Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: a systematic review and economic evaluation

Paton, Fiona; Paulden, Mike; Chambers, Duncan; Heirs, Morag; Duffy, Steve; Hunter, Jennifer M.; Sculpher, Mark; Woolacott, Nerys

doi:10.1093/bja/aeq269

Cited by 132 publications

(122 citation statements)

References 15 publications

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“…Due to its high cost, the use of sugammadex is limited to certain indications [22]. Paton and colleagues [25] noted the potential economic benefits that result from the markedly shorter time required for the care of patients who receive sugammadex compared to patients who are administered neostigmine and glycopyrrolate.…”

Section: Discussionmentioning

confidence: 99%

Zastosowanie sugammadeksu do odwracania bloku nerwowo-mięśniowego wywołanego wekuronium po operacjach wewnątrzczaszkowych

Karwacki¹,

Niewiadomski²,

Rzaska³

2015

Anaesthesiol Intensive Ther

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Background: Total intravenous anaesthesia with propofol and remifentanil is widely used in neuroanaesthesiology and enables the quick recovery and early neurological assessment of patients. The administration of muscle relaxants carries a risk of residual relaxation following surgery. The administration of a suitable dose of sugammadex reverses the neuromuscular block irrespective of its depth and has none of the side effects associated with acetylcholinesterase inhibitors. The aim of the present study was to evaluate the usefulness of sugammadex for the reversal of vecuroniuminduced effects following intracranial surgery. Method: The study involved 38 women who underwent supratentorial tumour removal. These women were randomly divided into two groups. Total intravenous anaesthesia with propofol and remifentanil using target-controlled infusion was administered according to the Schnider and Minto models, respectively. Endotracheal intubation was performed after the target concentrations of propofol and remifentanil reached 4 µg mL -1 and 4 ng mL -1 , respectively. Vecuronium (100 µg kg -1 ) was administered, and no response to TOF stimulation was observed. Relaxation was continued via the continuous infusion of vecuronium (0.8-1.2 µg kg -1 min -1 ) to provide a TOF of 2 throughout the surgery. In group I, neuromuscular conduction was restored with intravenous sugammadex (2 mg kg -1 ), whereas in group II, no reversal agents were administered. Results: The times of the return of spontaneous breathing, extubation, eye opening (both spontaneous and in response to a verbal command) were found to be longer in group II than group I. Conclusion: The use of sugammadex following craniotomy accelerates the achievement of optimal extubation conditions.

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Section: Discussionmentioning

confidence: 99%

Zastosowanie sugammadeksu do odwracania bloku nerwowo-mięśniowego wywołanego wekuronium po operacjach wewnątrzczaszkowych

Karwacki¹,

Niewiadomski²,

Rzaska³

2015

Anaesthesiol Intensive Ther

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“…For example, when two twitches are visible at the adductor pollicis, the recommended dose is 2 mgÁkg -1 ; if blockade is more profound, i.e., a post-tetanic count of 1-2, a 4 mgÁkg -1 dose is required. 32 A TOF ratio[ 0.9 is attained in two to three minutes when appropriate doses are given.…”

Section: Pharmacologymentioning

confidence: 99%

“…Par exemple, lorsque deux réponses sont visibles à l'adducteur du pouce, la dose recommandée est de 2 mgÁkg -1 ; si le bloc est plus profond, soit un décompte post-tétanique (post-tetanic count ou PTC) de 1-2, une dose de 4 mgÁkg -1 est nécessaire. 32 Un rapport de TDQ [ 0,9 est obtenu en deux à trois minutes lorsque des doses adaptées sont administrées.…”

Section: Pharmacologieunclassified

Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Purpose Over the past three decades, many studies have shown a high proportion of patients in the recovery room with residual neuromuscular blockade after anesthesia. The purpose of this Continuing Professional Development module is to present the physiological consequences of residual paralysis, estimate the extent of the problem, and suggest solutions to prevent its occurrence. Principal findings Residual paralysis is defined as a train-of-four ratio (TOFR) \ 0.9 at the adductor pollicis. While tidal volume and, to a lesser extent, vital capacity are well preserved as the intensity of blockade increases, the probability of airway obstruction, impaired swallowing, and pulmonary aspiration increases markedly as TOFR decreases. In recent studies, incidences of residual paralysis from 4-57% have been reported, but surveys indicate that anesthesiologists estimate the incidence of the problem at 1% or less. The decision to administer neostigmine or sugammadex should be based on the degree of spontaneous recovery at the adductor pollicis muscle (thumb), not on recovery at the corrugator supercilii (eyebrow). The most important drawback of neostigmine is its inability to reverse profound blockade, which is a consequence of its ceiling effect. When spontaneous recovery reaches the point where TOFR [ 0.4 or four equal twitch responses are seen, reduced doses of neostigmine may be given. The dose of sugammadex required in a given situation depends on the intensity of blockade. Conclusion Careful monitoring and delaying the administration of neostigmine until four twitches are observed at the adductor pollicis can decrease the incidence of residual paralysis. The clinical and pharmacoeconomic effects of unrestricted sugammadex use are unknown at this time. ObjectivesAfter reading this module, the reader should be able to:1. Describe the physiological effects of residual neuromuscular blockade 2. Define and justify the current threshold used for residual paralysis 3. Interpret the information provided by qualitative and quantitative monitors 4. Decide the dose and timing of administration of neostigmine 5. Manage neuromuscular blockade and reversal during and after anesthesia.In 1979, Viby-Mogensen et al. 1 reported that 42% of patients receiving non-depolarizing neuromuscular blocking agents during anesthesia followed by neostigmine at the end of the procedure had neuromuscular weakness in the recovery room, as documented by a train-of-four ratio 123Can J Anesth/J Can Anesth (2013) 60:714-729 DOI 10.1007 (TOFR) \ 0.7. This first description of what was later termed residual paralysis, residual curarization, or postoperative residual curarization was followed by many other observations in many countries around the world and in different settings. The introduction of shorter-acting agents, such as vecuronium and atracurium and later rocuronium and cisatracurium, to replace the longer-acting agents available in 1979 led to a decrease in the incidence of residual paralysis. 2 Nevertheless, many lines of evidence now...

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“…New NMB agents and their antagonists allow precise control of awakening times for efficient operating room scheduling, avoiding cost increases due to personnel overtime. For example, rapid recovery may prevent some of the frequent and numerous side effects associated with longer sedation, and the associated increases in hospital cost [21].…”

Section: Introductionmentioning

confidence: 99%

Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial (Preprint)

Robertis¹,

Miceli²,

Colombo³

et al. 2017

Preprint

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Post-operative pain, especially shoulder pain, is commonly reported following laparoscopic gynecologic procedures. Some studies suggest that a lower insufflation pressure may reduce the risk of post-operative pain; however, there is no agreement on the optimal pneumoperitoneum pressure during gynecologic laparoscopic surgery, or whether lower pressure would lead to clinically significant improvements without increasing operative complications. Questions remain regarding the clinical significance of improvements, safety and cost effectiveness of deep neuromuscular blockade with low pressure pneumoperitoneum.The primary objective of this study is to assess the superiority of anesthesia with deep neuromuscular blockade with pneumoperitoneum 8 mmHg over moderate blockade with pneumoperitoneum 12 mmHg, in terms of overall pain 24 hrs after surgery in adult women undergoing pelvic surgery for hysterectomy or benign adnexal diseases. Effects on the intensity and timing of postoperative pain in specific locations, surgeon satisfaction, respiratory and haemodynamic stability, operating times and direct and indirect costs will be assessed.In this multicenter, randomized controlled trial with a superiority design, 300 patients will be randomly allocated 1:1 to moderate neuromuscular blockade with a target insufflation pressure of 12 mmHg or deep neuromuscular blockade with a target insufflation pressure of 8 mmHg, with stratification by type of surgery and clinical center. The patient, the statistician and the nurse who will assess the primary endpoint will be blinded to the allocation.The present study is designed to confirm the reported benefits for postoperative pain and provide additional data needed to address questions regarding the effects of this intervention on operating theatre management, and direct and indirect costs. Strengths of this protocol include the large sample size distributed among diverse institutions across the Italian territory and the collection and analysis of data on numerous secondary objectives. Limitations include the possible introduction of bias because the surgeon and anesthesiologist are not blinded to the intervention.

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Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: a systematic review and economic evaluation

Cited by 132 publications

References 15 publications

Zastosowanie sugammadeksu do odwracania bloku nerwowo-mięśniowego wywołanego wekuronium po operacjach wewnątrzczaszkowych

Zastosowanie sugammadeksu do odwracania bloku nerwowo-mięśniowego wywołanego wekuronium po operacjach wewnątrzczaszkowych

Residual paralysis: a real problem or did we invent a new disease?

Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial (Preprint)

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