Sugammadex: Use in Specific Patient Population

Sugammadex: Use in Specific Patient Population
Volkan Hancı; M.D. Dokuz Eylul University İzmir, Turkey

Sugammadex Modified gamma cyclodextrin molecule.
Unique molecular structure. Encapsulates the neuromuscular blocker rocuronium and vecuronium. Removing its from the muscle-nerve junction. Selective and rapid reversal of neuromuscular blockage.

Sugammadex More effective than placebo or neostigmine
Reduced all signs of residual postoperative paralysis, and minor respiratory events Reduced drug-related side-effects, Cochrane Database Syst Rev Oct 7;(4):CD Anaesthesia Dec;70(12):

Sugammadex Dose 2 mg/kg, 4 mg/kg, 16 mg/kg Drug interaction
Steroidal drugs, endogenous steroids, oestrogens Atropine, vancomycin, gentamicin, salbutamol, aminophylline, ephedrine, phentolamine, verapamil (120–700 times lower than rocuronium) Precipitation Amiodarone, dobutamine, protamine Basic Clin Pharmacol Toxicol. 2013;113(4):280-5. Braz J Anesthesiol. 2013;63(1):163-4.

Sugammadex Special Patient Population /Special Situations

Renal Elderly Hepatic Pediatric Cardiac Obese Pulmonary Obstetric
Neuro-muscular Residual Paralysis Reinducing Neuromuscular Blockade Neurophysiologic Monitoring Anaphylaxis Experimental Studies Special Situtations Special Diseases S p e c i a l P t n s

Neuro-muscular Residual Paralysis Reinducing Neuromuscular Blockade Neurophysiologic Monitoring Anaphylaxis Experimental Studies Residual Paralysis Reinducing Neuromuscular Blockade Neurophysiologic Monitoring Anaphylaxis Experimental Studies Special Situtations Special Diseases S p e c i a l P t n s

Elderly Patients Sugammadex facilitates rapid reversal from moderate rocuronium-induced neuromuscular blockade in adults of all ages Recovery of the TOF ratio to 0.9 increased with age, from 2.3 ( ) min (adults) to 2.9 ( ) min Slower circulation time Anesthesiology Feb;114(2):

Pediatric Patients Sugammadex rapidly and effectively reverses rocuronium-induced NMB in pediatric patients Sugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients Sugammadex can be considered as a safe agent in order to reverse neuromuscular block in pediatric patients Saudi J Anaesth Jul-Sep;9(3): Rev Bras Anestesiol Nov-Dec;64(6):400-5. J Res Med Sci Aug;19(8):762-8.

Obese Patients Sugammadex quickly and effectively reverses NMB in obese patients Sugammadex dosing recommendations are based on total body weight. No dose adjustments are required in the obese patient. Morbidly obese patients can safely be decurarised from rocuronium-induced neuromuscular blockade T1-T2 with sugammadex dosed at 2 mg.kg(-1) ideal body weight + 40% Sugammadex dose calculated according to IBW is insufficient for reversing both deep and moderate blockades in morbidly obese patients. Am J Ther Sep 21. [Epub ahead of print] Anaesthesia Aug;66(8):721-5 Anesthesiology Jul;117(1):93-8

Obstetric Patients Sugammadex use in obstetric patients has also successfully reversed NMB The data regarding the teratogenicity and safety of sugammadex in pregnant women are limited. No reported teratogenicity has been found. Rocuronium 1.2 mg/kg reversed by sugammadex appears to be effective in the obstetric population Sugammadex could reverse rocuronium-induced neuromuscular blockade in a dose-response manner even in the patients treated with magnesium sulfate. Acta Anaesthesiol Scand Jul;55(6):694-9. Masui Mar;63(3):315-9.

Renal Disease Sugammadex-NMB complex mainly excreted by the kidneys
Decreased elemination High-flux dialysis (Large pore in dialyzing membranes) Renal failure; effectively and safely reversed profound rocuronium induced neuromuscular block, but the recovery was slower than healthy patients. rapid reversal of deep rocuronium-induced NMB current safety experience is insufficient to support recommended use of sugammadex in this population Eur J Anaesthesiol. 2015;32(10):681-6. Br J Anaesth May;114(5):

Hepatic Disease No hepatic metabolism
No restriction use in patient whit liver disease or hepatic surgery Liver transplantation effective and safe in liver transplant recipients. may reduce the risk of pulmonary complications Hepatic Surgery rapidly reverse NMB after continuous infusion of rocuronium Anaesth Pain & Intensive Care 2015;19(3) Acta Anaesthesiol Taiwan ;52(2):54-8.

Cardiac Disease Safe / efficacious Not change hemodynamic parameters
Might be preferred as it provides more hemodynamic stability compared to neostigmine-atropine combination Sugammadex can adequately restore neuromuscular function in heart failure patients under hemodynamically stable conditions. Not prolong QT interval J Clin Anesth. 2016;28:30-5. Acta Anaesthesiol Belg. 2012;63(2):69-73. Clin Drug Investig. 2013; 33(8):545-51 Acta Cir Bras. 2014;29(12):

Cardiac Disease Successfully used Brugada syndrome
Wolff-Parkinson-White (WPW) Syndrome Long QT syndrome On the other hand, one case report accuse one of the causative agents of cardiac arrest Anaesth Intensive Care ;41(3):434 Braz J Anesthesiol. 2013;63(1):159-60 J Med Invest Aug;58(3-4):273-6 J ECT Jun;28(2):e21-2 Balkan Med J. 2015;32(3):327-9 Anaesth Intensive Care. 2010;38(6):1138-9 Masui. 2015;64(6):622-7.

Pulmonary Disease No negative effects or side effects
Lung surgery

Neuromuscular Disease
Myasthenia Gravis Sugammadex appears to be a safe choice to avoid prolonged action of NMBA also in patients with myasthenia gravis , MG patients - rocuronium and sugammadex not observe any signs of postoperative residual curarization and respiratory depression.

Neuromuscular Disease
Other neuromuscular diseases, Duchenne Myotonic dystrophies Transverse myelitis Amyotrophic lateral sclerosis Huntington disease Spinal / Bulbar Muscular Atrophy Strumpell-Lorrain disease / familial spastic paraplegia NMB effectively reversed with sugammadex

Rescue of Residual Paralysis
Conventional reversal of NMB by a cholinesterase inhibitor is incomplete, sugammadex may be administered to fully reverse After inadequate reversal of NMB with neostigmine and glycopyrrolate, sugammadex immediately reverse the residual paralysis Residual NMB even after reversal with anticholinesterase agents, sugammadex, a safe alternative to reverse the NMB Anesth Analg Mar;104(3):585-6. Rev Bras Anestesiol Jul;62(4):543-7.

Reinducing Neuromuscular Blockade After Sugammadex Administration
After reversal by sugammadex Immediate reestablishment of NMB with an aminosteroidal NMB agent is difficult. Isoquinoline NMBAs (atracurium, cisatracurium and mivacurium) or succinylcholine should be use If the aminosteroidal NMB agent use necessary Elimination time of sugammadex should be considered. Sugammadex undergoes renal elimination It takes 8 hours after injection in individuals with normal renal function.

Neurophysiologic Monitoring
Sugammadex has been successfully used for patients requiring neurophysiologic monitoring during brain and spinal cord surgeries Sugammadex-induced reversal of NMB restores full motor function and better reflects a patient’s true baseline motor evoked potentials Somatosensory evoked potentials are not affected by NMB. Anaesth Intensive Care. 2012;40(6):1073-4

Anaphylaxis Severe allergic reaction after administration of sugammadex may ocur It can be seen bi-phasic reaction Sugammadex may potentially be a useful adjunct in the management of rocuronium-induced anaphylaxis. Sugammadex does not modify the clinical course of a suspected hypersensitivity reaction. Can J Anaesth Jul;60(7):733-4 Masui Jun;64(6): J Clin Anesth Feb;24(1):62-4. Br J Anaesth Feb;106(2): Anaesthesia Nov;70(11):

Experimental Studies Sugammadex-rocuronium complexes are cause histopathological and immunohistochemical changes in testis interstitial tissues, changes sperm density, germ cell number 16 mg/kg sugammadex delayed verapamil cardiotoxicity 1000mg/kg sugammadex accelerated verapamil cardiotoxicity 16 mg/kg sugammadex delayed teophylline toxicity, and raises mean lethal dose of teophylline J Mol Histol Apr;43(2):235-41 Basic Clin Pharmacol Toxicol Oct;113(4):280-5. Lat. Am. J. Pharm. 33 (8): (2014)

Experimental Studies Administration of sugammadex and dexmedetomidine to rabbits by intra-arterial routes caused histological arterial damage. Sugammadex prevented postoperative intra-abdominal adhesions Causes neuronal apoptosis in primary cultures Rev Bras Anestesiol Kaohsiung J Med Sci Sep;31(9):463-7. Int J Med Sci Aug 3;10(10):

Neuro-muscular Residual Paralysis Reinducing Neuromuscular Blockade Neurophysiologic Monitoring Anaphylaxis Experimental Studies Other Clinical Studies Residual Paralysis Reinducing Neuromuscular Blockade Neurophysiologic Monitoring Anaphylaxis Experimental Studies Other Clinical Studies Special Situtations Special Diseases S p e c i a l P t n s

Other Clinical Studies

Other Clinical Studies
IV dexamethasone, given after induction of anesthesia, does not substantively affect the reversal time of sugammadex Lower end-extubation IOP levels were obtained sugammadex Sugammadex produced limited, transient increases in aPTT and prothrombin time but not associated with increased risk of bleeding Pre-treatment with magnesium did not significantly affect sugammadex reversal time of moderate neuromuscular blockade induced by rocuronium. Anesth Analg Jan 14. [Epub ahead of print] J Pak Med Assoc Nov;65(11): Anesthesiology Nov;121(5): Anaesthesia Aug;70(8):

Sugammadex Special Patient Population /Special Situations

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