Sugammadex Administration Research Articles

Recurrence of the Neuromuscular Blockade after the Sugammadex Administration after Opioid-Induced Respiratory Depression: A Report of 3 Cases

Three elderly patients received sugammadex after confirmation of train-of-four (TOF) stimulation at the end of the surgery. They presented opioid-induced respiratory depression accompanied by severe acidosis postoperatively. Even after the reversal of opioid intoxication with naloxone, the respiration did not recover, and TOF revealed recurrent paralysis. Two of three cases completely recovered after additional sugammadex administration, but remnant 1 case without sugammadex transferred to intensive care unit with intubated status. Even if the recommended dose of sugammadex is administered, there can be recurrent neuromuscular blockade by complicated reasons. Continuous quantitative neuromuscular monitoring may be needed to prevent these unusual situations.

Neurologic Examination Facilitated by Reversal of Rocuronium with Sugammadex

Background: Patients with neurologic injuries often receive neuromuscular blocking agents to facilitate airway management. The urgent nature of intubation may result in paralytic administration prior to neurologic examination, delaying clinical assessment, prognostication, and surgical interventions. Objective: In October 2018, an institutional guideline was implemented to extend institutional sugammadex use to include patients with uncertain neurologic examinations with recent rocuronium administration. The guideline allowed for a dose range of 2 mg/kg to 16 mg/kg. The objective of this continuous quality improvement project was to describe the use of sugammadex after implementation of an institutional guideline. Methods: Patient records between October 2018 and March 2020 were reviewed for guideline adherence and outcomes. Information assessed included patient weight, injury mechanism, the dosage and timing of rocuronium and sugammadex administration, and neurologic examination findings. Descriptive statistics were used to assess outcomes. Results: During the study period, eleven patients received sugammadex to facilitate neurologic examinations. The most common dose of sugammadex was 4 mg/kg with a mean total dose of 498.4 ± 333.5 mg. The mean time between rocuronium and sugammadex administration was 73.9 ± 41 minutes. Most patients (72.7%) had definitive changes in neurologic examination after sugammadex administration. Five patients had neurosurgical interventions offered and performed, with 1 of the patients surviving. Conclusions: This case series suggests that sugammadex is useful for reversing rocuronium induced paralysis to facilitate neurologic examination needed to determine management strategies for patients with a neurologic injury.

Sugammadex for reversal of rocuronium-induced neuromuscular blockade during alfaxalone anesthesia in dogs

ObjectiveTo investigate the reversal effect of sugammadex on neuromuscular blockade induced by a single bolus of rocuronium in dogs under alfaxalone anesthesia. Study designRandomized, prospective, crossover experimental study. AnimalsA group of six adult Beagle dogs (three females and three males), weighing 11.3–15.8 kg and aged 6–8 years, were used. MethodsDogs were anesthetized twice with a 1.25 times minimum infusion rate of alfaxalone, with a washout period of at least 14 days between experiments. Neuromuscular function was monitored using acceleromyography with train-of-four (TOF) stimulation of the peroneal nerve. After recording the control TOF ratio (TOFRC), rocuronium (0.5 mg kg–1) was administered intravenously. Subsequently, sugammadex (4 mg kg–1) or an equal volume of saline (control treatment) was administered intravenously when the TOF count returned from 0 to 1 after neuromuscular blockade. Time from rocuronium injection to TOF count = 0 (onset time), time from TOF count = 0 to TOF count = 1 (maximum blockade period), time of first twitch amplitude recovery from 0.25 to 0.75 (recovery index), and time from sugammadex or saline administration to TOF ratio/TOFRC ≥ 0.9 (recovery time) were recorded. ResultsThe onset time and maximum blockade duration did not differ between sugammadex treatment [1.2 (0.7–1.5) minutes and 9.9 (6.3–10.5) minutes, respectively] and control treatment [median (range); 1.0 (0.7–1.1) minutes and 9.9 (8.8–11.5) minutes, respectively] (p = 0.219 and 0.844, respectively). Recovery index was 0.5 (0.3–0.7) minutes in sugammadex treatment, which was shorter than that in control treatment [4.5 (3.7–4.9) minutes] (p = 0.031). Recovery time was 0.8 (0.5–2.8) minutes in sugammadex treatment, which was shorter than that in control treatment [10.5 (6.8–14.3) minutes] (p = 0.031). Conclusions and clinical relevanceRocuronium-induced neuromuscular blockade was effectively reversed by sugammadex in dogs anesthetized with alfaxalone.

Successful reversal of remimazolam anesthesia in a “cannot intubate, can ventilate” situation: a case report

BackgroundCompared to other intravenous anesthetics, availability of a specific antagonist flumazenil is a clear advantage of remimazolam. We report a patient who could be rapidly woken up when laryngoscopy and tracheal intubation were unexpectedly difficult.Case presentationA 62-year-old man was scheduled to have resection of a small gingival tumor. Preoperative airway examination was unremarkable except for an omega-shaped epiglottis. Anesthesia was induced with remifentanil/remimazolam infusion and rocuronium. A small omega-shaped edematous epiglottis precluded identification of glottis. Consciousness and spontaneous ventilation were rapidly restored after administration of flumazenil and sugammadex. Tracheostomy was done under local anesthesia while the patient breathed spontaneously.ConclusionsRemimazolam can be a reasonable induction agent when there are concerns regarding airway management. Avoiding repeated airway manipulations is extremely important to prevent deterioration into a “cannot intubate, cannot ventilate (CICV)” emergency.

Chronic exposure to dexamethasone may not affect sugammadex reversal of rocuronium-induced neuromuscular blockade: an in vivo study on rats.

Chronic glucocorticoid exposure is associated with resistance to nondepolarizing neuromuscular blocking agents. Therefore, we hypothesized that sugammadex-induced recovery would occur more rapidly in subjects exposed to chronic dexamethasone compared to those who were not exposed. This study evaluated the sugammadex-induced recovery profile after neuromuscular blockade (NMB) in rats exposed to chronic dexamethasone. Sprague-Dawley rats were allocated to three groups (dexamethasone, control, and pair-fed group) for the in vivo study. The mice received daily intraperitoneal dexamethasone injections (500 μg/kg) or 0.9% saline for 15 days. To achieve complete NMB, 3.5 mg/kg rocuronium was administered on the sixteenth day. The recovery time to a train-of-four ratio ≥ 0.9 was measured to evaluate the complete recovery following the sugammadex injection. Among the groups, no significant differences were observed in the recovery time to a train-of-four ratio ≥ 0.9 following sugammadex administration (P = 0.531). The time to the second twitch of the train-of-four recovery following rocuronium administration indicated that the duration of NMB was significantly shorter in Group D than that in Groups C and P (P = 0.001). Chronic exposure to dexamethasone did not shorten the recovery time of sugammadex-induced NMB reversal. However, the findings of this study indicated that no adjustments to sugammadex dosage or route of administration is required, even in patients undergoing long-term steroid treatment.

Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy

BackgroundSugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. MethodsWe performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg−1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. ResultsTwenty-five patients were included in this study. Compared with baseline, BIS increased at 4–6 min (β coefficient: 3.63; 95% confidence interval [CI]: 2.22–5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2–4 min (β coefficient: 0.29; 95% CI: 0.05–0.52; P=0.016) and 4–6 min (β coefficient: 0.71; 95% CI: 0.47–0.94; P<0.001), and EMG increased at 4–6 min (β coefficient: 1.91; 95% CI: 1.00–2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2–4 min (β coefficient: 93; 95% CI: 1–185; P=0.046) and 4–6 min (β coefficient: 208; 95% CI: 116–300; P<0.001), and decreased delta power was observed at 4–6 min (β coefficient: −526.72; 95% CI: −778 to −276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. ConclusionsAfter neuromuscular block reversal with 2 mg kg−1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.

Evaluation of Sugammadex Dosing for Neurological Examination in the Emergency Department

Background: Prolong effects of non-depolarizing neuromuscular blocking agents after rapid sequence intubation may prevent meaningful neurological examination, delaying appropriate diagnosis and neurosurgical intervention. Sugammadex is indicated for the reversal of neuromuscular blockade induced by rocuronium. Objective: The objective of this study was to evaluate low- (2 mg/kg) vs standard-dose (4 mg/kg) sugammadex for rocuronium-induced deep neuromuscular blockade reversal in the emergency department (ED) by achieving a post-treatment train-of-four (TOF) of 4 to facilitate neurological examination. Methods: This was a single-center, retrospective, cohort study evaluating low-vs standard-dose sugammadex for neuromuscular blockade reversal in the ED. Results: 34 patients were identified within the designated time period, 24 of which were included in the final analysis ([n = 9 low-dose], [n = 15 standard-dose]). Median sugammadex doses were 2.3 mg/kg and 4.1 mg/kg for low- and standard-dose, respectively. The majority of patients presented for intraparenchymal hemorrhage (54.2%). No significant difference in success rate of NMBA reversal was found between low- and standard-dose sugammadex ([100.0% vs 93.3%], P = 1.000). A total of 9 patients had a neurosurgical procedure performed after sugammadex administration. Low-dose sugammadex was associated with significantly less acquisition cost compared to the standard dose (P < .001). Conclusion: Low- (2 mg/kg) and standard-dose (4 mg/kg) sugammadex successfully reversed rocuronium-induced deep neuromuscular blockade in the ED by achieving a post-treatment TOF of 4 to facilitate neurologic examination. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED and is associated with decreased institutional cost.

Retrospective Analysis of Sugammadex Use in Adolescent Females on Progestin-Containing Contraceptives

Sugammadex, a novel neuromuscular blockade reversal agent, functions as a steroid binder postulated to decrease hormone exposure used within progestin-containing contraceptive medications. Thus, alternative non-medication contraceptive methods are recommended to prevent unplanned pregnancies. The study aims were to evaluate sugammadex use in adolescent females prescribed a progestin-containing contraceptive and positive pregnancy screening frequency. We hypothesized that sugammadex use is infrequent in this population and no pregnancy screens would be positive. This is a retrospective observational cohort study utilizing the TriNetX electronic health record database of female subjects aged 12-21 years reported to be prescribed sugammadex. The data collected were analyzed for demographic characteristics, International Classification of Diseases 9th and 10th edition diagnostics, medication, procedural codes, progestin-containing medication timing, and timing of pregnancy screening. We included 18,686 subjects (contraceptive group, 2017 [10.8%], and no contraceptive group, 16,669 [89.2%]). Both groups had similar frequencies of pregnancy screening (contraceptive group, 54 [2.7%], vs no contraceptive group, 366 [2.2%]). Of the contraceptive group, 1 (0.05%) subject, 17 years of age, was confirmed to have a positive pregnancy screen 35 days after surgery. We found that sugammadex may be administered to adolescent females prescribed progestin-containing contraceptives, but positive pregnancy screens are rare. Effective counseling, use of nonhormonal contraceptives 7 days after sugammadex administration, and the theoretical reproductive risks of this agent may have contributed to these findings. Continued counseling after sugammadex use in the adolescent population is recommended to avoid the occurrence of unplanned pregnancies.

Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence.

Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence.

A Case Report of Acute Onset and Rapid Resolution of Atrioventricular Block After Sugammadex: Is the Autonomic System Involved?

Administering sugammadex to reverse neuromuscular blockade can cause marked bradycardia and rarely asystole. In this case, a rapid onset, biphasic heart rate response; slowing then speeding, after administering sugammadex was noted while at steady state, 1.3% end-tidal sevoflurane. On review of the electrocardiogram (ECG), the heart rate slowing coincided with the onset of a second-degree, Mobitz type I block that lasted 45 seconds. No other events, drugs, or stimuli coincided with the event. The acute onset and transient nature of the atrioventricular block without evidence of ischemia implies a brief parasympathetic effect on the atrioventricular node after sugammadex administration.

Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter.

Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter.

Changes in bispectral index and patient state index during sugammadex reversal of neuromuscular blockade under steady-state sevoflurane anesthesia

Few studies have investigated the changes in patient state index (PSI) and bispectral index (BIS) in response to abrupt increase in electromyographic (EMG) activity. These were performed using intravenous anesthetics or reversal agents for neuromuscular blockade (NMB) other than sugammadex. We compared the changes in BIS and PSI values caused by the sugammadex reversal of NMB during steady-state sevoflurane anesthesia. We enrolled 50 patients with American Society of Anesthesiologists physical status 1 and 2. At the end of the surgery, we administered 2 mg kg−1 sugammadex while maintaining sevoflurane for a 10-min study period. The changes in BIS and PSI from baseline (T0) to train of four ratio of 90% were not significantly different (median difference 0; 95% CI − 3 to 2; P = 0.83), neither were the changes in BIS and PSI values from T0 to their maximum values (median difference 1; 95% CI − 1 to 4; P = 0.53). Maximum BIS and PSI were significantly higher than their baseline values (median difference 6; 95% CI 4–9; P < 0.001 and median difference 5; 95% CI 3–6; P < 0.001, respectively). We found weak positive correlations between BIS and BIS-EMG (r = 0.12, P = 0.01), as well as PSI and PSI-EMG (r = 0.25, P < 0.001). Both PSI and BIS were affected to some extent by EMG artifacts after sugammadex administration.

Vial-splitting and Repackaging into Aliquot-specific Syringes: A Cost-effective and Waste-decreasing Strategy for Sugammadex.

The study was a retrospective, quality improvement study using the electronic medical record to identify every sugammadex administration over the last five years in a tertiary care pediatric institution. We divided patients into groups depending on the dose of sugammadex administered. The cost of sugammadex was calculated under three scenarios: (1) only 200-mg vials available; (2) 100-mg aliquots available; and (3) 50-mg aliquots. We then calculated the total money spent per patient in the 3 scenarios. 31,063 patients received sugammadex over the study period, of whom 23.6% received 151-200 mg. The greatest percentage of patients received ≤50 mg (32.9%). The average cost per patient was $113.58, $81.61, and $68.83 if 200 mg, 100 mg, and 50 mg doses were available, respectively. Over the last 5 years, $1,390,110.13 could have been saved by having 50 and 100 mg aliquots available. Pediatric patients generally receive lower doses of sugammadex due to weight-based dosing, leading to increased waste and cost when using only 200-mg vials. Vial-splitting into smaller aliquots can significantly cut costs for healthcare centers and patients while decreasing waste.

Sugammadex administration in patients with end-stage renal disease: a narrative review with recommendations.

Due to unknown safety concerns, sugammadex should not be administered to patients withend-stage renal disease (ESRD). However, because the supply of benzylisoquinolinium-typeneuromuscular blocking agents (NMBAs) has been discontinued, rocuronium is the onlynon-depolarizing NMBA that can be used in clinical settings in some countries, includingSouth Korea. The administration of sugammadex cannot be avoided to achieve rapid andcomplete neuromuscular recovery in patients with ESRD or renal transplantation after rocuronium administration. Although there has been a limited number of clinical studies involving the use of sugammadex in patients with ESRD, studies have shown that sugammadexcan effectively and safely reverse rocuronium-induced neuromuscular blockade (NMB) inpatients with ESRD, however recovery of neuromuscular function in patients with ESRD isslower than in patients with normal renal function. Nonetheless, safety-concerns are yet tobe addressed. Considering the small number of clinical studies, high heterogeneity amongstudies, and insufficient safety information, more extensive data on the efficacy and safetyof sugammadex in patients with ESRD are needed. In particular, it is important to securedata on safety, including residual NMB after surgery, recurarization and cardiorespiratorycomplications, anaphylactic reactions, and long-term morbidity and mortality. Furthermore,anesthesiologists should remember that performing proper quantitative neuromuscularmonitoring and neuromuscular management based on the monitoring signs are the mostessential requirements when using sugammadex in patients with ESRD.

Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study

BackgroundSugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery.MethodsThis single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes.ResultsOf the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (β = 0.29 95% confidence interval {CI}: [− 1.13, − 0.54], P = 0.4912). However, it was associated with shorter PACU stay (β = − 20.30 95% CI: [− 24.48, − 17.11], P < 0.0001), shorter time to postoperative ambulation movement (β = − 0.43 95% CI: [− 0.62, − 0.23], P < 0.0001), and reduced time-to-first-defecation (β = − 2.25 95% CI: [− 0.45, − 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05).ConclusionsNeuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.

Suspected Sinus Arrest after Sugammadex Administration : A Case Report

Suspected Sinus Arrest after Sugammadex Administration : A Case Report

Reply to: Earlier and lower dose administration of sugammadex. A randomized placebo-controlled trial

Reply to: Earlier and lower dose administration of sugammadex. A randomized placebo-controlled trial

Efficacy and Safety of Sugammadex to Shorten Time-to-Extubation Following Cardiac Surgery: A Single-Center Randomized Placebo-Controlled Trial.

Single-center, randomized, double-blind, placebo-controlled trial. University-based cardiothoracic ICU. Patients (n = 90) undergoing elective aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) surgery. Participants were randomized to receive either sugammadex (2 mg/kg) or placebo after arrival to the ICU. The primary study endpoint was time from study drug administration to extubation. Of the 90 patients included in the study (45 in each group), a total of 68 patients underwent CABG, 13 AVR, and nine combined AVR and CABG. Baseline characteristics and intraoperative anesthetic medications were comparable between groups. Patients in sugammadex group had reduced time to extubation compared with the placebo group (median [interquartile range (IQR)]-sugammadex group: 126.0 min [84.0-274.0 min] vs placebo: 219.0 min [121.0-323.0 min]; difference in means [95% CI], 72.8 [1.5-144.1 min]; p = 0.01. There were no differences in negative inspiratory force (mean [sd]-sugammadex group: 33.79 cm H2O [8.39 cm H2O] vs placebo: -31.11 cm H2O [7.17 cm H2O]) and vital capacity (median [IQR]-sugammadex group: 1.1 L [0.9-1.3 L] vs placebo: 1.0 L [0.9-1.2 L]). There were no differences between groups in postoperative blood product requirement, dysrhythmias, length of ICU, or hospital stay. There were no serious adverse events in either group. This randomized trial showed that the administration of sugammadex after cardiac surgery decreased time to extubation by approximately 1 hour. Larger trials may be required to confirm these findings and determine the clinical implications.

Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care

BackgroundSugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care. MethodsWe analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP–NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation). ResultsBased on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (–1.3% lower costs; 95% confidence interval [CI], –0.5 to –2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, –US$376 to –US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, –US$1198 to –US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation). ConclusionsThe effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities.

785: EVALUATION OF SUGAMMADEX DOSING FOR DEEP NEUROMUSCULAR BLOCKADE REVERSAL IN THE EMERGENCY DEPARTMENT

Introduction: Neuromuscular blocking agents (NMBAs) are often administered to facilitate rapid sequence intubation (RSI). The effects of neuromuscular blockade may be prolonged in the setting of organ dysfunction or need for rapid attainment of a neurological examination may be necessary. The primary objective of this study is to evaluate low (2 mg/kg) versus standard dose (4 mg/kg) sugammadex for reversal of deep neuromuscular blockade in the emergency department (ED) to facilitate neurological examination. Methods: A single-center, retrospective cohort study was performed and approved by the local Institutional Review Board. Patients were identified using sugammadex charge codes between 01/01/2017 - 07/15/2022. Adult patients were included if they received sugammadex in the ED to facilitate neurological examination, were given rocuronium or vecuronium for RSI, and had a documented train-of-four (TOF) before and after sugammadex administration. Patients were excluded if records were incomplete, initial sugammadex dose other than 2 mg/kg or 4 mg/kg was used and if initial TOF was 1 – 4. The primary outcome of this study was successful deep neuromuscular blockade reversal defined by achieving a post-treatment TOF of 4. Results: Of 36 sugammadex doses administered in the ED, 26 patients were included in the final analysis, with 10 in the low-dose group and 16 patients in the standard-dose group. The median dose was 2.28 mg/kg and 4.09 mg/kg for low- and standard-dose, respectively. The overall cohort was predominantly male (65.4%) with a median age of 68.4 years (49.7-76.9). Most patients presented for intraparenchymal hemorrhage (53.8%), with 57.7% of bleeds being traumatic in origin. Median initial Glasgow Coma Score was 3, and all initial TOF were zero. Paralytics were administered in the pre-hospital setting in 85% of patients, with rocuronium use predominating (92.3%). No significant difference in success rate of NMBA reversal was found between low-dose versus standard-dose sugammadex (100.0% vs. 93.8%, P = 1.000). Conclusions: Low-dose sugammadex did not result in a significantly different success rate of NMBA reversal when compared to standard-dose. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED to facilitate neurological examinations.