Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patients undergoing surgery – a series of 117 cases

Abstract

PurposeMyasthenia gravis (MG) is an autoimmune disease interfering with neuromuscular transmission. Patients are at risk of postoperative residual curarization (PORC) if nondepolarizing muscle relaxants are used. Clinically inapparent insufficient muscle strength may result in hypoventilation and postoperative bronchopneumonia. We describe a cohort of 117 cases in which sugammadex was used in MG patients undergoing surgery with muscle relaxation with rocuronium.Methods and patientsWe anesthetized 117 patients with MG using rocuronium and sugammadex as neuromuscular blockade reversal agent. One hundred five patients underwent surgical thymectomy and 12 underwent cholecystectomy (five laparotomic and seven laparoscopic). We measured time from sugammadex administration to recovery and to extubation, using the TOF-Watch® (series of four consecutive electrical impulses [the train-of-four] >0.9). We tracked peripheral capillary oxygen saturation (SpO2) <95%, elevation of partial pressure of carbon dioxide (pCO2) >10% above baseline, number of reintubations within the first 48 hours, and number of pneumonias within 120 hours, postoperatively. Results were processed as average, minimum, and maximum values.ResultsThe period needed to reach train-of-four of 0.9 following sugammadex administration was on average 117 seconds (minimum of 105 seconds/maximum of 127 seconds) and differed within deviation <10%. The time to extubation following sugammadex administration was on average 276 seconds (minimum of 251 seconds/maximum of 305 seconds) and differed minimally among patients as well. We observed no SpO2 <95%, no pCO2 elevation >10% above a baseline, no emergent reintubation within the first 48 hours, and no pneumonia diagnosed on clinical basis within 120 hours, postoperatively in all 117 patients.ConclusionIn this cohort of MG patients undergoing surgery using rocuronium and sugammadex, we did not observe any signs of postoperative residual curarization and respiratory depression. The neuromuscular blockade recovery was reliable, predictable, and rapid.

Sugammadex: A Review of Neuromuscular Blockade Reversal

“…In one trial, NEO was administered at the reappearance of T 2 [49] f Bolus dose of VEC 0.1 mg/kg followed by maintenance with VEC 0.015 ng/kg as needed g Bolus dose of SUC 1.0 mg/kg bronchitis, chronic obstructive pulmonary disease) undergoing noncardiac surgery [56], patients with cardiac disease (i.e. ischaemic heart disease, chronic heart failure, arrhythmia) undergoing noncardiac surgery [57], patients with hepatic dysfunction (liver damage class B or C) undergoing hepatic surgery [58], morbidly obese patients (body mass index C40 mg/m 2 ; mean total bodyweight &130 kg) undergoing laparoscopic removal of gastric banding [59], and patients with myasthenia gravis undergoing surgical thymectomy or cholecystectomy [60]. Comparative trials were of randomized, safety assessorblind, multicentre design [56,57], randomized, singlecentre design [59] or nonrandomized, single-centre design [58].…”

“…Comparative trials were of randomized, safety assessorblind, multicentre design [56,57], randomized, singlecentre design [59] or nonrandomized, single-centre design [58]. Data in patients with myasthenia gravis were obtained from a case series [60]. The trials included adults who were ASA physical status I-III [58,59], II-III [56] or II-IV [57,60] and scheduled to receive general anaesthesia induced with propofol [57][58][59][60] and maintained with propofol [57,58], desflurane [59] or isoflurane [60], with opioids also permitted, or according to local practice [56].…”

“…Data in patients with myasthenia gravis were obtained from a case series [60]. The trials included adults who were ASA physical status I-III [58,59], II-III [56] or II-IV [57,60] and scheduled to receive general anaesthesia induced with propofol [57][58][59][60] and maintained with propofol [57,58], desflurane [59] or isoflurane [60], with opioids also permitted, or according to local practice [56]. Neuromuscular blockade was induced by rocuronium [56][57][58][59][60].…”

“…The trials included adults who were ASA physical status I-III [58,59], II-III [56] or II-IV [57,60] and scheduled to receive general anaesthesia induced with propofol [57][58][59][60] and maintained with propofol [57,58], desflurane [59] or isoflurane [60], with opioids also permitted, or according to local practice [56]. Neuromuscular blockade was induced by rocuronium [56][57][58][59][60]. Patients received sugammadex 2 or 4 mg/kg [56][57][58]60] or placebo [57] (see Table 3 for further details), with obese patients randomized to receive sugammadex 4 mg/kg (total bodyweight) or neostigmine 70 lg/kg (lean bodyweight) [59].…”

Successful Use of Rocuronium and Sugammadex in a Patient with Myasthenia Gravis Undergoing Cervical Anterior Fusion: A Case Report

“…For recovery from anesthesia in patients with MG, some author recommended using sugammadex as a safe and reliable option for reversal of neuromuscular blocker in patients with MG [3,11,16], whether or not to reverse residual neuromuscular blockade at the end of surgery is controversial [8].The administration of sugammadex for reversal of neuromuscular blocker is useful to eliminate the risk of residual neuromuscular blockade in patients with MG [17]. Most case reports showed that neuromuscular blocker reversal using sugammadex seemed to be a safe, rapid, efficient, and reliable option without signs of postoperative residual neuromuscular block in patients with MG [17][18][19][20][21].…”