Staggering the dose of sugammadex lowers risks for severe emergence cough: a randomized control trial

Loh P.S,Chin Y.Z,M.M Miskan,R.A Zaki

doi:10.1186/s12871-017-0430-3

Abstract

BackgroundCough on emergence has been reported as a common adverse reaction with sugammadex reversal. We investigated if staggering the dose of sugammadex will reduce emergence cough in a single-center, randomized, double-blinded study.MethodsA hundred and twenty ASA 1–3 adults were randomly reversed with 1 mg/kg sugammadex prior to extubation followed by another 1 mg/kg immediately after extubation (staggered group), single dose of 2 mg/kg sugammadex (single bolus group) or neostigmine 0.02 mg/kg with glycopyrrolate (neostigmine group).ResultsWe found 70% of patients (n = 28) reversed with single boluses of sugammadex had Grade 3 emergence cough compared to 12.5% (n = 5) in the staggered sugammadex group and 17.5% (n = 7) in the neostigmine group (p < 0.001). Besides cough, emergence agitation also appeared highest in the single bolus sugammadex group (n = 14, 35%, p = 0.005). On the other hand, staggering sugammadex lowered risks of developing severe cough (RR 0.2, p < 0.001) and agitation (RR 0.43, p = 0.010) on emergence in addition to cough (RR 0.25, p = 0.039) and early sore throat (RR 0.70, p = 0.036) in the post-anesthetic care unit. The risks for severe emergence cough (RR 0.86, p = 0.762), severe cough in the post-anesthetic care unit (RR 1.0, p = 1.000) and sore throat (RR 1.17, p = 0.502) were also not different between the staggered sugammadex group and control given neostigmine. In terms of timing, there was no delay in time taken from discontinuing anesthetic agents to reversal and extubation if sugammadex was staggered (emergence time 6.0 ± 3.2 s, p = 0.625 and reversal time 6.5 ± 3.5, p = 0.809).ConclusionsStaggering the dose of sugammadex for reversal will effectively decrease common emergence and early postoperative complications.Trial registrationANZCTR Number ACTRN12616000116426. Retrospectively registered on 2nd February 2016.

Highlights

Cough on emergence has been reported as a common adverse reaction with sugammadex reversal
The postulated mechanism for sugammadex lies in its ability to unmask light anesthesia rapidly resulting in a projected faster recovery of muscle function represented by prevalent cough, movement, grimace or suckling on the tracheal tube upon awakening in the patients [10, 11]
Our study demonstrated that staggering the dose of sugammadex by administering 1 mg/kg at reversal and another 1 mg/kg immediately upon tracheal extubation had significantly less severe emergence cough than administering sugammadex in a single bolus of 2 mg/kg

Summary

Introduction

Cough on emergence has been reported as a common adverse reaction with sugammadex reversal. We investigated if staggering the dose of sugammadex will reduce emergence cough in a single-center, randomized, double-blinded study. P.S. et al BMC Anesthesiology (2017) 17:137 in post-operative hemorrhage, raised intracranial, intraocular and intra-abdominal pressures [4, 6, 7] These can lead to detrimental outcomes in a large number of procedures in neurosurgery, thyroidectomy, nasal, eye and spinal surgeries [8, 9]. We had not intended to study drugs that suppress emergence cough but wanted to focus on reducing its incidence in patients reversed with sugammadex by comparing a new method of administration to both the conventional way and our old standard, neostigmine. We hypothesized that if sugammadex is given in a staggered dose, the incidence and severity of emergence cough can be reduced compared to the recommended single bolus. We evaluated outcomes in hemodynamic changes during the emergence phase, other recovery profiles and risk factors involved in emergence cough

Methods

Results

Conclusion