Reversal of Neuromuscular Blockade with Sugammadex at the Reappearance of Four Twitches to Train-of-four Stimulation.

* Staff Anesthesiologist, † Resident, ‡ Professor and Head, § Titular Professor, Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary.
Anesthesiology (Impact Factor: 6.17). 05/2013; DOI: 10.1097/ALN.0b013e318297ce95
Source: PubMed

ABSTRACT BACKGROUND:: Doses of sugammadex required to reverse deep, moderate, and shallow rocuronium-induced neuromuscular blockade have been established. However, no adequate doses for the reversal of reappearance of four twitches of train-of-four (TOF) stimulation (threshold TOF-count-four) have been established. METHODS:: This single-center, randomized, controlled, double-blind, four-groups parallel-arm study included 80 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and rocuronium. Neuromuscular monitoring was performed with calibrated acceleromyography. Once rocuronium-induced neuromuscular blockade recovered spontaneously to threshold TOF-count-four, patients randomly received 0.5, 1.0, 2.0 mg/kg of sugammadex or 0.05 mg/kg of neostigmine. The time between study drug injection and reversal of TOF ratios to 1.0 was measured. Rapid reversal (≤2.0 min average, upper limit of 5.0 min) was the primary endpoint and slower reversal (≤5.0 min average, upper limit of 10 min) was the secondary endpoint of the study. RESULTS:: Sugammadex, in doses of 1.0 and 2.0 mg/kg, reversed threshold TOF-count-four to TOF ratios of 1.0 in 2.1 ± 0.8 min (mean ± SD) and 1.8 ± 0.9 min, respectively. Sugammadex, 0.5 mg/kg, induced a similar degree of reversal in 4.1 ± 1.9 min (P < 0.001 vs. 1.0 and 2.0 mg/kg). Neostigmine, 0.05 mg/kg, reversed TOF ratios to 1.0 in 8.5 ± 3.5 min (P < 0.001 vs. sugammadex groups). CONCLUSION:: Sugammadex, 1.0 mg/kg, rapidly and effectively reverses rocuronium-induced block that has recovered spontaneously to a threshold TOF-count-four. A dose of 0.5 mg/kg was equally effective, but satisfactory antagonism took as long as 8 min to take place.

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    ABSTRACT: Magnesium enhances the effect of rocuronium. Sugammadex reverses rocuronium-induced neuromuscular block. The authors investigated whether magnesium decreased the efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular block. Thirty-two male patients were randomized in a double-blinded manner to receive magnesium sulfate (MgSO4) 60 mg/kg or placebo intravenously before induction of anesthesia with propofol, sufentanil, and rocuronium 0.6 mg/kg. Neuromuscular transmission was monitored using TOF-Watch SX acceleromyography (Organon Ltd., Dublin, Ireland). In 16 patients, sugammadex 2 mg/kg was administered intravenously at reappearance of the second twitch of the train-of-four (moderate block). In 16 further patients, sugammadex 4 mg/kg was administered intravenously at posttetanic count 1 to 2 (deep block). Primary endpoint was recovery time from injection of sugammadex to normalized train-of-four ratio 0.9. Secondary endpoint was recovery time to final T1. Average time for reversal of moderate block was 1.69 min (SD, 0.81) in patients pretreated with MgSO4 and 1.76 min (1.13) in those pretreated with placebo (P = 0.897). Average time for reversal of deep block was 1.77 min (0.83) in patients pretreated with MgSO4 and 1.98 min (0.58) in those pretreated with placebo (P = 0.572). Times to final T1 were longer compared with times to normalized train-of-four ratio 0.9, without any difference between patients pretreated with MgSO4 or placebo. Pretreatment with a single intravenous dose of MgSO4 60 mg/kg does not decrease the efficacy of recommended doses of sugammadex for the reversal of a moderate and deep neuromuscular block induced by an intubation dose of rocuronium.
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    ABSTRACT: This randomized double-blind study was designed to determine if respiratory muscle weakness - measured by maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), forced vital capacity (FVC), and forced expiratory volume in one second (FEV1) - persists even if an acceleromyographic train-of-four ratio (TOFR) of 1.0 is reached after major abdominal surgery. Twenty patients underwent respiratory function tests before induction of anesthesia. Rocuronium was given, and the tests were repeated after extubation when the TOFR reached 1.0. The patients were then randomized to receive sugammadex 1 mg·kg(-1) or placebo, and the same tests were repeated five and 20 min later. Between-group comparisons were carried out with a mixed-model analysis of variance analysis. After anesthesia and adequate epidural analgesia, MIP and MEP decreased by 60% in both groups. In the placebo group, MIP decreased from a pre-induction value (median [range]) of 61.8 [31.3-96.1] to 19.6 [8.3-58.3] cm H2O after extubation without significant variation five and 20 min after placebo. In the sugammadex group, MIP decreased from a pre-induction value of 57.8 [13.0-96.4] to 20.5 [6.4-67.3] cm H2O after extubation. No differences were recorded after sugammadex administration (P = 0.246 between groups). In the placebo group, MEP decreased from 88.8 [65.1-120.3] before induction to 37.6 [13.4-70.6] cm H2O after extubation. In the sugammadex group, MEP decreased from 85.5 [58.6-132.7] to 30.8 [10.5-60.5] cm H2O, with no improvement five and 20 min after either placebo or sugammadex administration (P = 0.648). Similarly, the FCV and FEV1 decreased 30-40% after extubation in both study groups. Acceleromyographic TOFR of 1.0 excludes residual neuromuscular paralysis. However, major respiratory dysfunction is observed after abdominal surgery. This trial was registered at NCT01503840.
    Canadian Anaesthetists? Society Journal 04/2014; · 2.31 Impact Factor
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    ABSTRACT: The objective of this study was to determine the point after sugammadex administration at which sufficient or insufficient dose could be determined, using first twitch height of train-of-four (T1 height) or train-of-four ratio (TOFR) as indicators. Groups A and B received 1 mg/kg and 0.5 mg/kg of sugammadex, respectively, as a first dose when the second twitch reappeared in train-of-four stimulation, and Groups C and D received 1 mg/kg and 0.5 mg/kg of sugammadex, respectively, as the first dose at posttetanic counts 1-3. Five minutes after the first dose, an additional 1 mg/kg of sugammadex was administered and changes in T1 height and TOFR were observed. Patients were divided into a recovered group and a partly recovered group, based on percentage changes in T1 height after additional dosing. T1 height and TOFR during the 5 min after first dose were then compared. In the recovered group, TOFR exceeded 90% in all patients at 3 min after sugammadex administration. In the partly recovered group, none of the patients had a TOFR above 90% at 3 min after sugammadex administration. An additional dose of sugammadex can be considered unnecessary if the train-of-four ratio is ≥90% at 3 min after sugammadex administration. This trial is registered with UMIN000007245.
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