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EDITORIAL
Year : 2009  |  Volume : 53  |  Issue : 4  |  Page : 399-400 Table of Contents     

Reversal by Sugammadex


Editor, IJA, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Pramila Bajaj
Editor, IJA
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640200

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How to cite this article:
Bajaj P. Reversal by Sugammadex. Indian J Anaesth 2009;53:399-400

How to cite this URL:
Bajaj P. Reversal by Sugammadex. Indian J Anaesth [serial online] 2009 [cited 2019 Dec 9];53:399-400. Available from: http://www.ijaweb.org/text.asp?2009/53/4/399/60309

Reversal agents are often used to ensure the reversal of nondepolarizing neuromuscular blockade (NMB). The most widely used are the acetylcholinesterase inhibitors, neostigmine, and edrophonium. However, these agents are only partially effective against profound NMB, especially in the presence of volatile anaesthetics such as sevoflurane, and may also be associated with adverse effects, such as cholinergic cardiovascular and gastrointestinal events. [1]

Sugammadex is a modified gamma cyclodextrm specifically designed for the reversal of NMB induced bythe sternidal neuromuscular blocking agent (NMBA) rocuronium. Sugammadex acts by encapsulating unbound rocuronium molecules and reducingtheir concentration at the neuromuscular junction [2] Studies in surgical patients have shown that sugammadex rapidly and safely reverses rocuronium and vecuronium-induced NMB. [3] Unllce acetylcholinesterase inhibitors, sugammadex is also effective in the reversal of profound NMB. [4] In previous studies with sugammadex, patients received NMBAs as single orrepeat bolus doses. No safety orclinical effectdata have been published thus far on sugammadex after continuous infusion ofrocuronium, although ro curonium infusion provides stable drug concentrations with a constant degree of paralysis, and its use has become increasingly common [5] . However, continuous infusion ofrocuronium has been demonstrated to significantly increase the recov­ery time after NMB compared with single bolus doses. [6] In this study by Jellish and coworkers, the median recov­ery index (time required for the first twitch [T 1 ] of the train-of-four [TOF] to recover from 25% to 75% of baseline) aftera single b olus dose ofrocuronium was 17 min compared with a median recovery index of 24 mm after continuous rocuronium infusion. Furthermore, some patients experienced spontaneous recovery times to a TOF ratio of 75% of over 70 min after infusion dosing ofrocuronium, suggesting that patients undergoing pro­longed infusion are likely to require the administration of areversal agent. [6]

In clinical practice, ro curonium is administered in combination with volatile agents such as sevoflurane, or with intravenously administered agents such as propofol. Theneuromuscular-blocking effect of several NMBAs, in­cluding rocuronium, are potentiated under sevoflurane anaesthesia in contrastto propofol-based anesthesia; there­fore, the properties of NMBAs under those two anaesthetic regimens have been extensively investigated and compared. [7],[8] These studies have shown a delayed recovery induced by accetylcholinesterase inhibitors during sevoflurane anaesthesia as compared to propofol anaesthesia [8] The effects of sugammadex under maintenance anaesthesia with sevoflurane and propofol have recently been investigated, but only after administration at reap­pearance of the second twitch of the TOF after a single bolus dose ofrecuronium (representingatime ofpartial spontaneous recovery ofneuromuscularfunction). [9] This situation does differfiom continuous infusion, as illustrated by the potentiating effect of volatile anaesthetics, which is clinically most significant during infusion. [7],[10] Also, the rapid reversal of sugammadex has been explained by redistribution of rocuronium; during continuous infusion, the ability to redistribute the drug is decreased as a result of distribution compartment saturation [11] Thus, the question still remains to be answered whether volatile anaesthetics do influence the clinical effect and safety of sugammadex when used for reversal from neummuscular blokade induced by continuous infusion of rocuronium.

A single dose of sugammadex 4 mg.kg -1 after continuous infusion of rocuronium is equally effective for NMB reversal and well tolerated during maintenance anaesthesia with sevolfurane or propofol. One adverse event (pmcedural hypotension) is considered to be probably related to sugammadex.



 
   References Top

1.Booij L, de Boer HD, Van Egmond J: Reversal agents for nondepolarizingneuro scalar blockade: Reasons for and develop­ment of a new concept. SeminAn periop Med Pain 2002; 21:92-8.  Back to cited text no. 1      
2.Born A, BradleyM, Cam eronK, Clark iK, et al. Anovel concept of reversing neuromuscular block: Chemical encapsulation of rocuronium brom ide by a cyclodextrin-based synthetic host. Angew Chem Int EdEngl 2002; 41:266-70.  Back to cited text no. 2      
3.SuyK, Morias K, Canmu G, Hans P, van Duijnhoven WG Heeringa IM Demeyer I. Effective reversal of moderate rocuronium- or vecuronium-induced neuromuscular blockwith sugammadex, aselective relaxant binding agent. Anesthesiology2007; 106:283-8.  Back to cited text no. 3      
4.Sparr HJ, VermeyenKM, BeaufortAIM, RietbergenH, Proust JR. Saldien V, Vehk-Salchner C, Wierda JM. Earlyreversal of pro found rocuronium-inducedneuromuscular blockade by sugamm adex in a randomized m ulticenter study: Efficacy, safety, andpharrnacokinetics. Anesthesiology 2007; 106:935-43.  Back to cited text no. 4      
5.McCoy EP, MirakhurRK, Maddineni VR, Loan PB, ConnollyF. Administration of rocuronium(Org 9426) by continuous infusion and its reversibility with anticholinesterases. Anaesthesia 1994; 49:940-5.  Back to cited text no. 5      
6.JellishWS,BrodyM,SawickiK,SlogoffS.Recovery from neuromuscularblockadeafter either bolus andprolonged infusions of cisatracurium, orrocuronium using either isoflurane orpropofol-based anesthetics. AnesthAnalg 2000; 91:1250-5.  Back to cited text no. 6      
7.Wulf H, Ledowski T, linstedt U, Proppe D, Sitzlack D. Neuromuscular blocking effects of rocuronium during desflurane, isoflurane, and sevoflurane and anaesthesia. Can SAnaesth 1998;45:526-32.  Back to cited text no. 7      
8.Reid SE, Breslin DS, Itiiirakhur RK, Hayes AR. Neostigmine antagonism of rocuronium block during anesthesia with sevoflurane, isoflurane or propofol. Can JAnaesth 2001; 48:351-5.  Back to cited text no. 8      
9.Vanacker BF, Vermeyen KM, Strut's MM, Rietbergen H, Vandermeersch E, Saldien V, Kalmar AF, Prins ME. Reversal of rocuroniurn-induced neuromuscular block with the novel drug sugammadex is equally effective under maintenance anes­thesia withpropofol or sevoflurane. AnesthAnalg 2007;104:563-8.  Back to cited text no. 9      
10.Viby-Mogensen J. Dose-response relationship and time course of action of Rocuronium bromide in perspective. Eur J Anaesthesiol 1994; 9(Suppl):28-32.  Back to cited text no. 10      
11.Epemolu O, Born A, Hope F, MasonR. Reversal of neuromuscular blockade and simultaneous increase inplasma rocuronium concentration after the intravenous infusion of the novel reversal agent Org 25969. Anesthesiology 2003; 99:632-7.  Back to cited text no. 11      




 

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