Knowledge
-
-
-
Sugammadex is pharmacologically great. A modified γ-cyclodextrin Selective Relaxant Binding Agent that reverses rocuronium muscle relaxation 10-times faster than neostigmine (see: Is sugammadex as good as we think?).
At launch, its biggest obvious disadvantage was simply the new drug's high cost. Now as sugammadex has become more widely used, sugammadex-anaphylaxis has risen as a new, prominent concern.
In Japan, where there was a uniquely rapid take-up of sugammadex, it became one of the commonest causes of anaphylaxis. Oriharia (2020) demonstrated an incidence of sugammadex anaphylaxis in Japan of 1 in 5,000 – a risk that most medically communities would consider too high for routine use of a drug with acceptable alternatives.
Given that in some regions (notably Australia & New Zeleand) rocuronium itself has a high-risk of anaphylaxis, the combination of rocuronium-sugammadex may present a greater risk than even old-school drugs such as suxamethonium.
In other countries, such as the United Kingdom, there has not been quite the same incidence of sugammadex-anaphylaxis. Is this simply because of the lower initial use than in Japan, or are there environmental and phenotypical differences as have been implicated for rocuronium anaphylaxis?
Worryingly, if the Japanese experience is representative, then for some locations the combination of rocuronium-sugammadex may in fact have a higher risk of anaphylaxis than using suxamethonium alone.
The true risk of sugammadex-anaphylaxis is still unclear for many populations. However with the looming expiry of the sugammadex patent in 2023, we will see a rapid increase in its use and subsequently reveal any latent anaphylaxis risk.
summary
-
This growing collection of articles focuses on the evidence and expert guidance relating to the use of personal protective equipment (PPE) and the SARS-CoV-2 / COVID pandemic, with specific focus on PPE use by anaesthesiologists and anaesthetists.
More articles can found found via the PPE topic index.
What we know:
- Hospitals are frequent sources of outbreaks, among both staff, patients and the wider community.
- The quality of PPE evidence is low. Most evidence must be contextualised in consideration of expert opinion, and of the similarities between SARS-CoV-2 and SARS (SARS-CoV-1), MERS and influenza.
- Droplet-vs-airborne spread is a conceptual simplification and not a simple dichotomy. It is best understood as a spectrum of transmission risk.
- Time-exposed may be a more important consideration, especially in indoor, poorly ventilated spaces.
- PPE supply is globally limited, and so a pragmatic approach must be taken to its use, considering individual risk scenarios.
- Training, simulation and fit testing are critical for effective use of PPE.
- There are specific steps in the PPE donning & doffing workflow that are frequently associated with breaches exposing HCWs to infection. These require extra attention.
- Beyond cost, increasingly complex PPE (eg. PAPR, hoods, intubation boxes etc.) also increase the opportunity for PPE failure and exposure if users have not had adequate training in their use, and some PPE has been demonstrated to make intubation more difficult.
- The superiority of N95/P2 respirator masks over standard surgical masks for personal protection is unclear and unproven.
-