New way of dosing sugammadex for termination of vecuronium induced neuromuscular block
Abstract
Background and Goal of Study: Sugammadex is a selective binding agent that binds
aminosteroid muscle relaxants. Each molecule of sugammadex binds one molecule of muscle
relaxant. To produce the same depth of the neuromuscular block (NMB) much less molecules of
vecuronium are needed than molecules of rocuronium. In theory less sugammadex would be
needed to neutralise the neuromuscular block if vecuronium was used to produce the neuromuscular block. Our aim was to compare reversal of vecuronium induced muscle relaxation between a new way of dosing sugammadex, which takes into account TOF value at the end of the surgery and the amount of vecuronium given during the surgery with neostigmine atropine combination. We also wanted to know how much this dosage regime can save compared to standard per kg dosage.
Materials and Methods: 20 adult patients requiring a general anesthesia for surgery were analysed. The first group of 11 patients (SUG) received sugammadex at the end of the surgery according to the table one for NMB reversal. The second group of 9 patients (NEO) received neostigmine and atropine. Train of four (TOF) value was recorded at the end of the surgery and then continuously until the TOF value reached more than 0.9 and the patient was extubated. The time required for the TOF value reaching 0.9 was compared between the groups. For economical evaluation we compared the amount of sugammadex used in the SUG group to standard sugammadex per kg dosage.
Results and Discussion: Mean time to recovery to a TOF ratio of 0.9 with sugammadex was 5.12
min versus 12.6 min with neostigmine atropine (P < 0.05). No sign of postoperative residual curarisation was observed in the SUG group. For patients in our study 530 mg of sugammadex were used to neutralise the NMB. If standard per kg sugammadex dosing had been used we would have used 2420 mg for the NMB reversal.
Conclusion(s): New dosing for sugammadex was successful in neutralising the NMB regardless
of the TOF value at the end of the surgery. The economic impact of the proposed dosing is significant as an average cost for the vecuronium NMB reversal is reduced from around 80 € to 20 € per patient.
Downloads
References
Bom A, Hope F, Rutherford S, Thomson K. Preclinical pharmacology of sugammadex. J Crit Care. 2009;24(1):29–35.
Akha AS, Rosa J, Jahr JS, Li A, Kiai K. Sugammadex: cyclodextrins, development of selective binding agents, pharmacology, clinical development, and future directions. Anesthesiol Clin. 2010;28(4):691–708.
Adam JM, Bennett DJ, Bom A, Clark JK, Feilden H, Hutchinson EJ, Palin R, Prosser A, Rees DC, Rosair GM, Stevenson D, Tarver GJ, Zhang MQ. Cyclodextrin-derived host molecules as reversal agents for the neuromuscular blocker rocuronium bromide: synthesis and structure-activity relationships. J Med Chem. 2002 Apr 25;45(9):1806-16.
Fink H, Hollmann MW. Myths and facts in neuromuscular pharmacology. New developments in reversing neuromuscular blockade. Minerva Anestesiol. 2012 Apr;78(4):473-82.
Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core Evid. 2013;8:57-67.
Geldner G, Niskanen M, Laurila P, Mizikov V, Hübler M, Beck G, Rietbergen H, Nicolayenko E
A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia. 2012 Sep;67(9):991-8.
Blobner M, Eriksson LI, Scholz J, Motsch J, Della Rocca G, Prins ME. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol. 2010 Oct;27(10):874-81.
Lemmens HJ, El-Orbany MI, Berry J, Morte JB Jr, Martin G. Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine. BMC Anesthesiol. 2010 Sep 1;10:15.
Merck & Co Inc. BRIDION: EPAR – Product Information Annex I: Summary
of product characteristics. European Medicines Agency; London, UK. 2013 www.ema.europa.eu/docs/en_GB/document_library/EPAR_-Product_Information/human/000885/WC500052310 accessed september 2013
Schaller SJ, Fink H, Ulm K, Blobner M. Sugammadex and neostigmine dose-finding study for reversal of shallow residual neuromuscular block. Anesthesiology. 2010 Nov;113(5):1054-60.
Pongrácz A, Szatmári S, Nemes R, Fülesdi B, Tassonyi E. Reversal of neuromuscular blockade with sugammadex at the reappearance of four twitches to train-of-four stimulation. Anesthesiology. 2013 Jul;119(1):36-42.
Abrishami A, Ho J, Wong J, Yin L, Chung F. Cochrane corner: sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Anesth Analg. 2010 Apr 1;110(4):1239.
Peček B, Polh D, Priman T Succesful use of theoretically calculated dosage of sugammadex for routine reversal of vecuronium-induced muscle relaxation ZV 2013; 82: 200–4
Eleveld DJ, Kuizenga K, Proost JH, Wierda JM. A temporary decrease in twitch response during reversal of rocuronium-induced muscle relaxation with a small dose of sugammadex.
Anesth Analg. 2007 Mar;104(3):582-4.
Le Corre F, Nejmeddine S, Fatahine C, Tayar C, Marty J, Plaud B. Recurarization after sugammadex reversal in an obese patient. Can J Anaesth. 2011 Oct;58(10):944-7.
Sakai Y, Tsutsumi YM, Wakamatsu N, Soga T, Tanaka K, Oshita S. A case where rocuronium was unable to achieve neuromuscular block immediately after sugammadex administration. J Med Invest. 2011 Feb;58(1-2):163-5.
Godai K, Hasegawa-Moriyama M, Kuniyoshi T, Kakoi T, Ikoma K, Isowaki S, Matsunaga A, Kanmura Y. Three cases of suspected sugammadex-induced hypersensitivity reactions. Br J Anaesth. 2012 Aug;109(2):216-8.
Menéndez-Ozcoidi L, Ortiz-Gómez JR, Olaguibel-Ribero JM, Salvador-Bravo MJ. Allergy to low dose sugammadex. Anaesthesia. 2011 Mar;66(3):217-9.
Kalkan Y, Bostan H, Tumkaya L, Tomak Y, Bostan M, Yilmaz A, Turut H, Temiz A, Yalçin A, Turan A. The effect of rocuronium, sugammadex, and their combination on cardiac muscle and diaphragmatic skeletal muscle cells. J Anesth. 2012 Dec;26(6):870-7.
Bostan H, Kalkan Y, Tomak Y, Tumkaya L, Altuner D, Yılmaz A, Erdivanli B, Bedir R. Reversal of rocuronium-induced neuromuscular block with sugammadex and resulting histopathological effects in rat kidneys. Ren Fail. 2011;33(10):1019-24.
Palanca JM, Aguirre-Rueda D, Granell MV, Aldasoro M, Garcia A, Iradi A, Obrador E, Mauricio MD, Vila J, Gil-Bisquert A, Valles SL. Sugammadex, a neuromuscular blockade reversal agent, causes neuronal apoptosis in primary cultures. Int J Med Sci. 2013 Aug 3;10(10):1278-85.
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.
