Reversal with Sugammadex in the Absence of Monitoring Did Not Preclude Residual Neuromuscular Block

Kotake, Yoshifumi; Ochiai, Ryoichi; Suzuki, Takahiro; Ogawa, Setsuro; Takagi, Shuichi; Ozaki, Makoto; Nakatsuka, Itsuo; Takeda, Junzo

doi:10.1213/ane.0b013e3182999672

Cited by 171 publications

(108 citation statements)

References 38 publications

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“…Further research is needed to better understand the degree to which these rarer clinical events are linked to residual block and potentially avoidable with sugammadex use. It is evident, however, that both residual blockade and its sequelae are very common in the OR and PACU, with an estimated risk of residual blockade at extubation of 60% with neostigmine use as reported herein [6, 19, 20]. …”

Section: Discussionmentioning

confidence: 89%

“…In clinical practice, patients currently are rarely verified to have full neuromuscular recovery (TOF ratio ≥ 0.9) prior to extubation in the OR as evidenced by low use of quantitative neuromuscular monitoring [34, 35] and high incidences of RNMB with neostigmine use [6, 19, 20]. Thus, for the majority of patients currently managed with moderate neuromuscular block in Canada, the principal impact of the substitution of sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications.…”

Section: Discussionmentioning

confidence: 99%

“…Studies using quantitative neuromuscular monitoring to determine the time point for extubation were excluded. Three studies meeting review eligibility criteria were identified and meta-analyzed [6, 19, 20]. Rocuronium was used within each of the studies, and corresponding data were not found for patients receiving vecuronium.…”

Section: Methodsmentioning

confidence: 99%

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A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

Insinga

Joyal²,

Goyette³

et al. 2016

BMC Anesthesiol

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BackgroundThe objective of this analysis is to explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex (Bridion™, Merck & Co., Inc., Kenilworth, NJ USA) versus neostigmine for neuromuscular block reversal in Canada.MethodsA discrete event simulation (DES) model was developed to compare ORs using either neostigmine or sugammadex for NMB reversal over one month. Selected inputs included OR procedure and turnover times, hospital policies for paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use. Trials show sugammadex’s impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four ratio ≥0.9) is verified prior to extubation in the OR. Scenarios were therefore evaluated reflecting varied assumptions for neuromuscular reversal practices.ResultsWith use of moderate neuromuscular block, when full neuromuscular recovery is verified prior to extubation (93 procedures performed with sugammadex, 91 with neostigmine), use of sugammadex versus neostigmine avoided 2.4 procedural cancellations due to OR time over-run and 33.5 h of paid staff overtime, while saving an average of 62 min per OR day. No difference was observed between comparators for these endpoints in the scenario when full neuromuscular recovery was not verified prior to extubation, however, per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 51 cases prevented), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (23 cases avoided).Sugammadex impact in reversing deep neuromuscular block was evaluated in an exploratory analysis. When it was hypothetically assumed that 30 min of OR time were saved per procedure, the number of paid hours of staff over-time dropped from 84.1 to 32.0, with a 93% reduction in the per patient risk of residual blockade.ConclusionsIn clinical practice within Canada, for the majority of patients currently managed with moderate neuromuscular block, the principal impact of substituting sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications. For patients maintained at a deep level of block to the end of the procedure, sugammadex is likely to both enhance OR efficiency and reduce residual block complications.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0281-3) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

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A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

Insinga

Joyal²,

Goyette³

et al. 2016

BMC Anesthesiol

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show abstract

“…This shows that no complete elimination of residual NMB occurs, even after the reversal with sugammadex. Hence, using neuromuscular monitoring plays a key role in diagnosing and treating the residual NMB [10]. Our case is a perfect example showing the importance of utilization of neuromuscular monitoring to diagnose the incomplete reversal from muscle relaxants as well as the need to monitor recovery from residual NMB.…”

Section: Discussionmentioning

confidence: 99%

Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution

Green

Venkatesh

Venkataramani

2017

Case Reports in Anesthesiology

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Neostigmine has been traditionally used as the agent of choice to reverse Neuromuscular Blockade (NMB) after muscle paralysis during general anesthesia. However, the use of neostigmine has not been without untoward events. Sugammadex is a novel drug that selectively binds to aminosteroid nondepolarizing muscle relaxants and reverses even a deep level of NMB. Controversy exists regarding the optimal dose of sugammadex that is effective in reversing the NMB after the incomplete reversal with neostigmine and glycopyrrolate. We discuss a case where sugammadex reduced the time of the recovery from NMB in a patient who had incomplete antagonisms following adequate treatment with neostigmine, aiding timely extubation without persistent residual NMB, and hence prevented the requirement of postoperative ventilation and the improvement in patient care. More randomized control studies are needed in order to conclude the appropriate dose of sugammadex in cases of incomplete reversal.

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“…Generally effectivness of neostigmine and sugammadex should be observed with caution, because there are outlier patients in both groups, who exceed the mean recovery times (30,31,61,64). So quantitative monitoring is essential throughout to examine the reversing success (TOFR ≥0.9) (44,49,65,66).…”

Section: Debatementioning

confidence: 99%

Neuromuscular Block and Blocking Agents in 2018

Unterbuchner

2018

Turk J Anaesth Reanim

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Reversal with Sugammadex in the Absence of Monitoring Did Not Preclude Residual Neuromuscular Block

Cited by 171 publications

References 38 publications

A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution

Neuromuscular Block and Blocking Agents in 2018

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