Sugammadex

Abstract

Sugammadex reverses neuromuscular blockade by the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. In 2015, it was approved in the United States by the Food and Drug Administration for adult use. However, there are ongoing clinical trials investigating its use in the pediatric population. Before approval in adult use in the United States, several adverse effects were noted to occur in patients receiving sugammadex in clinical trials including prolonged QT interval, bradycardia, hypersensitivity reactions, and prolongation of coagulation parameters. Additional investigations further elucidated the risks of these adverse events. Sugammadex is approved for use in children older than 2 years in other countries in Europe and Asia. Investigations suggest that the efficacy, safety, and pharmacokinetic profile is similar in children when compared with adults. Published pediatric data favor the use of sugammadex in children older than 2 years, but there are some data in young children younger than 2 years. Case reports discuss the use of sugammadex in pediatric patients with neuromuscular diseases. Although sugammadex is typically used in the operating room for reversing neuromuscular blockade for surgical procedures, there is a small but important role for sugammadex use in the emergency department. In cases where rapid neurological examination is required after neuromuscular blockage with rocuronium or vecuronium, sugammadex can assist in facilitating a timely comprehensive neurological examination where pharmacologic or surgical management may depend on examination findings such as in the case of cerebral vascular accident, status epilepticus, or traumatic brain injury. Some clinicians have advocated for the use of sugammadex in the cannot intubate, cannot ventilate scenario. However, caution should be exercised in this situation as reversal of paralysis can take up to 22 minutes to occur.

Emergency department usage of sugammadex in a large regional health system

“…Little is known about the current usage of sugammadex in the ED. Two narrative reviews have explored the potential usage of sugammadex in the ED, highlighting the lack of published research on the subject, cautioning against its use in cannot intubate/cannot ventilate (CI/CV) scenarios, and proposing its usage for neurological examination after NMB 8,9 . The objective of this study was to describe the ED use of sugammadex in a large regional health system.…”

Management of the Difficult Airway

“…However, literature suggests that the possibility of delays in preparing and administering this medication, as well as case reports of prolonged time to reversal, limits this as a planned approach to difficult airway management. 77,78 Modified or controlled RSI differs from true RSI in that positive pressure breaths are delivered after the administration of induction and neuromuscular blocking medications. Given the risk of rapid desaturation in children, this approach is commonly used in pediatrics and has been shown to be both safe and effective.…”

“…When using full reversal dosing (16 mg/kg), return of motor activity (and respiratory effort) occurs in approximately 90 seconds in most patients. However, literature suggests that the possibility of delays in preparing and administering this medication, as well as case reports of prolonged time to reversal, limits this as a planned approach to difficult airway management 77,78 …”

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review

“…When the medicine is given, it is able to displace the steroidal neuromuscular blockade agents from sugammadex and re-paralysis may occur. 115 The recurrence of paralysis may also be caused by drugs that can potentiate neuromuscular blockade. 115 With the expanding use and further research of sugammadex in the reversal of deep NMB in clinical anesthesia, the possible mechanism will hopefully be elucidated to the maximum extent in the future.…”