Efficacy of Sugammadex for the Reversal of Moderate and Deep Rocuronium-Induced Neuromuscular Block in Patients Pretreated With Intravenous Magnesium

Abstract

Clearly, this study confirms that neostigmine alone does not enhance respiratory safety and may actually be harmful when given in high doses (>60 μg/kg) and when given in the absence of neuromuscular transmission monitoring. Administering neostigmine to a patient who has spontaneously recovered from ND-NMBA may cause a depolarizing neuromuscular block with no TOF fade. In addition, incomplete reversal of deep neuromuscular blockade exposes the patient to a prolonged period of respiratory muscle weakness. It is unsafe to administer neostigmine to a patient who has spontaneously recovered from neuromuscular blockade because neostigmine dose-dependently affects respiratory muscle function and increases upper airway collapsibility. Indeed, both residual neuromuscular blockade and neostigmineinduced neuromuscular blockade cause upper airway dilator muscle dysfunction resulting in upper airway obstruction, which can produce negative-pressure pulmonary edema.The current investigators, who are affiliated with an excellent, highly respected institution, commented that despite the widespread availability of both qualitative and quantitative neuromuscular transmission monitoring in their hospital 1 of 5 patients who received an ND-NMBA did not have a single TOF count recorded! This overconfidence and overreliance on clinical intuition are grossly inappropriate in an era when we are admonished to practice evidence-based medicine. Unwarranted use of neostigmine and neostigmine administration without the guidance of appropriate monitoring tools can result in preventable respiratory morbidity in our patients. Surely, our patients deserve better "care." Comment by Kathryn E. McGoldrick, MD, FCAI(Hon) Disclosure: The author declares no conflict of interest.

Effect of magnesium sulphate on sugammadex reversal time for neuromuscular blockade: a randomised controlled study

“…The median (range) Sx À TOF 0.9 of 115 (68À315) s, found in this study, is similar to that of Czarnetzki et al (1.55 (0.70À3.13) min) [25], indicating that pre-treatment with magnesium sulphate does not change the timing of the reversal of moderate neuromuscular blockade induced by a standard intubation dose of rocuronium. It is worth mentioning that a dose of 40 mg.kg À1 magnesium sulphate was used in our study, whereas the dose used by Czarnetzki et al was 60 mg.kg À1 .…”

“…Several studies have used magnesium sulphate in doses ranging from 30 to 60 mg.kg À1 [8,12,[21][22][23][24][25]. The dose of 40 mg.kg À1 magnesium sulphate was chosen for this study because it has been associated with reduced anaesthetic requirements and improved analgesia without significantly affecting the haemodynamic variables [21].…”

Dexamethasone Does Not Inhibit Sugammadex Reversal After Rocuronium-Induced Neuromuscular Block

“…10,11 To detect a 50% increase in the time required to reverse moderate blockade, assuming a similar SD, with an α error of 0.05 (β, 0.80; 1-sided P value), we estimated that 7 patients per group were required. To allow for dropouts, we analyzed 15 patients per group.…”

Magnesium‐induced recurarisation after reversal of rocuronium‐induced neuromuscular block with sugammadex. Findings vs. speculation

“…4 Magnesium sulphate does not decrease the efficacy of sugammadex for the reversal of moderate and deep rocuroniuminduced NMB. 5 In microcalorimetry experiments, no affinity or displacement interactions were found between magnesium and sugammadex, which may justify a recurrence of NMB by unbound rocuronium. 6 Therefore, when the rocuronium-induced NMB is reversed with a proper dose of sugammadex, subsequent administration of magnesium may result in the recurrence of NMB, which is equivalent to the effect of magnesium alone.…”

“…Sugammadex acts by encapsulating and irreversibly inactivating rocuronium. 4,5 Given in a dose equal to or greater than that which is recommended, sugammadex is able to liberate from rocuronium a proper amount of post-junctional nicotinic receptors, which is necessary for the complete reversal and prevention of NMB recurrence. 4 Magnesium sulphate does not decrease the efficacy of sugammadex for the reversal of moderate and deep rocuroniuminduced NMB.…”