Sugammadex Rapidly Reverses Rocuronium Paralysis
Full reversal of a 1.0 mg/kg dose of rocuronium takes less than 2 minutes.
Sugammadex is a novel agent designed to rapidly reverse rocuronium block (JW Emerg Med Mar 23 2007), but it has not been evaluated for reversal of the higher doses of rocuronium used for rapid sequence intubation (RSI). In a multicenter European study, investigators (including a clinical research scientist and statisticians employed by the manufacturer) randomized 168 patients who were undergoing elective anesthesia to receive one of five doses of sugammadex (2, 4, 8, 12, or 16 mg/kg) or placebo administered either 3 minutes or 15 minutes after administration of rocuronium (1.0 mg/kg or 1.2 mg/kg). Recovery of muscle function (to 90% of normal response to train-of-four stimulation, which permits normal breathing) was monitored continuously until recovery was noted and for at least 30 minutes after sugammadex administration to ensure that recovery was sustained.
When the highest dose of sugammadex (16 mg/kg) was administered 3 or 15 minutes after administration of 1.0 mg/kg of rocuronium, median recovery times were 1.6 and 0.9 minutes, respectively. Corresponding median recovery times in patients who received 1.2 mg/kg rocuronium were 1.3 and 1.9 minutes, respectively. Median times to recovery in patients who received placebo ranged from 91 to 124 minutes. Time to recovery was dependent on sugammadex dose. Twenty-two of 157 sugammadex recipients (14%) and none of 11 placebo recipients had drug-related adverse events, mostly nausea, vomiting, or anesthetic complications. Eleven patients in the sugammadex groups and one in the placebo group had serious adverse events, mostly QT interval prolongation, but the investigators considered this outcome to be related possibly to sugammadex in only one case.
Comment: The RSI dose of rocuronium (1.0 mg/kg) requires a larger dose of sugammadex for reversal than does the routine paralyzing dose of 0.6 mg/kg. The larger dose of sugammadex is effective and has few apparent adverse effects. The median reversal time of less than 2 minutes means that we could use rocuronium routinely for RSI, knowing that paralysis can be reversed if necessary. These findings might prove to be another significant nail in succinylcholine’s coffin.
Ron M. Walls, MD, FRCPC,FAAEM
Published in Journal Watch Emergency Medicine August 8, 2008
Citation(s): Puhringer FK et al. Reversal of profound, high-dose rocuronium–induced neuromuscular blockade by sugammadex at two different time points: An international, multicenter, randomized, dose-finding, safety assessor–blinded, phase II trial. Anesthesiology 2008 Aug; 109:188.