Sugammadex changing anesthesia practice

[wtbcrna]

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.

[zrmorgan]

sux is the fastest, but right behind it is well timed remifentanil.

interesting post catco...we have a doc here who went to Europe for a TIVA seminar...she has been doing a lot of no paralysis cases (including open abdomens) with Remi / Propofol. She keeps telling me I should try it, but for some reason, I am reluctant to giving up my NMB crutch. I do TIVAs , but I still use NDNMBs. She teases me and says "oh, thats not a real TIVA". I just tell her I am glad she is so avant-garde. What are your thoughts using Remi with no NMB (even during intubation)?

Thanks,

zrmorgan

[zrmorgan]

Well, I think we really need to make that distinction. When many nurses such as my self respond, in most cases we are looking at this from a RSI viewpoint. I know I have been very careful about emphasizing my experience with NMBA's is not anesthesia related.

With that, I am really not sure how much this will change true anesthesia practice. However, I suspect one concern that somebody has discussed could materialize. If we end up having an airway related adverse event, the media could run with a story about the bad anesthesia providers not using drugs that can be reversed with the new miracle drug. Then, the sheeple get ahold of it, and we have everybody but the actual anesthesia providers making policy for the practice of anesthesia.

I know this could be a big thing in EMS where lawyers stand to make big bucks on every RSI where Roc/Vec was not used and the media stands to gain great stories.

Pretty typical stuff in the era of modern medicine however.

since when did we ever place a priority of science over closed claims when determining the standard of care in our country?

usually only when science has a louder voice than the trial attorneys. and when that happens, the trial attorneys yell in chourus, and say they have advocated science all along.

I think the stuff that is coming out about sugammadex is very interesting. Think about our traditional methods of reversal...we have to wait until they have spontaneously resolved somewhat, then we inject them molecules similar in behavior to soman nerve gas, or organophosphate incecticides. After that we have to counter that with antimuscarinics which cause a whole new set of problems...and this current method cannot reverse deep NMB such as sugammadex is claimed to do.

If sugammadex ends up being as effective as they have reported, and with as wide of a therapeutic window as they are claiming it will become the standard care of reversing steroidal NDNMB. I don't think it will change our standard of care for RSI however...this is an apples and oranges thing as it does not matter how you reverse them when considering the indication for RSI.