Sugammadex changing anesthesia practice

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Specializes in Anesthesia.

With Sugammadex's recent approval in Europe, and final phase of approval in the US how do you think it will effect the practice of anesthesia? Has anyone here had the chance to use Sugammadex?

ANESTHETIC PHARMACOLOGY

Sugammadex: Another Milestone in Clinical Neuromuscular Pharmacology

Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD

From the Department of Anesthesiology and Pain Medicine, Unit 409, Anderson Cancer Center, The University of Texas M. D., Houston, Texas.

Sugammadex is a revolutionary investigational reversal drug currently undergoing Phase III testing whose introduction into clinical practice may change the face of clinical neuromuscular pharmacology. A modified -cyclodextrin, sugammadex exerts its effect by forming very tight water-soluble complexes at a 1:1 ratio with steroidal neuromuscular blocking drugs (rocuronium > vecuronium >> pancuronium). During rocuronium-induced neuromuscular blockade, the IV administration of sugammadex creates a concentration gradient favoring the movement of rocuronium molecules from the neuromuscular junction back into the plasma, which results in a fast recovery of neuromuscular function. Sugammadex is biologically inactive, does not bind to plasma proteins, and appears to be safe and well tolerated. Additionally, it has no effect on acetylcholinesterase or any receptor system in the body. The compound's efficacy as an antagonist does not appear to rely on renal excretion of the cyclodextrin-relaxant complex. Human and animal studies have demonstrated that sugammadex can reverse very deep neuromuscular blockade induced by rocuronium without muscle weakness. Its future clinical use should decrease the incidence of postoperative muscle weakness, and thus contribute to increased patient safety. Sugammadex will also facilitate the use of rocuronium for rapid sequence induction of anesthesia by providing a faster onset-offset profile than that seen with 1.0 mg/kg succinylcholine. Furthermore, no additional anticholinesterase or anticholinergic drugs would be needed for antagonism of residual neuromuscular blockade, which would mean the end of the cardiovascular and other side effects of these compounds. The clinical use of sugammadex promises to eliminate many of the shortcomings in our current practice with regard to the antagonism of rocuronium and possibly other steroidal neuromuscular blockers.

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I had posted about this med a while back. I am not sure about anesthesia; however, I suspect ER and field providers may look to this medication and the use of Zemuron over other NMBA's.

I have seen a couple of different arguments:

First: People argue that sux still has the quickest onset of all of the NMBA's. Even when we use larger doses of Zemuron 0.6 - 1.2 mg/kg range, sux in most cases will still have a faster onset of action. Fifteen seconds can make a difference when we need intubating conditions ASAP.

Second: People argue the reversal aspect and say, "now we can use much larger doses of Zemuron to have an even faster onset of action. It is not a concern because we now have a drug to reverse it." It makes sense because non depolarizing NMBA's are competative, so the more NMBA we have competing, the faster the onset should be. (To a point I suspect.)

I look at it like this, we now have a reversal medication and perhaps a very valuable tool that we can use. I suspect it will take a while to really see how people end up using this medication and how it will ultimately effect our practice.

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Specializes in Anesthesia.
I had posted about this med a while back. I am not sure about anesthesia; however, I suspect ER and field providers may look to this medication and the use of Zemuron over other NMBA's.

I have seen a couple of different arguments:

First: People argue that sux still has the quickest onset of all of the NMBA's. Even when we use larger doses of Zemuron 0.6 - 1.2 mg/kg range, sux in most cases will still have a faster onset of action. Fifteen seconds can make a difference when we need intubating conditions ASAP.

Second: People argue the reversal aspect and say, "now we can use much larger doses of Zemuron to have an even faster onset of action. It is not a concern because we now have a drug to reverse it." It makes sense because non depolarizing NMBA's are competative, so the more NMBA we have competing, the faster the onset should be. (To a point I suspect.)

I look at it like this, we now have a reversal medication and perhaps a very valuable tool that we can use. I suspect it will take a while to really see how people end up using this medication and how it will ultimately effect our practice.

Suggamedex should work with all the non-depolarizing neuromuscular blockers (at least the major ones ..Vec etc.) not just Zemuron/Rocuronium. Rocuronium is being so heavily pushed, because it is the same drug company that made Sugammedex.

I don't think succs will be replaced totally, because you are not supposed to use Sugammedex in renal patients. There are lots of anesthesia providers out there that absolutely refuse to use Succs right now d/t MH.

I am hoping to get a chance to use Sugammedex (who came up with that freakin name...geeze) before I graduate.

Maybe we can get some of European counterparts to post after they use Sugammedex to see if it lives up to all the press!

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Thus far, everything that I have heard regarding Sugammedex is good. It appears to work as advertised. I did not know that it works with all non depolarizing NMBA's. I knew about Zemuron and documented cases of it working on Vec.

The Sugammedex structure is a ring of multiple starch like molecules that form an ionic bond with the Zemuron molecule. I was only aware that it worked with Vec & Roc?

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Specializes in Anesthesia.
Thus far, everything that I have heard regarding Sugammedex is good. It appears to work as advertised. I did not know that it works with all non depolarizing NMBA's. I knew about Zemuron and documented cases of it working on Vec.

The Sugammedex structure is a ring of multiple starch like molecules that form an ionic bond with the Zemuron molecule. I was only aware that it worked with Vec & Roc?

Yeah, but guess what Vec and Roc are owned by the same company...lol. Let me look through my pharm notes and see what I can find. I can always be wrong.

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Specializes in Anesthesia.

Sugammadex works on steroidal NDMBs (Roc>Vec>>Panc), so I was wrong once as an SRNA...lol or was that once an hour since becoming an SRNA.

Thanks for the catch.

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Funny, I just finished up on some research and was going to post that I was incorrect. Sugammadex does have at least limited action against Pancuronium. Sugammadex may prove to be more effective for Panc.. as we see more information from the trials.

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I primarily use Cisatracurium in my practice. Sugammadex will not reverse this type of NDMR.

I think having a reversal agent like Sug. is a good idea for those times you can't use Sux or for very short cases where Sux is not acceptable The manufacturer has not set a price but I'm going to assume it will be pretty expensive and to use it to do routine reversals is not good use of health care dollars. IMHO.

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Specializes in Anesthesia.
I primarily use Cisatracurium in my practice. Sugammadex will not reverse this type of NDMR.

I think having a reversal agent like Sug. is a good idea for those times you can't use Sux or for very short cases where Sux is not acceptable The manufacturer has not set a price but I'm going to assume it will be pretty expensive and to use it to do routine reversals is not good use of health care dollars. IMHO.

Interesting, why do you choose to use Cis? The drug rep that came and talked to us was very closed mouthed about the potential release date/price etc. I know the military seems to very interested in using it. I wonder if the cost would be offset using Sugammadex in the overall patient turnover times?

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Interesting, why do you choose to use Cis?

In my hands, Cis is way more predictable than Roc. I give an appropriate dose and I have a relaxed patient. With Roc, I give what is supposed to be an appropriate dose that's supposed to last..yeah long...and I find I have 4 strong twitches way before I feel I'm supposed to. Or on the other hand, with Roc, I give what I think is an appropriate dose and I don't have twitiches for the longest time???? What's up with that? Acts like 2 different drugs, in my hands. So I've given up using it unless I have to.

I also like any drug with 2 ways, not just 1 way, of metabolism. It's good for all patients ie....Renal etc...so I don't have to worry about that.

I'm not a salesperson for Cis, and I don't get paid for this...but give it a try, you'll love it.

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Specializes in Anesthesia.
In my hands, Cis is way more predictable than Roc. I give an appropriate dose and I have a relaxed patient. With Roc, I give what is supposed to be an appropriate dose that's supposed to last..yeah long...and I find I have 4 strong twitches way before I feel I'm supposed to. Or on the other hand, with Roc, I give what I think is an appropriate dose and I don't have twitiches for the longest time???? What's up with that? Acts like 2 different drugs, in my hands. So I've given up using it unless I have to.

I also like any drug with 2 ways, not just 1 way, of metabolism. It's good for all patients ie....Renal etc...so I don't have to worry about that.

I'm not a salesperson for Cis, and I don't get paid for this...but give it a try, you'll love it.

Thanks, I will remember that.

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I'm not a salesperson for Cis, and I don't get paid for this...but give it a try, you'll love it.

Nimbex for president!!!!!!!!!!!!!!!!!

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