Conditions to optimise the reversal action of neostigmine upon a vecuronium‐induced neuromuscular block

Baurain, Michel; Dernovoi, Boris; D’Hollander, Alain; Hennart, Danielle; Cantraine, Francis

doi:10.1111/j.1399-6576.1996.tb04490.x

Cited by 31 publications

(28 citation statements)

References 16 publications

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“…To optimize the reversal achieved with acetylcholinesterase inhibitors, some spontaneous recovery of neuromuscular function is required before administration [8], and our study confirms this. This means that clinicians may be unable to maintain profound block to the end of surgery without the penalty of the time required for spontaneous recovery prior to acetylcholinesterase inhibitor administration, as well as the fear of residual block in the recovery room in a patient who has not adequately recovered from the block.…”

Section: Discussionsupporting

confidence: 78%

Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine

et al. 2010

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BackgroundAcetylcholinesterase inhibitors cannot rapidly reverse profound neuromuscular block. Sugammadex, a selective relaxant binding agent, reverses the effects of rocuronium and vecuronium by encapsulation. This study assessed the efficacy of sugammadex compared with neostigmine in reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia.MethodsPatients aged ≥18 years, American Society of Anesthesiologists class 1-4, scheduled to undergo surgery under general anesthesia were enrolled in this phase III, multicenter, randomized, safety-assessor blinded study. Sevoflurane anesthetized patients received vecuronium 0.1 mg/kg for intubation, with maintenance doses of 0.015 mg/kg as required. Patients were randomized to receive sugammadex 4 mg/kg or neostigmine 70 μg/kg with glycopyrrolate 14 μg/kg at 1-2 post-tetanic counts. The primary efficacy variable was time from start of study drug administration to recovery of the train-of-four ratio to 0.9. Safety assessments included physical examination, laboratory data, vital signs, and adverse events.ResultsEighty three patients were included in the intent-to-treat population (sugammadex, n = 47; neostigmine, n = 36). Geometric mean time to recovery of the train-of-four ratio to 0.9 was 15-fold faster with sugammadex (4.5 minutes) compared with neostigmine (66.2 minutes; p < 0.0001) (median, 3.3 minutes with sugammadex versus 49.9 minutes with neostigmine). No serious drug-related adverse events occurred in either group.ConclusionsRecovery from profound vecuronium-induced block is significantly faster with sugammadex, compared with neostigmine. Neostigmine did not rapidly reverse profound neuromuscular block (Trial registration number: NCT00473694).

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Section: Discussionsupporting

confidence: 78%

Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine

et al. 2010

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“…Measurements of T1 ⁄ control and train-of-four ratio (TOFR) were taken 3 min, 6 min, 9 min, 12 min and 15 min after the administration of neostigmine, and the values for the two groups were compared. It has been shown that 15 min after the administration of neostigmine at a T1 ⁄ control value of 0.25, TOFR often does not return to 0.9 [14][15][16][17].…”

Section: Methodsmentioning

confidence: 99%

“…Thus, the amount of acetylcholine released from nerve endings may decrease in diabetic patients. Anticholinesterases increase the release of acetylcholine, resulting in an increased postjunctional endplate potential [17]. As the number of axons and therefore nerve endings decrease in diabetics, the release of acetylcholine provoked by anticholinesterase should also be decreased.…”

Section: R E T R a C T E Dmentioning

confidence: 99%

“…For this reason, recovery from neuromuscular blockade was studied for 15 min after neostigmine administration in this study. It has been recommended that an anticholinesterase should only be given when T1 ⁄ control has returned to 0.25 [17,[25][26][27]. Furthermore, it has been shown that when an anticholinesterase is administered at a T1 ⁄ control of 0.25, TOFR may only barely return to a value of 0.9 [14][15][16][17].…”

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confidence: 99%

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Retracted: Reversal of vecuronium with neostigmine in patients with diabetes mellitus

Saitoh

Hattori²,

Sanbe³

et al. 2004

Anaesthesia

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SummaryReversal of vecuronium-induced neuromuscular blockade with neostigmine was compared in two groups of 16 subjects: patients with Type 2 diabetes mellitus and normal controls. When the first twitch of the train-of-four had returned to 25% of the control value, neostigmine 40 lg.kg )1 and atropine 20 lg.kg )1 were given to reverse the neuromuscular blockade. The train-of-four ratio was lower at 3 min, 6 min, 9 min, 12 min and 15 min after reversal in the diabetic group than in the control group but the differences did not reach statistical significance. Fifteen minutes after reversal, the number of patients in whom recovery from neuromuscular blockade was judged insufficient to guarantee good respiratory function (train-of-four ratio < 0.74) did not differ between the groups. However, 15 min after reversal, the number of patients with a train-of-four ratio < 0.9 was significantly higher in the Diabetic Group than in the Control Group (15 vs. 10, p = 0.033).

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“…To obtain optimal reversal as measured by a TOF ratio of 0.9 during a vecuronium-induced neuromuscular block, a dose of neostigmine 40 µg/kg was required at 25-50% recovery of twitch height. 26 Administration of increasing and multiple doses of acetylcholinesterase inhibitors does not confer linear pharmacologic effects on reversal. Neostigmine, pyridostigmine, and edrophonium were equally effective at reversal of blockade as measured by TOF stimulation.…”

Section: Onset Of Acetylcholinesterase Inhibitorsmentioning

confidence: 99%

Sugammadex: A Novel Agent for the Reversal of Neuromuscular Blockade

2007

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To achieve spontaneous ventilation after completion of surgery, the nondepolarizing effects on skeletal muscle relaxation are often reversed by administration of an acetylcholinesterase inhibitor. However, these agents increase acetylcholine at both the neuromuscular junction and the muscarinic receptors. Therefore, coadministration of an anticholinergic agent is required to prevent parasympathetic adverse effects. In addition, a relative pharmacologic ceiling effect is seen with inhibition of acetylcholinesterase, necessitating some recovery of neuromuscular function before an acetylcholinesterase inhibitor is administered. Sugammadex is a new modified gamma-cyclodextrin compound under clinical investigation in the United States. It does not interact with cholinergic mechanisms to elicit reversal. Instead, it is a selective relaxant binding agent and acts by forming a 1:1 complex with steroidal nondepolarizing neuromuscular blockers in the plasma, lowering the effective concentration available at the receptor. Due to its selectivity, sugammadex does not inhibit the effects of nondepolarizing agents of the benzylisoquinolinium class. In contrast to acetylcholinesterase inhibition, sugammadex is effective even when administered during profound blockade, and it does not require coadministration of an anticholinergic agent. It provides a novel mechanism of action for reversal of the neuromuscular block induced by nondepolarizing aminosteroidal agents.

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Conditions to optimise the reversal action of neostigmine upon a vecuronium‐induced neuromuscular block

Abstract: To optimise the reversal action of neostigmine in order to obtain the highest neuromuscular transmission recovery (0.9 TOF ratio and RF100Hz) during a vecuronium-induced neuromuscular block, the 40 micrograms/kg dose has to be given at 25 to 50% recovery of TH.

Cited by 31 publications

References 16 publications

Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine

Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine

Retracted: Reversal of vecuronium with neostigmine in patients with diabetes mellitus

Sugammadex: A Novel Agent for the Reversal of Neuromuscular Blockade

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