BACKGROUND Rocuronium,a nondepolarizing muscle relaxant,is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery.Sugammadex,the selective re...BACKGROUND Rocuronium,a nondepolarizing muscle relaxant,is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery.Sugammadex,the selective reversal agent of rocuronium,fully reverses the neuromuscular blockade(NMB)at the end of surgery.Most reports show that sugammadex rapidly achieves a ratio of train-offour(TOF),a quantitative method of neuromuscular monitoring,of 0.9 which ensures adequate recovery for safe extubation.However,very rare patients with neuromuscular diseases may respond poorly to sugammadex.CASE SUMMARY A 69-year-old female presented with abdominal fullness and nausea,and was diagnosed with gastroparesis.She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium(0.7 mg/kg).At the end of surgery,sugammadex 3.6 mg/kg was administered when TOF showed 2 counts.Afterward,the TOF ratio recovered to 0.65 in 30 min.She was awake but could not fully open her eyelids.The tidal volume during spontaneous breathing was low.After additional doses of sugammadex(up to 7.3 mg/kg)in the following 3 h,the TOF ratio was 0.9,and the endotracheal tube was smoothly removed.After excluding possible mechanisms underlying the prolonged recovery course,we speculated our patient may have had an undiagnosed neuromuscular disease,hinted by her involuntary movement of the tongue and mouth.Furthermore,her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.CONCLUSION In our case,both prolonged rocuronium-induced NMB and poor response to sugammadex were noted.To optimize the dose of rocuronium,perioperative TOF combined with other neuromuscular monitoring is suggested.展开更多
The Myasthenia gravis (MG) is an autoimmune disease that affects neuromuscular transmission and leads to a large variation of sensibility on depolarizing and nondepolarizing neuromuscular blocking drugs. Sugammadex is...The Myasthenia gravis (MG) is an autoimmune disease that affects neuromuscular transmission and leads to a large variation of sensibility on depolarizing and nondepolarizing neuromuscular blocking drugs. Sugammadex is a new drug with the capability to successfully revert the nondepolarizing neuromuscular blocking. This case report will show a patient with MG that was scheduled for thymectomy, with the objective to use sugammadex to reverse a rocuronium induced deep level of neuromuscular block and observing the safe use of sugammadex without complications.展开更多
Anticholinesterase does not allow adequate reversal of the deep neuromuscular blockade (NMB) achieved using high doses of relaxants. A 71-year-old female patient (weight 70 kg, height 169 cm) was scheduled for a trans...Anticholinesterase does not allow adequate reversal of the deep neuromuscular blockade (NMB) achieved using high doses of relaxants. A 71-year-old female patient (weight 70 kg, height 169 cm) was scheduled for a transurethral resection of a bladder tumor under general anesthesia. We administered rocuronium 30 mg (0.43 mg/kg) for tracheal intubation due to an estimated short surgical time. During the operation, an additional rocuronium 10 mg was injected. The surgical procedure ended abruptly 10 minutes after receiving the last dose of rocuronium. At the end of surgery, the patient received pyridostigmine as a reversal. However, residual NMB persisted, and neuromuscular monitoring did not show the expected degree of recovery. Sugammadex 2 mg/kg was used, and the patient experienced complete reversal from NMB in just 2 min.展开更多
Sugammadex has revolutionized anaesthetic management of reversal of neuromuscular block(NMB) by way of its unique mechanism of action encapsulating the amino steroid neuromuscular blocking drugs rocuroniumand vecuroni...Sugammadex has revolutionized anaesthetic management of reversal of neuromuscular block(NMB) by way of its unique mechanism of action encapsulating the amino steroid neuromuscular blocking drugs rocuroniumand vecuronium. The cholinesterase inhibitors have significant pharmacological and clinical limitations whereas sugammadex allows predictable, safe and rapid reversal from any depth of blockade. The financial cost of sugammadex is significant. Many hospitals in the United Kingdom use clinical guidelines to direct best use of sugammadex in their institutions. Auditing the use of sugammadex provides useful information on which patients are benefiting from sugammadex. The clinical benefits of sugammadex are well understood. No patient should now be subjected to the danger of post-operative residual curarization. Versatility in the ability to reverse NMB has brought opportunities to the anaesthetist in the management of rapid sequence induction using high dose rocuronium with the knowledge that safe reversal of NMB is now possible in the unlikely event of a "can't intubate can't ventilate" situation. Do we still need suxamethonium to be available? The nature of surgery continues to evolve with ever-increasing enthusiasm for minimally invasive laparoscopic techniques. There is evidence to support using a deeper level of NMB to improve the working space and operating conditions in laparoscopic surgery. It is now possible to maintain a deep level of NMB right up until the end of surgery with no concerns about the ability to effect safe reversal of NMB. Vigilance about the possibility of allergic sensitivity to sugammadex needs to be maintained. The increased usage of rocuronium has the potential for rocuroniuminduced anaphylaxis. Conversely, there is a potential role for sugammadex in the treatment of rocuronium anaphylaxis. Clinicians who have used sugammadex are struck with the quality of recovery seen in their patients. It is important that the economic implications of the use of sugammadex are fully understood. This article considers the current role of sugammadex in clinical practice outside of routine reversal of NMB and discusses how the addition of sugammadex to the anaesthetic armamentarium brings safety benefits for patients.展开更多
With the introduction of the rocuronium and vecuronium binding agent sugammadex into clinical practice in the United States, its use for reversal of neuromuscular blockade will likely start in some institutions as a ...With the introduction of the rocuronium and vecuronium binding agent sugammadex into clinical practice in the United States, its use for reversal of neuromuscular blockade will likely start in some institutions as a “rescue” after failed reversal with neostigmine. However, sugammadex after neostigmine has not been extensively studied. Therefore, there is a question as to its effectiveness when used in this way especially in the airway compromised patients that the anesthesia provider will commonly face in this situation. Furthermore, there is a possibility of hemodynamic compromise. These two case reports demonstrate the safe and effective use of sugammadex after failed reversal with neostigmine.展开更多
In rare cases, rocuronium has been associated with dose-related tachycardia, probably by a cardiac muscarinic M2 receptor blockade mechanism. We report the case of a 30-year-old female who underwent excision of a bran...In rare cases, rocuronium has been associated with dose-related tachycardia, probably by a cardiac muscarinic M2 receptor blockade mechanism. We report the case of a 30-year-old female who underwent excision of a branchial cyst under general anesthesia. This patient presented an episode of sinus tachycardia (130 bpm) shortly after anesthesia induction with propofol, sufentanyl, and rocuronium. Tachycardia could not be explained by any cause other than the use of rocuronium, which was reverted with sugammadex. Two minutes after sugammadex administration, heart rate normalized, corroborating our hypothesis that rocuronium induced the sinus tachycardia observed in our patient. The patient recovered well from the anesthetic-surgical procedure and showed no further cardiovascular, ventilatory, or neurological changes, being transferred to the post-anesthesia care unit, and finally discharged to the ward.展开更多
AIM: To evaluate the effects of two different doses of sugammadex after maintenance anesthesia with sevofluorane and remifentanil and deep rocuroniuminduced neuromuscular blockade(NMB).METHODS: Patients between 20 and...AIM: To evaluate the effects of two different doses of sugammadex after maintenance anesthesia with sevofluorane and remifentanil and deep rocuroniuminduced neuromuscular blockade(NMB).METHODS: Patients between 20 and 65 years of age, with American Society of Anesthesiologists physical status classification Ⅰ-Ⅱ, undergoing gynecological surgery were included in a prospective, comparative and randomized study. NMB was induced with an injection of 0.6 mg/kg of rocuronium followed by continuous infusion of 0.3-0.6 mg/kg per hour to maintain a deep block. Anesthesia was maintained with sevofluorane and remifentanil. Finally, when surgery was finished, a bolus of 2 mg/kg(group A) or 4 mg/kg(group B) of sugammadex was applied when the NMB first response in the train-of-four was reached. The primary clinical endpoint was time to recovery to a train-of-four ratio of 0.9. Other variables recorded were the time until recovery of train-of-four ratio of 0.7, 0.8, hemodynamic variables(arterial blood pressure and heart rate at baseline, starting sugammadex, and minutes 2, 5 and 10) and adverse events were presented after one hour in the post-anesthesia care unit.RESULTS: Thirty-two patients were included in the study: 16 patients in group A and 16 patients in group B. Only 14 patients each group were recorded because arterial pressure values were lost in two patients from each group in minute 10. The two groups were comparable. Median recovery time from starting of sugammadex administration to a train-of-four ratio of 0.9 in group A and B was 129 and 110 s, respectively.The estimated difference in recovery time between groups was 24 s(95%CI: 0 to 45 s, Hodges-Lehmann estimator), entirely within the predefined equivalence interval. Times to recovery to train-of-four ratios of 0.8(group A: 101 s; group B: 82.5 s) and 0.7(group A: 90 s; group B: 65 s) from start of sugammadex administration were not equivalent between groups. There was not a significant variation in the arterial pressure and heart rate values between the two groups and none of the patients showed any clinical evidence of residual or recurrent NMB. CONCLUSION: A dose of 2 mg/kg of sugammadex after continuous rocuronium infusion is enough to reverse the NMB when first response in the Train-OfFour is reached.展开更多
Complete and reliable neuromuscular reversal is important to successful anaesthetic recovery in the morbidly obese patient undergoing laparoscopic surgery.Our goal was to determine whether sugammadex,a selective rever...Complete and reliable neuromuscular reversal is important to successful anaesthetic recovery in the morbidly obese patient undergoing laparoscopic surgery.Our goal was to determine whether sugammadex,a selective reversal agent is associated with better respiratory recovery than neostigmine following the reversal of anaesthesia-associated neuromuscular blockade by rocuronium in the morbidly obese.Peak Expiratory Flow Rate a surrogate marker for respiratory function,was the primary outcome measured and secondary outcome measures included post-operative nausea and vomiting,pain and head lifting.We found that patients reversed with sugammadex had a significantly higher post-operative PEFR as compared to those reversed with neostigmine and glycopyrrolate group.展开更多
Background:Postoperative pulmonary complications often lead to increased mortality and financial burden.Residual paralysis plays a critical role in postoperative pulmonary complications.This meta-analysis was performe...Background:Postoperative pulmonary complications often lead to increased mortality and financial burden.Residual paralysis plays a critical role in postoperative pulmonary complications.This meta-analysis was performed to determine whether sugammadex overmatches neostigmine in reducing postoperative pulmonary complications.Methods:PubMed,Embase,Web of Science,Medline through Ovid,Cochrane Library,Wanfang,China National Knowledge Infrastructure,and Chinese BioMedical Literature Databases were searched from their inception to 24 June,2021.Random effects models were used for all analyses.Cochrane risk of bias tool was used to assess the quality of RCTs,while Newcastle Ottawa Quality Assessment Scale was used to assess for the quality of cohort studies.Results:Seventeen studies were included in the meta-analysis.Pooled data from cohort studies showed reversing neuromuscular blocking with sugammadex had less risk of compound postoperative pulmonary complications(relative risk[RR]:0.73;95%confidence interval[CI]:0.60-0.89;P=0.002;I^(2)=81%),pneumonia(RR:0.64;95%CI:0.48-0.86;I^(2)=42%)and respiratory failure(RR:0.48;95%CI:0.41-0.56;I^(2)=0%).However,pooled data from RCTs did not show any difference between the two groups in pneumonia(RR:0.58;95%CI:0.24-1.40;I^(2)=0%)and no respiratory failure was reported in the included RCTs.The difference was not found between sugammadex and neostigmine about atelectasis in pooled data from either RCTs(RR:0.85;95%CI:0.69-1.05;I^(2)=0%)or cohort studies(RR:1.01;95%CI:0.87-1.18;I^(2)=0%).Conclusion:The evidence of superiority of sugammadex was limited by the confounding factors in cohort studies and small scale of RCTs.Whether sugammadex precedes neostigmine in preventing pulmonary complications after surgery is still unknown.Well-designed RCTs with large scale are needed.Registration:PROSPERO(https://www.crd.york.ac.uk/PROSPERO/);CRD 42020191575.展开更多
基金Far-Eastern Memorial Hospital,No.FEMH-2022-C-057.
文摘BACKGROUND Rocuronium,a nondepolarizing muscle relaxant,is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery.Sugammadex,the selective reversal agent of rocuronium,fully reverses the neuromuscular blockade(NMB)at the end of surgery.Most reports show that sugammadex rapidly achieves a ratio of train-offour(TOF),a quantitative method of neuromuscular monitoring,of 0.9 which ensures adequate recovery for safe extubation.However,very rare patients with neuromuscular diseases may respond poorly to sugammadex.CASE SUMMARY A 69-year-old female presented with abdominal fullness and nausea,and was diagnosed with gastroparesis.She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium(0.7 mg/kg).At the end of surgery,sugammadex 3.6 mg/kg was administered when TOF showed 2 counts.Afterward,the TOF ratio recovered to 0.65 in 30 min.She was awake but could not fully open her eyelids.The tidal volume during spontaneous breathing was low.After additional doses of sugammadex(up to 7.3 mg/kg)in the following 3 h,the TOF ratio was 0.9,and the endotracheal tube was smoothly removed.After excluding possible mechanisms underlying the prolonged recovery course,we speculated our patient may have had an undiagnosed neuromuscular disease,hinted by her involuntary movement of the tongue and mouth.Furthermore,her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.CONCLUSION In our case,both prolonged rocuronium-induced NMB and poor response to sugammadex were noted.To optimize the dose of rocuronium,perioperative TOF combined with other neuromuscular monitoring is suggested.
文摘The Myasthenia gravis (MG) is an autoimmune disease that affects neuromuscular transmission and leads to a large variation of sensibility on depolarizing and nondepolarizing neuromuscular blocking drugs. Sugammadex is a new drug with the capability to successfully revert the nondepolarizing neuromuscular blocking. This case report will show a patient with MG that was scheduled for thymectomy, with the objective to use sugammadex to reverse a rocuronium induced deep level of neuromuscular block and observing the safe use of sugammadex without complications.
文摘Anticholinesterase does not allow adequate reversal of the deep neuromuscular blockade (NMB) achieved using high doses of relaxants. A 71-year-old female patient (weight 70 kg, height 169 cm) was scheduled for a transurethral resection of a bladder tumor under general anesthesia. We administered rocuronium 30 mg (0.43 mg/kg) for tracheal intubation due to an estimated short surgical time. During the operation, an additional rocuronium 10 mg was injected. The surgical procedure ended abruptly 10 minutes after receiving the last dose of rocuronium. At the end of surgery, the patient received pyridostigmine as a reversal. However, residual NMB persisted, and neuromuscular monitoring did not show the expected degree of recovery. Sugammadex 2 mg/kg was used, and the patient experienced complete reversal from NMB in just 2 min.
文摘Sugammadex has revolutionized anaesthetic management of reversal of neuromuscular block(NMB) by way of its unique mechanism of action encapsulating the amino steroid neuromuscular blocking drugs rocuroniumand vecuronium. The cholinesterase inhibitors have significant pharmacological and clinical limitations whereas sugammadex allows predictable, safe and rapid reversal from any depth of blockade. The financial cost of sugammadex is significant. Many hospitals in the United Kingdom use clinical guidelines to direct best use of sugammadex in their institutions. Auditing the use of sugammadex provides useful information on which patients are benefiting from sugammadex. The clinical benefits of sugammadex are well understood. No patient should now be subjected to the danger of post-operative residual curarization. Versatility in the ability to reverse NMB has brought opportunities to the anaesthetist in the management of rapid sequence induction using high dose rocuronium with the knowledge that safe reversal of NMB is now possible in the unlikely event of a "can't intubate can't ventilate" situation. Do we still need suxamethonium to be available? The nature of surgery continues to evolve with ever-increasing enthusiasm for minimally invasive laparoscopic techniques. There is evidence to support using a deeper level of NMB to improve the working space and operating conditions in laparoscopic surgery. It is now possible to maintain a deep level of NMB right up until the end of surgery with no concerns about the ability to effect safe reversal of NMB. Vigilance about the possibility of allergic sensitivity to sugammadex needs to be maintained. The increased usage of rocuronium has the potential for rocuroniuminduced anaphylaxis. Conversely, there is a potential role for sugammadex in the treatment of rocuronium anaphylaxis. Clinicians who have used sugammadex are struck with the quality of recovery seen in their patients. It is important that the economic implications of the use of sugammadex are fully understood. This article considers the current role of sugammadex in clinical practice outside of routine reversal of NMB and discusses how the addition of sugammadex to the anaesthetic armamentarium brings safety benefits for patients.
文摘With the introduction of the rocuronium and vecuronium binding agent sugammadex into clinical practice in the United States, its use for reversal of neuromuscular blockade will likely start in some institutions as a “rescue” after failed reversal with neostigmine. However, sugammadex after neostigmine has not been extensively studied. Therefore, there is a question as to its effectiveness when used in this way especially in the airway compromised patients that the anesthesia provider will commonly face in this situation. Furthermore, there is a possibility of hemodynamic compromise. These two case reports demonstrate the safe and effective use of sugammadex after failed reversal with neostigmine.
文摘In rare cases, rocuronium has been associated with dose-related tachycardia, probably by a cardiac muscarinic M2 receptor blockade mechanism. We report the case of a 30-year-old female who underwent excision of a branchial cyst under general anesthesia. This patient presented an episode of sinus tachycardia (130 bpm) shortly after anesthesia induction with propofol, sufentanyl, and rocuronium. Tachycardia could not be explained by any cause other than the use of rocuronium, which was reverted with sugammadex. Two minutes after sugammadex administration, heart rate normalized, corroborating our hypothesis that rocuronium induced the sinus tachycardia observed in our patient. The patient recovered well from the anesthetic-surgical procedure and showed no further cardiovascular, ventilatory, or neurological changes, being transferred to the post-anesthesia care unit, and finally discharged to the ward.
文摘AIM: To evaluate the effects of two different doses of sugammadex after maintenance anesthesia with sevofluorane and remifentanil and deep rocuroniuminduced neuromuscular blockade(NMB).METHODS: Patients between 20 and 65 years of age, with American Society of Anesthesiologists physical status classification Ⅰ-Ⅱ, undergoing gynecological surgery were included in a prospective, comparative and randomized study. NMB was induced with an injection of 0.6 mg/kg of rocuronium followed by continuous infusion of 0.3-0.6 mg/kg per hour to maintain a deep block. Anesthesia was maintained with sevofluorane and remifentanil. Finally, when surgery was finished, a bolus of 2 mg/kg(group A) or 4 mg/kg(group B) of sugammadex was applied when the NMB first response in the train-of-four was reached. The primary clinical endpoint was time to recovery to a train-of-four ratio of 0.9. Other variables recorded were the time until recovery of train-of-four ratio of 0.7, 0.8, hemodynamic variables(arterial blood pressure and heart rate at baseline, starting sugammadex, and minutes 2, 5 and 10) and adverse events were presented after one hour in the post-anesthesia care unit.RESULTS: Thirty-two patients were included in the study: 16 patients in group A and 16 patients in group B. Only 14 patients each group were recorded because arterial pressure values were lost in two patients from each group in minute 10. The two groups were comparable. Median recovery time from starting of sugammadex administration to a train-of-four ratio of 0.9 in group A and B was 129 and 110 s, respectively.The estimated difference in recovery time between groups was 24 s(95%CI: 0 to 45 s, Hodges-Lehmann estimator), entirely within the predefined equivalence interval. Times to recovery to train-of-four ratios of 0.8(group A: 101 s; group B: 82.5 s) and 0.7(group A: 90 s; group B: 65 s) from start of sugammadex administration were not equivalent between groups. There was not a significant variation in the arterial pressure and heart rate values between the two groups and none of the patients showed any clinical evidence of residual or recurrent NMB. CONCLUSION: A dose of 2 mg/kg of sugammadex after continuous rocuronium infusion is enough to reverse the NMB when first response in the Train-OfFour is reached.
文摘Complete and reliable neuromuscular reversal is important to successful anaesthetic recovery in the morbidly obese patient undergoing laparoscopic surgery.Our goal was to determine whether sugammadex,a selective reversal agent is associated with better respiratory recovery than neostigmine following the reversal of anaesthesia-associated neuromuscular blockade by rocuronium in the morbidly obese.Peak Expiratory Flow Rate a surrogate marker for respiratory function,was the primary outcome measured and secondary outcome measures included post-operative nausea and vomiting,pain and head lifting.We found that patients reversed with sugammadex had a significantly higher post-operative PEFR as compared to those reversed with neostigmine and glycopyrrolate group.
基金Sichuan Science and Technology Program(Nos.2020YFS0188 and 2020YJ0283)
文摘Background:Postoperative pulmonary complications often lead to increased mortality and financial burden.Residual paralysis plays a critical role in postoperative pulmonary complications.This meta-analysis was performed to determine whether sugammadex overmatches neostigmine in reducing postoperative pulmonary complications.Methods:PubMed,Embase,Web of Science,Medline through Ovid,Cochrane Library,Wanfang,China National Knowledge Infrastructure,and Chinese BioMedical Literature Databases were searched from their inception to 24 June,2021.Random effects models were used for all analyses.Cochrane risk of bias tool was used to assess the quality of RCTs,while Newcastle Ottawa Quality Assessment Scale was used to assess for the quality of cohort studies.Results:Seventeen studies were included in the meta-analysis.Pooled data from cohort studies showed reversing neuromuscular blocking with sugammadex had less risk of compound postoperative pulmonary complications(relative risk[RR]:0.73;95%confidence interval[CI]:0.60-0.89;P=0.002;I^(2)=81%),pneumonia(RR:0.64;95%CI:0.48-0.86;I^(2)=42%)and respiratory failure(RR:0.48;95%CI:0.41-0.56;I^(2)=0%).However,pooled data from RCTs did not show any difference between the two groups in pneumonia(RR:0.58;95%CI:0.24-1.40;I^(2)=0%)and no respiratory failure was reported in the included RCTs.The difference was not found between sugammadex and neostigmine about atelectasis in pooled data from either RCTs(RR:0.85;95%CI:0.69-1.05;I^(2)=0%)or cohort studies(RR:1.01;95%CI:0.87-1.18;I^(2)=0%).Conclusion:The evidence of superiority of sugammadex was limited by the confounding factors in cohort studies and small scale of RCTs.Whether sugammadex precedes neostigmine in preventing pulmonary complications after surgery is still unknown.Well-designed RCTs with large scale are needed.Registration:PROSPERO(https://www.crd.york.ac.uk/PROSPERO/);CRD 42020191575.
