Reversal of Neuromusclar Blockade and Simultaneous Increase in Plasma Rocuronium Concentration after the Intravenous Infusion of the Novel Reversal Agent Org 25970

Epemolu, Ola; Bom, A.; Hope, Frank; Mason, Rona

doi:10.1097/00000542-200309000-00018

Cited by 139 publications

(91 citation statements)

References 6 publications

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“…To the Editor, Sugammadex specifically antagonizes the steroidal neuromuscular blocking agent (NMBA), rocuronium, 1 and it also has affinity for other steroidal NMBAs. A period of 24 hr is currently recommended before re-administering rocuronium after sugammadex.…”

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confidence: 99%

Repeat dosing of rocuronium after reversal of neuromuscular block by sugammadex

Matsuki

Takahata

Iwasaki

2011

Can J Anesth/J Can Anesth

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To the Editor, Sugammadex specifically antagonizes the steroidal neuromuscular blocking agent (NMBA), rocuronium, 1 and it also has affinity for other steroidal NMBAs. A period of 24 hr is currently recommended before re-administering rocuronium after sugammadex. A If neuromuscular block (NMB) is needed before this time interval ends, a nonsteroidal NMBA should be given; however, nonsteroidal NMBAs are not available clinically in Japan. We present herein a 35-yr-old male patient (weight 73 kg, height 173 cm) in whom NMB was achieved using rocuronium 19 min after administering sugammadex. The authors have obtained agreement from the patient for submission of this case report to a medical journal.The patient was scheduled for elective parotidectomy, and his preoperative blood chemistry was within normal limits. Anesthesia was induced with propofol, and endotracheal intubation was facilitated using rocuronium 40 mg. Maintenance of anesthesia was achieved with sevoflurane, remifentanil, and fentanyl. Repetitive train-of-four (TOF) stimulation was applied at the ulnar nerve using a TOF Watch (Organon Ltd, Dublin, Ireland) monitor. Rocuronium 10 mg was added every 30-40 min, for a total dose of 100 mg over 204 min. At the end of surgery, 60 min after rocuronium, sugammadex 200 mg (2.75 mgÁkg -1 ) was administered, and the patient's trachea was extubated.After that, bleeding from the drainage tube and progressive bulging of the surgical field were observed. The otolaryngologists requested immediate re-exploration for hemostasis. We prepared to monitor NMB at the adductor pollicis muscle using a TOF-WatchÒ SX with preload (the Hand Adapter, Organon, Oss, the Netherlands), and we obtained digitized data. Anesthesia was induced with propofol, remifentanil, and sevoflurane inhalation, and neuromuscular blockade was monitored throughout the second surgery. Peripheral skin temperature, measured at the thenar eminence of the palm, was maintained at 32.5-34.5°C, and body temperature was maintained at 36.2-37.2°C.Rocuronium 70 mg was administered 19 min after sugammadex, but the first twitch to TOF stimulation (T1) did not disappear 195 sec after this dose so an additional 30 mg was added (Figure). The first twitch disappeared 105 sec after the second dose, for an onset time of 300 sec. Anesthesia was maintained using sevoflurane, remifentanil, and fentanyl.A single response following post-tetanic stimulation (post-tetanic count) was observed 50 min after rocuronium, and T1 appeared at 64 min. At the end of the second surgery, sugammadex 150 mg was again administered when the train-of-four ratio was 16%. The train-of-four ratio reached 102% within 150 sec, and the patient's trachea was extubated ( Figure).Cammu et al. examined the onset and duration of re-administration of 1.2 mgÁkg -1 rocuronium after sugammadex 4.0 mgÁkg -1 under propofol anesthesia in healthy volunteers. 2 They found that sugammadex prolongs the onset time of rocuronium when the time interval from sugammadex administration was \25 min. Our patient was given ...

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Repeat dosing of rocuronium after reversal of neuromuscular block by sugammadex

Matsuki

Takahata

Iwasaki

2011

Can J Anesth/J Can Anesth

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“…These fresh rocuronium molecules in plasma are soon bound to sugammadex, and the interstitial tissue, where the neuromuscular junction lies, is rapidly depleted of its rocuronium molecules. Evidence for this process can be found in a study by Epemolu et al,8 who demonstrated that, consistent with the above hypothesis, sugammadex was associated with an increase of total (free plus bound) plasma concentration of rocuronium.…”

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confidence: 56%

“…[8][9][10][11] One may criticize the studies because of the choice of accelerometry, which overestimates the degree of recovery, but this drawback is minor considering how effective sugammadex is compared with either placebo or neostigmine. In most clinical circumstances, the time interval from blockade until full recovery is not expected to be particularly critical.…”

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Sugammadex: an opportunity for more thinking or more cookbook medicine?

Donati

2007

Can J Anesth/J Can Anesth

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“…Binding is rapid, and steroidal NMBs show a high affinity for sugammadex, especially rocuronium and to a lesser degree vecuronium. 8 Beyond the rapid reversal of NMBs allowed by sugammadex, 7 neutralizing the NMB molecules by masking the causal allergen (i.e., the quaternary ammonium ion) should also be considered when an NMB-related allergic event is suspected. This hypothesis was reported for the first time through a case report.…”

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“…La fixation est rapide et l'affinité des curares stéroïdiens pour le sugammadex est élevée, surtout pour le rocuronium, et à un moindre degré pour le vécuronium. 8 Au-delà de la levée du bloc neuromusculaire rapide que permet le sugammadex, 7 il pourrait être envisageable de neutraliser les molécules d'un curare stéroïdien en cas de suspicion d'accident allergique lié à celui-ci en masquant l'allergène responsable, en l'occurrence l'ion ammonium quaternaire. Cette hypothèse a été rapportée pour la première fois grâce à la publication d'un cas clinique.…”

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A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports?

Plaud

2014

Can J Anesth/J Can Anesth

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Neuromuscular blockers (NMBs) are commonly used in anesthesia to facilitate tracheal intubation and optimize surgical conditions. However, these compounds share a common side effect -the risk of an allergic reaction. Anaphylactic shock is a rare (approximately one case in 10,000-20,000 procedures) but life-threatening complication of anesthesia. 1 In France, various epidemiological studies over the last three decades have shown that the most common causal agents of anaphylaxis are NMBs. 2 In the event of anaphylactic shock, epinephrine is the first-line therapy. The dose is usually titrated -except in case of cardiac arrest -depending on the clinical presentation and based on heart rate and blood pressure, to avoid the occurrence of arrhythmia with large doses of epinephrine. 3 This symptomatic treatment, coupled with crystalloid fluid resuscitation, allows to counteract hemodynamic (decreased blood pressure and cardiac output) and respiratory (bronchoconstriction) effects of the numerous mediators that are released during the course of an anaphylactic reaction. Despite these measures, the outcome remains potentially lethal in approximately 10% of cases. 4 However, there is no specific therapy of NMBassociated anaphylaxis. Proposed therapies could involve a substance able to rapidly inhibit the anaphylactic reaction by masking or binding the causal allergen. A specific therapy for the anaphylactic reaction to dextran, used in some countries as a fluid therapy, was attempted during the 1980s with the arrival on the market of a dextran-inhibitor hapten. 5 This hapten was purported to reduce the allergystimulating effects of dextrans through specific inhibition. The effectiveness of this preventive strategy proved unreliable, notwithstanding the other adverse effects of dextrans, renal in particular. 6 Thus, there remains no specific strategy at this time regarding the prevention or treatment of allergic reactions to NMBs. Could this situation change with the recent availability of sugammadex? Sugammadex is a gammacyclodextrine that was modified by the addition of side chains that specifically encapsulate the steroidal core of the NMB, mainly through interactions between the negative charges of the cyclodextrine molecule and the positive charges of the quaternary ammonium ions. 7 Their binding at the centre of the cyclodextrine molecule, more specifically the sterol moiety, is strong and prolonged, implying the presence of various high-energy chemical bonds. Binding is rapid, and steroidal NMBs show a high affinity for sugammadex, especially rocuronium and to a lesser degree vecuronium. 8 Beyond the rapid reversal of NMBs allowed by sugammadex, 7 neutralizing the NMB molecules by masking the causal allergen (i.e., the quaternary ammonium ion) should also be considered when an NMB-related allergic event is suspected. This hypothesis was reported for the first time through a case report. 9 The authors of that report described a serious anaphylactic reaction that occurred immediately after an induction sequence that i...

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Reversal of Neuromusclar Blockade and Simultaneous Increase in Plasma Rocuronium Concentration after the Intravenous Infusion of the Novel Reversal Agent Org 25970

Cited by 139 publications

References 6 publications

Repeat dosing of rocuronium after reversal of neuromuscular block by sugammadex

Repeat dosing of rocuronium after reversal of neuromuscular block by sugammadex

Sugammadex: an opportunity for more thinking or more cookbook medicine?

A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports?

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