Reversal with sugammadex for rocuronium-induced deep neuromuscular block after pretreatment of magnesium sulfate in rabbits

Abstract

BackgroundMagnesium sulfate (MgSO4) has been used in the treatment of pre-eclampsia, hypertension and arrhythmia. Magnesium enhances the neuromuscular block of rocuronium. This study has been conducted to evaluate the reversal efficacy of sugammadex from deep rocuronium-induced neuromuscular block (NMB) during consistent pretreatment of MgSO4 in rabbits.MethodsTwenty-eight rabbits were randomly assigned to four groups, a control group or study groups (50% MgSO4 150–200 mg/kg and 25 mg/kg/h IV), and received rocuronium 0.6 mg/kg. When post-tetanic count 1–2 appeared, sugammadex 2, 4, and 8 mg/kg was administered in the 2-mg group, control and 4-mg group, and 8-mg group, respectively. The recovery course after reversal of sugammadex administration was evaluated in each group.ResultsThe mean serum concentration of magnesium was maintained at more than 2 mmol/L in the study groups, and the total dose of MgSO4 was more than 590 mg. The reversal effect of sugammadex on rocuronium-induced NMB in pretreated MgSO4 was not different from that in the group without MgSO4. The recovery time to train-of-four ratio 0.9 after sugammadex administration in the 2-mg group was longer than in the other groups (P < 0.001); there were no other significant differences among the groups.ConclusionsThe reversal of sugammadex from a deep rocuronium-induced NMB during large pretreatment of MgSO4 was not affected. However, we should consider that the reversal effect of sugammadex varied depending on the dose.

The effect of magnesium sulfate concentration on the effective concentration of rocuronium, and sugammadex-mediated reversal, in isolated left phrenic nerve hemi-diaphragm preparations from the rat

“…Thus, changes in magnesium concentration (from 1 to 4 mM) did not seem to affect recovery mediated by sugammadex. This result is consistent with that of a rabbit study in which sugammadex at doses of more than 4 mg/kg was associated with similar recoveries among magnesium-infused and non-infused groups of rabbits [ 21 ]. It is likely that the dose of sugammadex is more important than the magnesium concentration in terms of clinically acceptable limits; neuromuscular transmission monitoring is essential to ensure that sufficient sugammadex is administered.…”

Preparing for the unexpected: special considerations and complications after sugammadex administration

“…With the significant impact of magnesium on neuromuscular blockade and subsequent reversal with acetylcholinesterase inhibition, its effect on reversal with sugammadex has been questioned. Animal models demonstrate mixed results when investigating whether raising plasma magnesium levels impacts the dose of sugammadex needed to reverse neuromuscular blockade [ 80 , 81 ]. Aside from one observational study that suggested patients may need sugammadex doses exceeding 14 mg/kg in the presence of a magnesium infusion for the treatment of HELLP syndrome [ 82 ], the remaining literature suggests that reversal with standard doses of sugammadex is not prolonged in patients receiving clinically-relevant doses of intravenous magnesium.…”

Advantages and pitfalls of clinical application of sugammadex

“…Further, it was reported that pretreatment with magnesium did not significantly affect sugammadex reversal time for moderate NMB [ 32 ]. In addition, magnesium did not affect the reversal effects of sugammadex in animal studies [ 33 , 34 ]. However, administration of magnesium after rocuronium‐induced NMB reversal with sugammadex may lead to recurarization, requiring continuous neuromuscular monitoring [ 35 ].…”