SUGAMMADEX versus neostigmine after ROCURONIUM continuous infusion in patients undergoing liver transplantation

Abstract

Background: Rapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation. This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation. Methods: The TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution's internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine). Results: Data from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001). Conclusion: Sugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice. Trial registration: ClinicalTrials.gov NCT02697929 (registered 3rd March 2016).

Diaphragm ultrasonography as a monitor in assessing antagonistic effect of sugammadex on rocuronium in patients with Child-Pugh grades A and B

“…The delay noted could be linked to the pharmacokinetics of intravenous propofol in patients with liver disease. Additionally, aligning our results with those of Deana et al ( 25 ), it is essential to highlight that recovery time with sugammadex in hepatopathic patients may significantly surpass that in other surgical settings, a factor that should be taken into consideration in clinical practice. A population pharmacokinetic-pharmacodynamic interaction model of sugammadex has been employed to simulate the reversal of rocuronium-induced neuromuscular blockade in patients with hepatic impairment.…”

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

“…The body of evidence enrolling adults included 191 studies (133 randomized controlled trials, 4,59–90,92,95,98–104,110–114,118–127,132–141,145–148,155–157,163,173–181,206–254 11 nonrandomized trials, 17,128,142,182–184,191,255–258 45 cohort studies, 15,42,86,91,93,94,96,97,105–109,116,117,129–131,143,144,186–190,227,259–277 and 2 before–after designs 115,168 ) evaluating efficacy and safety of antagonist drugs for neuromuscular blockade. The randomized controlled trials enrolling only adults had a median of 88 participants (range, 16 to 350).…”

Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery

“…Despite remaining controversies, sugammadex may be of particular advantage in certain settings, including patients with higher cardiopulmonary vulnerability, procedures with higher peri-operative risk, interventions requiring deep NMB, patients with neuromuscular disease, and in emergency situations demanding urgent neuromuscular recovery 29 . Here neostigmine is ineffective in reversing deep NMB given its competitive mechanism of action, whereas sugammadex facilitates predictable and rapid extubation, without residual curarisation 30,31 . Benefits of sugammadex may extend to cardioprotective effects, prevention of early pulmonary complications and possibly time savings in workflow because of elimination of residual NMB 32 .…”

“…29 Here neostigmine is ineffective in reversing deep NMB given its competitive mechanism of action, whereas sugammadex facilitates predictable and rapid extubation, without residual curarisation. 30,31 Benefits of sugammadex may extend to cardioprotective effects, prevention of early pulmonary complications and possibly time savings in workflow because of elimination of residual NMB. 32 More evidence is needed to establish the comparative effectiveness of sugammadex and neostigmine, particularly as higher acquisition costs may have previously restricted sugammadex use.…”