Article Notes
Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.
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.
Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.
Rescue from residual paralysis despite having given neostigmine.
- 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.
Ledowski et al. investigated the effect of unrestricted access to sugammadex in an Australian teaching hospital with a retrospective observational audit.
Use of both sugammadex and amino steroid relaxants increased dramatically, with average reversal costs per case increasing by AUS$85.
Although there was no change in anaesthesia, surgical or PACU time, there was a statistically significant decrease in median time from surgery to hospital discharge (0.2 days shorter) after introduction of sugammadex. Do to the nature of the study, it is nevertheless impossible to infer a causal link.
Daniel Jolley
The actual cost of both operating theatre and recovery room time in the U.S., Canada, Australia and greater Europe is likely much, much higher than figures used by the researchers. Thus even at its current high cost there is a strong economic argument to be made for using sugammadex for routine reversal.
However, the opposing point is that the economic benefit is only real if the liberated operating room time can actually be utilised for productive surgical work – this is currently unlikely in many hospitals due to inefficient and inflexible scheduling.
Daniel Jolley
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).
Daniel Jolley
As the evidence-base increases and the cost falls, it will be indications #2 and #4 that carry our shift in practice to using sugammadex and its successors. We will recognise larger groups of patients for whom residual paralysis is detrimental (everyone?) while simultaneously appreciating better how common the problem truly is.
Daniel Jolley
Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
Daniel Jolley
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:
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.
Daniel Jolley
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%)
Daniel Jolley
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?”
Daniel Jolley