La terapia electroconvulsiva en el síndrome neuroléptico maligno / Electroconvulsive therapy in neuroleptic malignant syndrome

Resumen: Uno de los efectos adversos más importantes de los neurolépticos es la posibilidad de desencadenar el síndrome neuroléptico maligno (NMS). El diagnóstico se determina por exclusión y el manejo terapéutico inicial será retirado por neurolépticos por la administración de benzodiacepinas y, en casos extremos, el uso de la terapia electroconvulsiva (ECT). La ECT es una opción terapéutica eficaz en estos pacientes y en esos casos se obtiene una mala respuesta a la administración con fármacos antipsicóticos. Basándonos en el caso del artículo «Rocuronium-sugammadex for electroconvulsive therapy management in neuroleptic malignant síndrome. A case report¼ donde se describe el manejo exitoso del uso de relajantes no despolarizantes y su reversor específico en terapias electroconvulsivas en pacientes diagnosticados de síndrome neuroléptico maligno, comentamos la fisiopatología e implicaciones anestésicas además de similitudes con otras entidades hipertérmicas, como es la hipertermia maligna.

Abstract: One of the most important adverse effects of neuroleptics is the possibility of triggering neuroleptic malignant syndrome (NMS). The diagnosis is determined by exclusion and the initial therapeutic management will be withdrawn by neuroleptics by the administration of benzodiazepines and, in extreme cases, the use of electroconvulsive therapy (ECT). ECT is an effective therapeutic option in these patients and in these cases a poor response to administration with antipsychotic drugs is obtained. Based on the case of the article «Rocuronium-sugammadex for the management of electroconvulsive therapy in neuroleptic malignant syndrome. A case report¼ where the successful management of the use of non-depolarizing relaxants and their specific reversal in electroconvulsive therapies in patients diagnosed with of malignant neuroleptic syndrome, we comment on the pathophysiology and anesthetic images as well as similarities with other hyperthermic entities, such as malignant hyperthermia.

Bradycardia in a pediatric population after sugammadex administration: case series

Abstract Sugammadex is a distinctive neuromuscular reversal drug that acts by encapsulating the neuromuscular relaxant molecule and dislodging it from its site of action. Sugammadex has been approved for pediatric patients over 2 years of age. Although arrhythmias have been reported, there is no report of adverse effects in healthy children, such as severe bradycardia requiring intervention. We report two cases of severe bradycardia immediately after the administration of sugammadex in healthy children. Our aim is to alert to the occurrence of one of the most severe adverse effects of sugammadex, in the healthy pediatric population as well.

Effect of sugammadex on long-term prognosis in patients undergoing kidney transplantation / 中华麻醉学杂志

Objective:To evaluate the effect of sugammadex on the long-term prognosis in the patients undergoing kidney transplantation.Methods:American Society of Anesthesiologists Physical Status classification Ⅲ or Ⅳ patients of either sex, aged 18-64 yr, underwent donation after cardiac death renal transplantation from January 1, 2018 to October 31, 2021, were included in this study. Their clinical data were retrospectively analyzed, and then the patients were divided into 2 groups: sugammadex group (group S) and control group (group C). The complications at 1 yr after surgery and patient/graft survival at 1 and 3 yr after surgery were recorded.Results:A total of 645 patients were finally enrolled in this study, with 319 patients in group S and 326 patients in group C. There was no significant difference in the incidence of postoperative complications within 1 yr after surgery between two groups ( P>0.05). The overall patient survival rate at 1 and 3 yr after surgery were 94.7% and 92.8% respectively, and the death-censored graft survival at 1 and 3 yr after surgery were 94.4% and 89.4% respectively in group S. The overall patient survival rate at 1 and 3 yr after surgery were 96.6% and 94.7% respectively, and the death-censored graft survival at 1 and 3 yr after surgery were 93.9% and 88.6% respectively in group C. There was no significant difference in patient/graft survival rate between two groups ( P>0.05). Conclusions:Sugammadex has no obvious effect on the long-term prognosis in the patients undergoing kidney transplantation.

Transient hypoxemia after endotracheal tube extubation in a patient who received reversal of muscle relaxation using sugammadex after general anesthesia: A case report

Post-operative respiratory depression is common in patients recovering from anesthesia and can result in fatal cardiopulmonary collapse, anoxic brain injury, and mortality. We report a case of a 54-year-old morbidly obese female patient who developed transient hypoxemia after general anesthesia. The patient with obstructive sleep apnea (OSA) underwent breast excision surgery. At the end of the surgery, her muscle function was fully restored using sugammadex. However, the patient developed transient hypoxemia in the post-anesthesia care unit. The clinician should keep in mind that OSA patients are likely to develop hypoxemia due to the residual sedative effects and airway obstruction despite the recovery of muscle function after anesthesia.

A randomized trial evaluating the safety profile of sugammadex in high surgical risk ASA physical class 3 or 4 participants / 中华麻醉学杂志

Objective:The aim of this randomized, double-blind trial was to evaluate the safety and tolerability profile, including cardiac safety, of sugammadex-mediated recovery from neuromuscular block in participants undergoing surgery who met the American Society of Anesthesiologists (ASA) Physical Class 3 or 4 criteria.Specifically, this study assessed the impact of sugammadex on cardiac adverse events (AEs) and other prespecified AEs of clinical interest.Methods:Participants meeting ASA Class 3 and 4 criteria were stratified by ASA Class and NMBA (rocuronium or vecuronium) then randomized to one of the following: 1) Moderate neuromuscular block, sugammadex 2 mg/kg; 2) Moderate neuromuscular block, neostigmine and glycopyrrolate (neostigmine/glycopyrrolate); 3) Deep neuromuscular block, sugammadex 4 mg/kg; 4) Deep neuromuscular block, sugammadex 16 mg/kg (rocuronium only). Primary endpoints included incidences of treatment-emergent (TE) sinus bradycardia, TE sinus tachycardia and other TE cardiac arrhythmias.Results:Of 344 participants randomized, 331 received treatment (61% male, BMI 28.5 ± 5.3 kg/m 2, age 69 ± 11 years). Incidence of TE sinus bradycardia was significantly lower in the sugammadex 2 mg/kg group vs neostigmine/glycopyrrolate.The incidence of TE sinus tachycardia was significantly lower in the sugammadex 2 and 4 mg/kg groups vs neostigmine/glycopyrrolate.No significant differences in other TE cardiac arrythmias were seen between sugammadex groups and neostigmine/glycopyrrolate.There were no cases of adjudicated anaphylaxis or hypersensitivity reactions in this study. Conclusions:Compared with neostigmine/glycopyrrolate, incidence of TE sinus bradycardia was significantly lower with sugammadex 2 mg/kg and incidence of TE sinus tachycardia was significantly lower with sugammadex 2 mg/kg and 4 mg/kg.These results support the safety of sugammadex for reversing rocuronium- or vecuronium-induced moderate and deep neuromuscular block in ASA Class 3 or 4 participants.

Effects of sugammadex on quality of recovery after laparoscopic bariatric surgery in severely obese patients / 中华麻醉学杂志

Objective:To evaluate the effects of sugammadex on the quality of recovery after laparoscopic bariatric surgery in severely obese patients.Methods:One hundred and eighty patients, aged 18-65 yr, with body mass index ≥ 40 kg/m 2, undergoing elective laparoscopic bariatric surgery, of American Society of Anesthesiologists physical status Ⅲ, were enrolled and divided into 2 groups ( n=90 each) by the random number table method: sugammadex group (S group) and neostigmine group (N group). Before anesthesia, bilateral T 6 and T 9 paravertebral nerve blocks were performed, and 0.33% ropivacaine 15 ml was injected on each side.When the reappearance of T 2 was monitored under train-of-four (TOF) stimulation after the end of surgery, and sugammadex 2 mg/kg was intravenously injected in S group, and neostigmine 0.04 mg/kg and atropine 0.02 mg/kg were intravenously injected in N group.After the patient was transferred to the general ward, flurbiprofen axetil 50 mg was injected intravenously every 12 h, and oxycodone and flurbiprofen axetil were used for patient-controlled intravenous analgesia at the same time.When the numerical rating scale (NRS) score ≥4 and the analgesic pump was ineffective, bilateral T 7 paravertebral nerve block was performed for rescue analgesia, and 0.33% ropivacaine 15 ml was injected on each side.The postoperative quality of recovery was assessed by the 15-item Quality-of-Recovery scale before operation and at 24 h after operation.The TOF ratio ≥ 0.9 and extubation time were recorded.The SpO 2 at the time of transfer to post-anesthesia care unit (PACU), the lowest SpO 2 and occurrence of SpO 2 < 92% during PACU were recorded.The occurrence of residual muscle relaxation and Ramsay sedation score were recorded at 30 min after entering PACU.The time of PACU stay, time to the first off-bed activity and length of hospital stay were recorded.The cumulative consumption of oxycodone, requirement for rescue analgesia, dizziness, nausea and vomiting, hypoxemia, and pulmonary complications were recorded within 48 h after operation. Results:There were no significant differences in the total score of 15-item Quality-of-Recovery scale before surgery and at 24 h after surgery, cumulative consumption of oxycodone within 48 h after surgery, rate of rescue analgesia, and incidence of dizziness, nausea and vomiting, hypoxemia and pulmonary complications between the two groups ( P>0.05). Compared with N group, the scores of the three recovery indicators (feel energized with enough rest, engagement in work or family activities, and tension and anxiety) were significanatly increased, time to TOF ratio ≥ 0.9, extubation time, time of PACU stay, time to the first off-bed activity and length of hospital stay were shortened, and the incidence of residual muscle relaxation was decreased in S group ( P<0.05). Conclusions:Antagonizing residual muscle relaxation with sugammadex is helpful for the recovery of severely obese patients after laparoscopic bariatric surgery.

Application of sugammadex in tracheal extubation under deep anesthesia in children undergoingadenoidectomy / 中国医师杂志

Objective:To compare the effects of deep anesthesia extubation with sugammadex and neostigmine on perioperative respiratory adverse events (PRAE) and the duration of anesthesia recovery room (PACU) in children undergoing adenoidectomy.Methods:The clinical data of 470 children with adenoidectomy who underwent deep anesthesia extubation from February 2021 to April 2022 in Shenzhen Hospital of Southern Medical University were retrospectively analyzed. According to the use of muscle relaxant, they were divided into sugammadex group (group S) and neostigmine group (group N). Group S was intravenously injected with sugammadex 2 mg/kg after operation, and group N was intravenously injected with neostigemine 0.05 mg/kg combined with atropine 0.02 mg/kg when the train-of-four (TOF) value was >25%. The extubation time and PACU residence time of the two groups were recorded. Changes of heart rate (HR) and mean arterial pressure (MAP) immediately after surgery (T 0), within 1min after extubation (T 1), 5 min after extubation (T 2), and 20 min after extubation (T 3). PRAE was record. Results:There were 138 cases of propensity score matching in group S and group N respectively. The extubation time and PACU residence time in group S were shorter than those in group N (all P<0.05). At T 1, T 2 and T 3, HR and MAP in group S were significantly lower than those in group N (all P<0.05). The incidence of persistent cough and decreased blood oxygen in group S was lower than that in group N (all P<0.05). Conclusions:Compared with neostigmine, postoperative deep anesthesia extubation with sugammadex antagonistic residual muscle relaxant can shorten the duration of extubation and PACU retention after adenoidectomy, accelerate the recovery of children, make the peri-extubation cycle more stable, and reduce the occurrence of PRAE.

Use of sugammadex in acute intermittent porphyria / Uso de sugammadex en la porfiria aguda intermitente

Abstract: Porphyrias are a group of rare diseases, which include acute intermittent porphyria. It is essential for the anesthesiologist to identify acute porphyrias and to recognize a porphyric crises. These can be triggered by several factors, which can be present throughout the perioperative period. A 70-year-old male, ASA III, with a personal history of acute intermittent porphyria and ischemic heart disease, scheduled for laparoscopic sigmoidectomy. Prolonged fasting, dehydration and potentially porphyrinogenic drugs were avoided. General anesthesia was induced with fentanyl, lidocaine, propofol and rocuronium and maintained with desflurane. The decision to reverse the neuromuscular blockade with sugammadex was considered due to the benefits over risks of this drug when compared to neostigmine (associated with atropine) and the description of its use without harm in two cases of variegate porphyria. The following paper emphasize the importance of careful anesthetic management throughout the perioperative period and describe a case of successful reversal of neuromuscular block with sugammadex, highlighting this case as the first case reported of its use in acute intermittent porphyria.

Resumen: Las porfirias son un grupo de enfermedades raras, entre las que se encuentra la porfiria aguda intermitente. Es fundamental que el anestesista identifique las porfirias agudas y reconozca una crisis porfírica. Éstos pueden ser desencadenados por varios factores, que pueden estar presentes durante todo el periodo perioperatorio. Varón de 70 años, ASA III, con antecedentes personales de porfiria aguda intermitente y cardiopatía isquémica, programado para sigmoidectomía laparoscópica. Se evitó el ayuno prolongado, la deshidratación y los fármacos potencialmente porfirinógenos. La anestesia general se indujo con fentanilo, lidocaína, propofol y rocuronio y se mantuvo con desflurano. La decisión de revertir el bloqueo neuromuscular con sugammadex se consideró debido a los beneficios sobre los riesgos de este fármaco en comparación con la neostigmina (asociada con la atropina) y a la descripción de su uso sin daños en dos casos de porfiria variegada. El siguiente artículo enfatiza la importancia de un manejo anestésico cuidadoso durante todo el periodo perioperatorio y describe un caso de reversión exitosa del bloqueo neuromuscular con sugammadex, destacando este caso como el primero reportado de su uso en porfiria aguda intermitente.

Pharmacokinetics of sugammadex in reversal of postoperative residual neuromuscular blockade in obese patients / 中华麻醉学杂志

Objective:To investigate the pharmacokinetics of sugammadex in reversal of postoperative residual neuromuscular blockade in obese patients.Methods:Sixteen patients of both sexes, aged 18-65 yr, of American Society of Anesthesiologists physical statusⅠ or Ⅱ, with body mass index of ≥25 kg/m 2, scheduled for elective laparoscopic bariatric surgery, were selected.The patients were divided into 2 groups ( n=8 each) according to the degree of obesity: group O (25 kg/m 2≤BMI<40 kg/m 2) and group M (BMI≥40 kg/m 2). In group O and group M, vecuronium was administered by closed-loop muscle relaxant injection system to maintain moderate neuromuscular blockade.The administration was stopped at the end of surgery, and sugammadex 2 mg/kg was injected according to corrected body weight (CBW) of patients when the muscle relaxation monitoring T 2 recovered naturally.The recovery time of neuromuscular blockade and the occurrence of residual neuromuscular blockade within 3 h after surgery were recorded.Arterial blood samples were collected at 2, 3, 5, 10, 15, 20, 30, 60, 120, 240, 360 and 480 min after administration of sugammadex.The concentration of sugammadex in plasma was determined by ultra-performance liquid chromatography-mass spectrometry.The pharmacokinetic parameters were calculated with PKSolver software. Results:No residual neuromuscular blockade occurred, and the pharmacokinetics of sugammadex in plasma were consistent with the linear non-compartmental model in the two groups.Compared with group O, apparent clearance was increased ( P<0.05), and no significant change was found in other pharmacokinetic parameters, recovery time of neuromuscular blockade and concentrations of sugammadex in plasma at different time point ( P>0.05) in group M. Conclusion:The pharmacokinetics of sugammadex in reversal of postoperative residual neuromuscular blockade in obese patients are consistent with the linear non-compartmental model, and the clearance of sugammadex is higher in morbidly obese patients.

Value of sugammadex for ultra-fast-track anesthesia in pediatric patients undergoing surgery for correction of congenital heart disease / 中华麻醉学杂志

Objective:To evaluate the value of sugammadex for ultra-fast-track anesthesia in pediatric patients undergoing surgery for correction of congenital heart disease.Methods:Forty pediatric patients of both sexes, aged 1-6 yr, with American Society of Anesthesiologists physical status Ⅱ, scheduled for elective surgery for correction of congenital heart disease, were enrolled in this study and randomly assigned into sugammadex group (group S) and control group (group C) with a random number table.Sugammadex 4.0 mg/kg was injected intravenously to reverse neuromuscular relaxation in group S and the equal volume of normal saline was administrated in group C when the train-of-four (TOF) count was 0 and post-tetanic count was 1 or 2 during recovery from anesthesia.The recovery time of TOF ratio to 25%, 75% and 90%, the extubation time and the success rate of ultra-fast-track anesthesia were recorded.Results:Compared to group C, sugammadex significantly shortened the recovery time of TOF ratio to 25%, 75% and 90% and the extubation time in group S ( P<0.05); Furthermore, the success rate of ultra-fast-track anesthesia reached 100% in group S compared to 0% in group C. Conclusion:Intravenous administration of sugammadex 4.0 mg/kg significantly shortens the recovery time of neuromuscular relaxation and extubation time and enhances the success rate of ultra-fast-track anesthesia in pediatric patients undergoing surgical correction of congenital heart disease.

Sugammadex versus neostigmine for reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation: a large-scale, retrospective study / 中华麻醉学杂志

Objective:To compare the efficacy of sugammadex versus neostigmine on reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation. Methods:The clinical data of patients undergoing kidney transplantation from donation after cardiac death in our hospital from January 2018 to December 2020 were retrospectively analyzed.Patients were divided into sugammadex group (group S) and neostigmine group (group N) according to the use of muscle relaxant antagonists.The onset time of antagonism, time of tracheal extubation, and time of postanesthesia care unit stay were recorded.The creatinine clearance rate was recorded before operation and at 1, 3, 5 and 7 days after operation.The occurrence of postoperative complications was recorded.Results:A total of 603 patients were enrolled in this study, with 278 patients in group S and 325 patients in group N. Compared with group N, the onset time of antagonism, time of extubation , and time of postanesthesia care unit stay were significantly shortened, the incidence of hypoxemia within 24 h after surgery and pulmonary infection occurred within 7 days after surgery was decreased ( P<0.05), and no significant change was found in the creatinine clearance rate at each time point and incidence of postoperative cardiovascular complications and graft complications in group S ( P>0.05). Conclusion:Compared with neostigmine, sugammadex can reverse rocuronium-induced residual neuromuscular blockade more quickly, which is helpful for early recovery with a higher safety when applied in the patients undergoing renal transplantation.

Effects of rocuronium, sugammadex and rocuronium-sugammadex complex on coagulation in rats / Efeitos do rocurônio, sugamadex e complexo rocurônio-sugamadex sobre a coagulação em ratos

Abstract Background and objectives: Sugammadex is an alternative pharmacological drug capable of reversing neuromuscular blockades without the limitations that are presented by anticholinesterase drugs. Coagulation disorders that are related to treatment with sugammadex were reported. The exact mechanism of the effects on coagulation are not fully understood. The objective of this research is to evaluate the effects of rocuronium, sugammadex and the rocuronium-sugammadex complex on coagulation in an experimental model in rats. Methods: This is an experimental randomized animal study. Wistar rats were randomly assigned into the following groups: the Control Group; the Ssal Group - 0.5 mL of intravenous saline; the Sugammadex Group - intravenous sugammadex (100 mg kg−1); and the Rocuronium-Sugammadex Group - intravenous solution with rocuronium (3.75 mg kg−1) and sugammadex (100 mg kg−1). Anesthesia was performed by using isoflurane with controlled ventilation. Coagulation factors were measured 10 minutes after the end of the preoperative preparation and 30 minutes after the administration of the drugs in accordance with the chosen groups. Results: Platelet counts, prothrombin times, and activated partial thromboplastin times were similar between the groups and between the moments within each group. There were reductions in the plasma fibrinogen levels between sample times 1 and 2 in the Rocuronium-Sugammadex group (p = 0.035). Conclusions: The rocuronium-sugammadex complex promoted reductions in plasma fibrinogen counts, although the levels were still within normal limits.

Resumo Introdução e objetivos: O sugamadex é uma substância farmacológica alternativa capaz de reverter o bloqueio neuromuscular sem as limitações apresentadas pelos anticolinesterásicos. Entretanto, há relatos de transtornos de coagulação relacionados ao tratamento com sugamadex sem que mecanismos exatos de seus efeitos sobre a coagulação sejam totalmente compreendidos. O objetivo da presente pesquisa foi avaliar os efeitos do rocurônio, sugamadex e do complexo rocurônio-sugamadex sobre a coagulação em um modelo experimental com ratos. Métodos: Este é um estudo randomizado experimental animal. Ratos Wistar foram aleatoriamente designados aos seguintes grupos: grupo controle; Grupo Ssal - 0,5 mL de solução salina intravenosa; Grupo sugamadex - sugamadex intravenoso (100 mg.kg-1); e Grupo rocurônio-sugamadex - solução intravenosa com rocurônio (3,75 mg.kg-1) e sugamadex (100 mg.kg-1). A anestesia foi realizada utilizando-se isoflurano com ventilação controlada. Os fatores de coagulação foram medidos 10 minutos após o final do preparo pré-operatório e 30 minutos após a administração de drogas de acordo com os grupos escolhidos. Resultados: Contagem de plaquetas, tempo de protrombina e tempo de tromboplastina parcial ativada foram semelhantes entre os grupos e entre os momentos dentro de cada grupo. Houve redução nos níveis de fibrinogênio plasmático entre os tempos 1 e 2 no grupo rocurônio-sugamadex (p = 0,035). Conclusões: O complexo rocurônio-sugamadex promoveu reduções na contagem de fibrinogênio plasmático, apesar de os níveis continuarem dentro dos limites normais.

Influence of methylprednisolone on the reversal time of sugammadex: a randomized clinical trial / Influência da metilprednisolona no tempo de reversão do sugammadex: estudo clínico randomizado

Abstract Background and objectives: Sugammadex is a modified gamma-cyclodextrin that reverses the effects of aminosteroidal neuromuscular blocking agents. Likewise, some steroid molecules, such as toremifene, fusidic acid, and flucloxacillin, can also be encapsulated by sugammadex. Methylprednisolone, which is a synthetic steroid used commonly for airway edema prophylaxis, can also be encapsulated by sugammadex. The objective of this study was to compare the recovery times of sugammadex for reversing rocuronium-induced moderate neuromuscular blockade in those who received intraoperative 1 mg kg-1 methylprednisolone or saline. Method: This single-centered, randomized, controlled, prospective study included 162 adult patients undergoing elective ear-nose-throat procedures (aged from 18 to 65, an ASA physical status I-II, a BMI less than 30 kg m-2, and not taking steroid drug medication) with propofol, remifentanyl, rocuronium and sevoflurane. Neuromuscular monitoring was performed using calibrated acceleromyography. The Control Group (Group C) received 5 mL of saline, while the Methylprednisolone Group (Group M) received 1 mg kg-1 of methylprednisolone in 5 mL of saline just after induction. After the completion of surgery, regarding the TOF count, two reappeared spontaneously and 2 mg kg-1 sugammadex was administered to all patients. Recovery of the TOF ratio to 0.9 was recorded for both groups, and the estimated recovery time to reach a TOF ratio (TOFr) of 0.9 was the primary outcome of the study. Results: Median time to TOFr = 0.9 was for 130.00 s (range of 29-330) for Group C and 181.00 s (100-420) for Group M (p < 0.001). The differences between the two groups were statistically significant. Conclusion: When using 2 mg kg-1 of sugammadex to reverse rocuronium-induced neuromuscular blockade in patients who received 1 mg kg-1 of intraoperative methylprednisolone, demonstrated delayed recovery times.

Resumo Justificativa e objetivos: Sugammadex é uma gama-ciclodextrina modificada que reverte os efeitos de agentes de bloqueio neuromuscular aminoesteroides. Da mesma forma, algumas moléculas esteroides, como toremifene, ácido fusídico e flucloxacilina, podem ser encapsulados pelo sugammadex. A metilprednisolona, esteroide sintético usado geralmente para a profilaxia de edema de vias aéreas, também pode ser encapsulada pelo sugammadex. O objetivo do estudo foi comparar os tempos de recuperação do sugammadex na reversão de bloqueio neuromuscular moderado induzido pelo rocurônio em pacientes em que foi administrado 1 mg.kg-1 de metilprednisolona ou solução salina no período intraoperatório. Método: Este estudo prospectivo, randomizado, controlado, unicêntrico incluiu 162 pacientes adultos (idades de 18-65, ASA I-II, IMC abaixo de 30 kg.m-2, e não usando medicação esteroide) submetidos à anestesia geral para procedimento eletivo de otorrinolaringologia com propofol, remifentanil, rocurônio e sevoflurano. A monitorização neuromuscular foi realizada usando aceleromiógrafo calibrado. O grupo controle (Grupo C) recebeu 5 mL de solução salina, enquanto o grupo metilprednisolona (Grupo M) recebeu 1 mg.kg-1 de metilprednisolona em 5 mL de solução salina logo após a indução. Ao término da cirurgia, em relação à contagem do número de respostas à sequência de quatro estímulos (TOFc), dois pacientes mostraram recuperação espontânea e todos os pacientes receberam 2 mg.kg-1 de sugammadex. A recuperação da razão T4/T1 (TOFr) para 0,9 foi registrada nos dois grupos, e o desfecho primário do estudo foi o tempo estimado de recuperação, momento em que a razão TOFr alcançou o valor de 0,9 (TOFr = 0.9). Resultados: O tempo mediano para TOFr = 0,9 foi 130 s (29-330) para o Grupo C e 181s (100-420) para o Grupo M (p < 0,001). As diferenças entre os dois grupos foi estatisticamente significante. Conclusões: Pacientes que receberam 1 mg.kg-1 de metilprednisolona no intraoperatório apresentaram tempo de recuperação mais prolongado após o uso de 2 mg.kg-1 de sugammadex para reverter o bloqueio neuromuscular induzido pelo rocurônio.

Evaluation of the Toxicity of Sugammadex in Zebrafish Larvae

BACKGROUND: Sugammadex is a new neuromuscular blockade reversal agent. Recently, it has been used in patients under general anesthesia. However, sugammadex could be toxic to fetuses and pediatric patients under 3 years of age. In this study, we demonstrated the safety of sugammadex in fetuses, using zebrafish larvae. Furthermore, its neurotoxicity was evaluated using neuronal cell lines.METHODS: We used SH-SY5Y cells to determine the viability of neuronal cells treated with sugammadex. Zebrafish larvae were used to determine the teratogenic effects of sugammadex.RESULTS: Sugammadex showed no adverse effects on neuronal cells and zebrafish larvae. The survival rates of neuronal cells were not different in all concentrations. In addition, the heart formation of zebrafish embryos, which were exposed to various concentrations of sugammadex, were not different.CONCLUSION: This study demonstrated the feasibility of using sugammadex during pregnancy. However, further clinical studies will be required to extrapolate these results to humans.

Is 1 mg/kg of sugammadex sufficient to reverse moderate neuromuscular block? A randomized clinical trial / ¿Es suficiente 1mg/kg de sugammadex para revertir el bloqueo neuromuscular moderado? Ensayo clínico aleatorizado

Abstract Background: Sugammadex has made it possible to reverse any type of rocuronium-induced block quickly and safely. The most frequent neuromuscular blockade is the moderate one where doses smaller than those recommended by the industry could get a full reversal. Objective: We aimed to evaluate the effectiveness of half the industry recommended dose of sugammadex to reverse a moderate neuromuscular block. Methods: Unicenter phase IV clinical trial that included 34 patients undergoing laparoscopic cholecystectomy. Intravenous general anesthesia was induced, with acceleromyographic monitoring of the neuromuscular block. After the intervention, the block was reversed with all or half the dose of sugammadex recommended for moderate blocks, using a blinded syringe. Results: Patient characteristics of the 2 groups were similar. Mean time to recovery was 3.6± 1.7minutes for the study group and 3.1 ± 1.7minutes for the control group (P=0.42). Reversal of the block was complete with a single dose of sugammadex in all patients. There was an important linear correlation between depth of block and time to recovery. Conclusion: Intraoperative monitoring is essential to allow us to individualize the dose of the neuromuscular blocking agent. To reverse a moderate block under neuromuscular monitoring, a dose of 1 mg/kg is sufficient in most cases and is equally safe and effective.

Resumen Introducción: El sugammadex permite revertir cualquier tipo de bloqueo inducido por rocuronio de forma rápida y segura. El bloqueo neuromuscular más frecuente es el moderado, en el cual dosis inferiores a las recomendadas por la industria podrían revertirlo completamente. Objetivo: Evaluar la efectividad de la mitad de la dosis de sugammadex recomendada por la industria para revertir un bloqueo neuromuscular moderado. Métodos: Ensayo clínico de fase IV en un unico centro que incluyó a 34 pacientes intervenidos de colecistectomía laparoscópica. Se realizó anestesia general intravenosa con monitoreo aceleromiográfico del bloqueo neuromuscular. Tras la intervención, el bloqueo se revirtió con la totalidad o con la mitad de la dosis de sugammadex recomendada para bloqueos moderados, utilizando una jeringa ciega. Resultados: Las características de los pacientes de los dos grupos fueron similares. La media de tiempo de recuperación fue de 3,6 ± 1,7 minutos para el grupo de estudio y de 3,1 ± 1,7 minutos para el grupo de control (p = 0,42). La reversión del bloqueo se completó con una dosis única de sugammadex en todos los pacientes. Hubo una correlación lineal importante entre la profundidad del bloqueo y el tiempo de recuperación. Conclusión: El monitoreo transquirúrgico es esencial para individualizar la dosis del agente de bloqueo neuromuscular. Para revertir un bloqueo moderado bajo monitoreo neuromuscular, una dosis de 1mg/kg es suficiente e igualmente segura y efectiva.

Anaphylactic shock after sugammadex administration, induced by formation of a sugammadex-rocuronium complex: a case report / 대한마취과학회지

BACKGROUND: Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers and widely used worldwide on account of its rapid and effective reversal from neuromuscular blockade, despite its advantages, multiple cases of sugammadex-induced anaphylactic shock have been reported. CASE: A 42-year-old man developed anaphylactic shock in the postanesthesia care unit. Initially, sugammadex was suspected as the causative agent, but an intradermal skin test revealed negative results. A further skin test was performed with sugammadex-rocuronium complex that yielded positive results. CONCLUSIONS: Anesthesiologists and healthcare providers should be aware of the possibility of anaphylaxis from the sugammadex-rocuronium complex, as well as from sugammadex or rocuronium alone.

Effects of dexamethasone and hydrocortisone on rocuronium-induced neuromuscular blockade and reversal by sugammadex in phrenic nerve-hemidiaphragm rat model / 대한마취과학회지

BACKGROUND: The facilitator effects of steroids on neuromuscular transmission may cause resistance to neuromuscular blocking agents. Additionally, steroids may hinder sugammadex reversal of neuromuscular blockade, but these findings remain controversial. Therefore, we explored the effect of dexamethasone and hydrocortisone on rocuronium-induced neuromuscular blockade and their inhibitory effect on sugammadex. METHODS: We explored the effects of steroids, dexamethasone and hydrocortisone, in vitro using a phrenic nerve-hemidiaphragm rat model. In the first phase, an effective dose of rocuronium was calculated, and in the second phase, following sugammadex administration, the recovery of the train-of-four (TOF) ratio and T1 was evaluated for 30 minutes, and the recovery index was calculated in dexamethasone 0, 0.5, 5, and 50 μg/ml, or hydrocortisone 0, 1, 10, or 100 μg/ml. RESULTS: No significant effect of steroids on the effective dose of rocuronium was observed. The TOF ratios at 30 minutes after sugammadex administration were decreased significantly only at high experimental concentrations of steroids: dexamethasone 50 μg/ml and hydrocortisone 100 μg/ml (P < 0.001 and P = 0.042, respectively). There were no statistical significances in other concentrations. No differences were observed in T1. Recovery index was significantly different only in 100 μg/ml of hydrocortisone (P = 0.03). CONCLUSIONS: Acute exposure to steroids did not resist the neuromuscular blockade caused by rocuronium. And inhibition of sugammadex reversal on rocuronium-induced neuromuscular blockade is unlikely at typical clinical doses of dexamethasone and also hydrocortisone. Conclusively, we can expect proper effects of rocuronium and sugammadex when dexamethasone or hydrocortisone is used during general anesthesia.

Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: a prospective randomized study

BACKGROUND: Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. Herein, we compared the efficacy of sugammadex and pyridostigmine in the reversal of rocuronium-induced light block or minimal block in pediatric patients scheduled for elective entropion surgery. METHODS: A prospective randomized study was conducted in 60 pediatric patients aged 2–11 years who were scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using the train-of-four (TOF) technique. Patients were randomly assigned to 2 groups receiving either sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg and glycopyrrolate 0.01 mg/kg at the end of surgery. Primary outcomes were time from administration of reversal agents to TOF ratio 0.9 and TOF ratio 1.0. Time from the administration of reversal agents to extubation and postoperative adverse events were also recorded. RESULTS: There were no significant differences in the demographic variables. Time from the administration of reversal agents to TOF ratio 0.9 and TOF ratio 1.0 were significantly shorter in the sugammadex group than in the pyridostigmine plus glycopyrrolate group: 1.30 ± 0.84 vs. 3.53 ± 2.73 min (P < 0.001) and 2.75 ± 1.00 vs. 5.73 ± 2.83 min (P < 0.001), respectively. Extubation time was shorter in the sugammadex group. Adverse events, such as skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction), were not statistically different between the two groups. CONCLUSIONS: Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery than did pyridostigmine plus glycopyrrolate.

A suspected sugammadex-induced anaphylactic shock: A case report

BACKGROUND: The reversal of a neuromuscular blockade has typically been achieved with a cholinesterase inhibitor and the concomitant use of an anticholinergic agent, and this remains a popular method. Since the introduction of sugammadex in the market, its use has been increasing because of the rapid recovery from a neuromuscular blockade achieved by rocuronium. The occurrence of anaphylaxis or an anaphylactic reaction resulting from sugammadex is rare and has been reported sparsely. Thus, one may not recognize the possibility of sugammadex-induced hypersensitivity when sudden life-threatening hypotension occurs, especially without skin manifestations during the emergence of anesthesia. This may delay treatment and increase morbidity. CASE: We report a case of a sugammadex-related hypersensitivity reaction which manifested as pure cardiovascular collapse during the emergence of anesthesia. CONCLUSIONS: We emphasize that vigilance should be paid for at least five minutes following sugammadex administration in daily clinical practice.

Sugammadex associated profound bradycardia and sustained hypotension in patient with the slow recovery of neuromuscular blockade: A case report

BACKGROUND: New complications associated with sugammadex have been increased since its widespread use. We report a case of an 80-year-old male who experienced profound bradycardia and sustained hypotension after administration of sugammadex. CASE: Following administration of 200 mg sugammadex after laparoscopic cholecystectomy, sudden bradycardia (29 beats/min) developed for 10 seconds and his train-of-four (TOF) ratio remained at 0.2 for 5 min. An additional 200 mg sugammadex was administered and profound bradycardia (21–30 beats/min) and hypotension (60/40 mmHg) developed. Atropine at 0.5 mg was administered, but the effect lasted only 30 s. Profound bradycardia occurred four more times at 30 s intervals, and ephedrine and phenylephrine were injected intermittently to increase the patient's heart rate and blood pressure. The TOF ratio became 0.9 about 10 min after administration of additional sugammadex. CONCLUSIONS: Awareness must be heightened regarding the possibility of sugammadexinduced bradycardia and hypotension, and more attention should be paid to patients with slow recovery times following muscle relaxation, despite the use of sugammadex.