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summary
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An early review and economic study of the cost effectiveness of sugammadex, concluding that it may be cost effective to routinely reverse with sugammadex if there are significant time savings in the operating theatre, but not if the time savings occur instead in the PACU.
The study assumed NHS costs of operating room time of £266/h (US$412/h) and PACU time of £20/h (US$31/h).
Paton F, Paulden M, Chambers D et al. Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: a systematic review and economic evaluation. Br J Anaesth. 2010 Nov 1;105(5):558-67.
  Daniel Jolley
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Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
1. Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.

2. Reversal of rocuronium when even very mild residual neuromuscular block carries significant patient risk. For example, patients with neuromuscular disorders such as myotonic dystrophy or myasthenia gravis; and patients with severe pulmonary disease with limited reserve.

3. Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.

4. Rescue from residual paralysis despite having given neostigmine.
Gibbs NM Kam PC. Sugammadex: restricted vs unrestricted or selective vs non-selective? Anaesth Intensive Care. 2012 Mar 1;40(2):213-5.
  Daniel Jolley
pearl
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Sugammadex is superior to neostigmine for reversal of rocuronium neuromuscular blockade.
Abrishami A, Ho J, Wong J et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Db Syst Rev. 2009 Jan 1(4):CD007362.
  Daniel Jolley
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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.
Abrishami A, Ho J, Wong J et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Db Syst Rev. 2009 Jan 1(4):CD007362.
  Daniel Jolley
pearl
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Reversal with sugammadex is 10 times faster than with neostigmine and three times faster than with edrophonium.
Sacan O, White PF, Tufanogullari B et al. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth. Analg. 2007 Mar 1;104(3):569-74.
  Daniel Jolley
summary
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Time to achieve full reversal (TOFR > 0.9) was significantly faster with sugammadex (107s ± 61) than neostigmine (1044 ±590s) or edrophonium (331s ± 27).
All sugammadex-reversed patients were completely reversed within 5 minutes, compared with no patients receiving neostigmine.
Reversal with sugammadex lead to less increase in heart-rate than when neostigmine-glycopyrrolate or edrophonium-atropine and almost total avoidance of the dry-mouth associated with the later (5% vs 85-95%)
Sacan O, White PF, Tufanogullari B et al. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth. Analg. 2007 Mar 1;104(3):569-74.
  Daniel Jolley
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Miller enthusiastically states:
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.”
...and hints at where benefits may begin:
“Will sugammadex’s increased effectiveness, in comparison to neostigmine, lessen the need for or use of monitoring neuromuscular function?”
Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology? Anesth. Analg. 2007 Mar 1;104(3):477-8.
  Daniel Jolley
summary
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An interesting CICO case study highlighting that while sugammadex will rapidly and completely reverse paralysis, this is only one consideration when managing an airway crisis. The use of any reversal agent in an airway crisis should be considered within the context of the case and a clear understanding of the objective of our actions.
Neuromuscular reversal will only improve a CICO scenario if spontaneous ventilation will improve patient oxygenation, otherwise return of muscle function may actually make other CICO interventions more difficult.
Kyle BC, Gaylard D, Riley RH. A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex. Anaesth Intensive Care. 2012 Mar 1;40(2):344-6.
  Daniel Jolley
pearl
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Adequate reversal of neuromuscular blockade may not always be helpful when successfully managing a cannot intubate-cannot-ventilate crisis.
Kyle BC, Gaylard D, Riley RH. A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex. Anaesth Intensive Care. 2012 Mar 1;40(2):344-6.
  Daniel Jolley
summary
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A reminder that hypersensitivity reactions are possible with almost any drug or chemical. At the time of this publication, the risk of anaphylaxis to sugammadex appeared to be lower than that for muscle relaxants – however newer studies from Merck (Kam 2018 and Min 2018) worryingly suggest that sugammadex sensitivity may be a lot more common than we thought.
The FDA’s caution now no longer seems quite so unwarranted...
Godai K, Hasegawa-Moriyama M, Kuniyoshi T et al. Three cases of suspected sugammadex-induced hypersensitivity reactions. Br J Anaesth. 2012 Aug 1; 109 (2): 216-8.
  Daniel Jolley