Rocuronium–sugammadex as an alternative to succinylcholine in electroconvulsive therapy

Abstract

To the Editor:We read with great interest the article by Hoshi et al. [1]dealing with the recovery time from neuromuscularblockade induced by rocuronium combined with sug-ammadex versus succinylcholine during electroconvulsivetherapy (ECT). Sugammadex has recently been introducedas a fast-acting, selective relaxant-binding agent that wasspecifically designed to rapidly reverse rocuronium-induced neuromuscular blockade. This study is interestingfor anesthesiologists who frequently encounter ECT ses-sions in their operating rooms and are waiting for safeagents that rapidly reverse neuromuscular blockade in thissubgroup of patients. The authors revealed that recoverytime of T1 to 10 and 90% in the rocuronium–sugammadexgroup was shorter than in the succinylcholine groupalthough the difference was not statistically significant. Theauthors also revealed that seizure duration with succinyl-choline (33 ± 8 s) was shorter than that with rocuronium–sugammadex (39 ± 4 s) and reported a potential benefit ofthe use of rocuronium–sugammadex as an alternative tosuccinylcholine for muscle relaxation during ECT [1]. Inour opinion, some points of this work are not sufficientlyclear.The authors reported a tendency to shorter time torecovery of T1 to 10 and 90% with rocuronium–sug-ammadex compared with succinylcholine but the differ-ence was not statistically significant (p = 0.26, p = 0.07)and no significant differences in time to first spontaneousbreath and eye opening in response to verbal commandswere found with either muscle relaxant (p = 0.94,p = 0.48). Absence of such a statistically significant dif-ference might be because of the small sample size (n = 5in this clinical report) and/or increased variability of thetime to recovery of T1 to 10 and 90% and the time to thefirst spontaneous breath between the first case and theremaining group. Not only the absence of statisticallysignificant differences between the two medications—possibly—formethodologicalreasons,butalsotheincreasedpercentage of elderly ([65 years) subjects (2/5: 40%)weakens the findings of this report, because reversal ofrocuronium neuromuscular blockade with sugammadex wasfound to be slightly slower in elderly patients [2].Further large-scale prospective studies on sugammadexare mandatory, especially for patients with contraindica-tions to the use of succinylcholine, although the cost ofsugammadex may preclude such trials.References