe side-effects [5]. The possibility of rapidly reversing the effects of rocuronium has raised the question of whether suxamethonium is still necessary in clinical practice [6,7]. High dose rocuronium administration can provide fast neuromuscular blockade that permits early tracheal intubation comparable to that found when using suxamethonium [8,9]. Lee et al. [10] found that the intravenous administration of 16 mg.kg )1 sugammadex, 3 min after giving 1.2 mg.kg )1 rocuronium, resulted in reversal of neuromuscular blockade that was faster than the spontaneous recovery following 1 mg.kg )1 suxamethonium.Sugammadex has the potential to provide early reversal of profound neuromuscular blockade should a 'cannot intubate, cannot ventilate' situation arise following induction of anaesthesia [11]. However, as it still takes 2.2 min for the train-of-four (TOF) ratio (the ratio of magnitudes of the fourth to the first twitches) to recover to 0.9 following administration of sugammadex, the margin of safety is narrow in the event of failed tracheal intubation with inability to vent...

Checking the ability to mask ventilate before administering long‐acting neuromuscular blocking drugs

“…However, it does add considerable weight to the argument that confirmation is not necessary since neuromuscular blockade is known to facilitate tracheal intubation, and we have now shown that it facilitates mask ventilation as well. Clinicians still remain divided on this issue [5], and our hope is that our findings will add value to this important discussion. In relation to the first question, Broomhead et al divided anaesthetists using a questionnaire into 'checkers' (who assess the ability to mask ventilate the lungs before administering NBDs) and 'non-checkers' [3].…”

“…Note that in this context, rocuronium, with sugammadex if needed, is assumed to be akin to a short-acting NBD, although some evidence suggests that it may not be [5].…”

Wenn Kasuistiken fehlende Evidenz ersetzen müssen

“…Trotzdem befallen mich Zweifel, wie dieses Vorgehen im Fall eines Haftpflichtschadens bewertet wür-de. Denn, um im Notfall auch wirklich schnell genug 16 mg/kgKG injizieren zu können, muss Sugammadex vor der Narkoseeinleitung vorbereitet sein [3]. Damit ist Sugammadex Teil des Anästhesie-konzepts, das den Einsatz schon vor der Entwicklung des Kindes impliziert.…”

Our love-hate relationship with succinylcholine: Is sugammadex any better?

“…Though sugammadex is not without problems, 19,20 data from phase 1-3 clinical trials as well as post-marketing data from millions of patients have shown that sugammadex is safe. There is only a rare risk (\ 1%) of anaphylactic reactions with sugammadex, and these are treatable with standard therapy.…”

“…Bien que le sugammadex ne soit pas parfait, 19,20 les données d'études cliniques de phase 1-3 ainsi que les données recueillies depuis sa commercialisation chez des millions de patients démontrent que cet agent est sécuritaire. Il n'existe qu'un risque rare (\ 1%) de réactions anaphylactiques avec le sugammadex, et ces réactions sont traitables avec la thérapie usuelle.…”