Sugammadex: Applications in Pediatric Critical Care

Abstract

Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade with a mechanism that differs from acetylcholinesterase inhibitors such as neostigmine. There is a growing body of literature demonstrating its efficacy in pediatric patients of all ages. Prospective trials have demonstrated a more rapid and more complete reversal of rocuronium-induced neuromuscular blockade than the acetylcholinesterase inhibitor, neostigmine. Unlike the acetylcholinesterase inhibitors, sugammadex effectively reverses intense or complete neuromuscular blockade. It may also be effective in situations where reversal of neuromuscular blockade is problematic including patients with neuromyopathic conditions or when acetylcholinesterase inhibitors are contraindicated. This article reviews the physiology of neuromuscular transmission as well as the published literature, regarding the use of sugammadex in pediatric population including the pediatric intensive care unit population. Clinical applications are reviewed, adverse effects are discussed, and dosing algorithms are presented.

Sugammadex in Emergency Situations

“…A case report of the use of sugammadex at a dose of 16 mg/kg in an 850-g neonate in a CICV situation was reported to be effective [ 16 ]. This report, together with other sparse data of successful treatment with sugammadex in CICV situations in children, still does not support the use of sugammadex in that particular emergency situation, as the duration of apnea can last for approximately 15 min in 5% of patients [ 45 ]. In the United States, the use of sugammadex in children was only introduced in 2016 [ 46 ].…”

Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis

“…According to previous retrospective analysis and review [ 14 , 43 ], bradycardia, one of significant adverse effects of NMB reversal agents, was found more commonly in neostigmine patients than in sugammadex patients. The results of our present study suggested that incidence of both bradycardia and dry mouth was significant lower in sugammadex patients, and no difference was found in occurrence of pain, bronchospasm, laryngospasm, apnea and oxygen desaturation between two groups.…”

“…Since the first-in-man clinical research in 2005 [ 10 ], sugammadex has been used extensively in surgical practice for adult patients in recent years [ 11 ]. Simultaneously, although the drug package insert evidently declares that “the safety and efficacy of sugammadex in pediatric patients have not been established” [ 12 ], according to recent studies [ 13 , 14 ] and a latest survey [ 15 ], this novel agent has been frequently used in pediatric anesthesia, especially among anesthesiologists with fewer years of practice.…”

Novel use of probiotic as acetylcholine esterase inhibitor and a new strategy for activity optimization as a biotherapeutic agent

“…These applications could be violent such as toxins and chemical warfare agents (e.g., organophosphate toxins, nerve agents, soman, and sarin) that lead to inhibition of AChE in nerve junctions by irreversibly covalently binding to the enzyme inhibitor, leading to muscle paralysis, increased respiratory secretions, respiratory failure, seizures, coma, and death [8]. Peaceful and therapeutic applications also exist, for example, tacrine, rivastigmine, and donepezil that are used in dementia with Lewy bodies patients [9], huperzine A for glaucoma treatment [10], rivastigmine, galantamine, and donepezil for alleviation of AD symptoms [1,11], and neostigmine in the cases of neuromuscular blockade and MG patients [12].…”