Abrishami et al.'s Cochrane review of 18 RCTs totalling 1,300 patients confirmed the superiority of sugammadex compared with neostigmine at all studied levels of blockade. They identified sugammadex dosing of:

• 2 mg/kg - for reversal of rocuronium neuromuscular blockade at TOF-T2 reappearance.
• 4 mg/kg - for reversal at post-tetanic count of 1 to 2.
• 16 mg/kg - for reversal 3 to 5 minutes after a rocuronium intubating dose.

Importantly there was similar frequency of adverse events compared to neostigmine (< 1%), although overall small sample sizes mean no conclusion can be made regarding rare serious adverse events.

summary

• Amir Abrishami, Joyce Ho, Jean Wong, Ling Yin, and Frances Chung.
• Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, 2-241A McLaughlin Wing, Toronto, Ontario, Canada, M5T 2S8.
• Cochrane Db Syst Rev. 2009 Jan 1(4):CD007362.

BackgroundSugammadex is the first selective relaxant binding agent that has been studied for reversal of neuromuscular blockade induced by rocuronium and other steroidal non-depolarizing neuromuscular blocking agents (NMBAs).ObjectivesTo assess the efficacy and safety of sugammadex in reversing neuromuscular blockade induced by steroidal non-depolarizing NMBAs and in preventing postoperative residual neuromuscular blockade.Search StrategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), and EMBASE (1980 to August 2008). In addition, we handsearched reference lists of relevant articles and meeting abstracts. Furthermore, we contacted the medication's manufacturer for more information.Selection CriteriaAll randomized controlled trials (RCTs) on adult patients (>/= 18 years old) in which sugammadex was compared with placebo or other medications, or in which different doses of sugammadex were compared with each other. We excluded non-randomized trials and studies on healthy volunteers.Data Collection And AnalysisWe independently performed determination of trial inclusion, quality assessment, and data extraction. We applied standard meta-analytic techniques.Main ResultsWe included18 RCTs (n = 1321 patients). Seven trials were published as full-text papers, and 11 trials only as meeting abstracts. All the included trials had adequate methods of randomization and allocation concealment. The results suggest that, compared with placebo or neostigmine, sugammadex can more rapidly reverse rocuronium-induced neuromuscular blockade regardless of the depth of the block. We identified 2, 4, and 16 mg/kg of sugammadex for reversal of rocuronium-induced neuromuscular blockade at T(2) reappearance , 1 to 2 post-tetanic counts, and 3 to 5 minutes after rocuronium, respectively. The number of trials are very limited regarding vecuronium and pancuronium. Serious adverse events occurred in < 1% of all patients who received the medication. There was no significant difference between sugammadex and placebo in terms of the prevalence of drug-related adverse events (RR 1.20, 95% CI 0.61 to 2.37; P = 0.59, I(2) = 0%, 5 RCTs). Also, no significant difference was found between sugammadex and neostigmine for adverse events (RR 0.98, 95% CI 0.48 to1.98; P = 0.95, I(2) = 43%, 3 RCTs).Authors' ConclusionsSugammadex was shown to be effective in reversing rocuronium-induced neuromuscular blockade. This review has found no evidence of a difference in the instance of unwanted effects between sugammadex, placebo or neostigmine. These results need to be confirmed by future trials on larger patient populations and with more focus on patient-related outcomes.

This article appears in the collection: Is sugammadex as good as we think?.

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