Article Notes
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.
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...
A collection of evidence looking specifically at the issue of our poor stewardship of neuromuscular blocking agents can be found here: Neuromuscular myths: the lies we tell ourselves
Possibly... but with some important caveats.
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.” – RD Miller (2007).
Sugammadex (Bridion®) is a remarkable drug – and the anaesthesia community has moved very quickly to embrace the potential of this first ‘selective relaxant binding agent’ (SRBA), despite it’s considerable cost.
Sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular from rocuronium. The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex’s onset is 10 times faster than neostigmine and three times faster than edrophonium.
Though beyond the parlour-trick of speedy action, or the possibility of rescuing a cannot-intubate-cannot-ventilate crisis – the biggest benefit of sugammadex for our patients may be in the dramatic reduction of post-operative residual paralysis. A common problem with serious consequences that the anaesthetic community has ignored for far too long.
What's significant here is not confirmation that spinal anaesthesia improves ECV success, which has been noted before, but rather that this is not due to the analgesic effect as previously thought (ie. IV remifentanil improved pain during the ECV but not success rate), but instead may be primarily due to abdominal muscle relaxation.