Abstract:We report the use of rocuronium to re-establish neuromuscular block after reversal with sugammadex. The aim of this study was to investigate the relationship between the dose of rocuronium needed to re-establish neuromuscular block and the time interval between sugammadex administration and re-administration of rocuronium. Patients who required re-establishment of neuromuscular block within 12 h after the reversal of rocuronium-induced neuromuscular block with sugammadex were included. After inducing general a… Show more
“…The steroidal NMBA dosage needed to re-establish neuromuscular blockade following administration of sugammadex largely depends on the time elapsed since sugammadex was administered [76]. Local prescribing information should be consulted for recommended waiting times before readministration of rocuronium or vecuronium [6,25].…”
Section: Place Of Sugammadex In Neuromuscularmentioning
Sugammadex (Bridion(®)) is a modified γ-cyclodextrin that reverses the effect of the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. Intravenous sugammadex resulted in rapid, predictable recovery from moderate and deep neuromuscular blockade in patients undergoing surgery who received rocuronium or vecuronium. Recovery from moderate neuromuscular blockade was significantly faster with sugammadex 2 mg/kg than with neostigmine, and recovery from deep neuromuscular blockade was significantly faster with sugammadex 4 mg/kg than with neostigmine or spontaneous recovery. In addition, recovery from neuromuscular blockade was significantly faster when sugammadex 16 mg/kg was administered 3 min after rocuronium than when patients spontaneously recovered from succinylcholine. Sugammadex also demonstrated efficacy in various special patient populations, including patients with pulmonary disease, cardiac disease, hepatic dysfunction or myasthenia gravis and morbidly obese patients. Intravenous sugammadex was generally well tolerated. In conclusion, sugammadex is an important option for the rapid reversal of rocuronium- or vecuronium-induced neuromuscular blockade.
“…The steroidal NMBA dosage needed to re-establish neuromuscular blockade following administration of sugammadex largely depends on the time elapsed since sugammadex was administered [76]. Local prescribing information should be consulted for recommended waiting times before readministration of rocuronium or vecuronium [6,25].…”
Section: Place Of Sugammadex In Neuromuscularmentioning
Sugammadex (Bridion(®)) is a modified γ-cyclodextrin that reverses the effect of the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. Intravenous sugammadex resulted in rapid, predictable recovery from moderate and deep neuromuscular blockade in patients undergoing surgery who received rocuronium or vecuronium. Recovery from moderate neuromuscular blockade was significantly faster with sugammadex 2 mg/kg than with neostigmine, and recovery from deep neuromuscular blockade was significantly faster with sugammadex 4 mg/kg than with neostigmine or spontaneous recovery. In addition, recovery from neuromuscular blockade was significantly faster when sugammadex 16 mg/kg was administered 3 min after rocuronium than when patients spontaneously recovered from succinylcholine. Sugammadex also demonstrated efficacy in various special patient populations, including patients with pulmonary disease, cardiac disease, hepatic dysfunction or myasthenia gravis and morbidly obese patients. Intravenous sugammadex was generally well tolerated. In conclusion, sugammadex is an important option for the rapid reversal of rocuronium- or vecuronium-induced neuromuscular blockade.
“…In a clinical study, the recommended dose (0.6 mg/kg) of rocuronium re-established neuromuscular blockade within 3 min when it was administered >3 h after sugammadex reversal (Fig. 1 ) [ 7 ]. Since re-onset time of rocuronium after sugammadex administration is unpredictable, 1.2 mg/kg rocuronium or more should be used when reliable and rapid induction of neuromuscular blockade is needed.…”
Section: Reviewmentioning
confidence: 99%
“…Since re-onset time of rocuronium after sugammadex administration is unpredictable, 1.2 mg/kg rocuronium or more should be used when reliable and rapid induction of neuromuscular blockade is needed. In clinical settings where rapid induction of neuromuscular blockade is not absolutely necessary and if more than 3 h have passed after the initial sugammadex administration, utilizing rocuronium at a dose of 0.6 mg/kg becomes an additional option to re-establish neuromuscular blockade [ 7 ]. Fig.…”
Section: Reviewmentioning
confidence: 99%
“…Residual neuromuscular paralysis is a remaining complication even with the use of sugammadex [ 3 ]. Appropriate dosing [4 mg/kg at post tetanic count (PTC) of 1–2; 2 mg/kg at reappearance of two twitches to train of four (TOF) stimulation; 1 mg/kg [ 4 ] at reappearance of four twitches to TOF stimulation; 0.49 mg/kg [ 5 ] at TOF ratio (TOFR) of ≥0.2; and 0.22 mg/kg [ 6 ] at TOFR of ≥0.5] is necessary; excessive doses of sugammadex may prevent residual neuromuscular paralysis, but may also result in excessive costs and pose an entirely new set of challenges when re-establishment of neuromuscular blockade is needed [ 7 ]. Moreover, aspects of the clinical use of sugammadex are controversial or may require special attention in some clinical situations.…”
Sugammadex, a modified gamma-cyclodextrin, has changed clinical practice of neuromuscular reversal dramatically. With the introduction of this selective relaxant binding agent, rapid and reliable neuromuscular reversal from any depth of block became possible. Sugammadex can reverse neuromuscular blockade without the muscarinic side effects typically associated with the administration of acetylcholinesterase inhibitors. However, what remained unchanged is the incidence of residual neuromuscular blockade. It is known that sugammadex cannot always prevent its occurrence, if appropriate dosing is not chosen based on the level of neuromuscular paralysis prior to administration determined by objective neuromuscular monitoring. Alternatively, excessive doses of sugammadex administered in an attempt to ensure full and sustained reversal may affect the effectiveness of rocuronium in case of immediate reoperation or reintubation. In such emergent scenarios that require onset of rapid and reliable neuromuscular blockade, the summary of product characteristics (package insert) recommends using benzylisoquinolinium neuromuscular blocking agents or a depolarizing agent. However, if rapid intubation is required, succinylcholine has a significant number of side effects, and benzylisoquinolinium agents may not have the rapid onset required. Therefore, prior administration of sugammadex introduces a new set of potential problems that require new solutions. This novel reversal agent thus presents new challenges and anesthesiologists must familiarize themselves with specific issues with its use (e.g., bleeding risk, hypermagnesemia, hypothermia). This review will address sugammadex administration in such special clinical situations.
“…We recently reported a case series on re-establishment of neuromuscular block with rocuronium after sugammadex reversal [1]. We found no reports on the usage of succinylcholine to re-establish neuromuscular block, therefore we present our case.…”
relaxants may cause resistance to the effects of succinylcholine [2]. The mean onset time of succinylcholine 1 mg/ kg is reported to be 56 s [3]. We successfully re-established neuromuscular block with a similar onset time, even after the initial use of rocuronium and sugammadex. Since little is known about the effects of residual nondepolarizing muscle relaxants on succinylcholine, it is important to administer an adequate dose of sugammadex according to objective neuromuscular monitoring to prevent residual neuromuscular block.
Keywords Succinylcholine · SugammadexTo the Editor:We recently reported a case series on re-establishment of neuromuscular block with rocuronium after sugammadex reversal [1]. We found no reports on the usage of succinylcholine to re-establish neuromuscular block, therefore we present our case. A 69-year-old female (weight 57.5 kg) was scheduled for right breast total resection. Anesthesia was induced and maintained with propofol, remifentanil, and fentanyl. A total of 50 mg rocuronium was given during the surgery. Sugammadex 120 mg (2 mg/kg) was administered before extubation when spontaneous breathing was observed. After the initial surgery, the patient underwent hemostatic surgery for continuous postoperative bleeding. Anesthesia was induced with propofol and remifentanil, and ulnar nerve stimulation was performed using TOF Watch ® (Organon, Dublin, Ireland). A 50-mA train-of-four (TOF) stimulation was delivered every 15 s. Succinylcholine 60 mg (1 mg/kg) was administered 3 h after sugammadex administration. TOF responses disappeared at 85 s and tracheal intubation was successfully performed. It is known that sugammadex does not affect the onset of succinylcholine. However, residual nondepolarizing muscle This comment refers to the article available at
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