Article Notes
- Ensuring at least 30 min since last epidural bolus.
- Reducing spinal dose by 20%. (NB: plain bupivacaine used)
- Delay supine positioning for 2 min after spinal performed.
- 2 mg/kg - for reversal of rocuronium neuromuscular blockade at TOF-T2 reappearance.
- 4 mg/kg - for reversal at post-tetanic count of 1 to 2.
- 16 mg/kg - for reversal 3 to 5 minutes after a rocuronium intubating dose.
Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.
Reversal of rocuronium when even very mild residual neuromuscular block carries significant patient risk. For example, patients with neuromuscular disorders such as myotonic dystrophy or myasthenia gravis; and patients with severe pulmonary disease with limited reserve.
Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.
Rescue from residual paralysis despite having given neostigmine.
An audit of 115 parturients requiring spinal anesthesia for cesarean section in the setting of an inadequate, pre-existing epidural block. Median dose of 9.38 mg of bupivacaine + 15 mcg fentanyl was used. No patients received an epidural bolus within 30 min of their subarachnoid block.
There were no cases of total spinal block.
Because total spinal after inadequate epidurals had been 'not uncommon' in the department, the researchers had altered the department's practice to be:
(Plus patient weight < 120 kg and height > 1.47 m)
An early review and economic study of the cost effectiveness of sugammadex, concluding that it may be cost effective to routinely reverse with sugammadex if there are significant time savings in the operating theatre, but not if the time savings occur instead in the PACU.
The study assumed NHS costs of operating room time of £266/h (US$412/h) and PACU time of £20/h (US$31/h).
Ledowski et al. investigated the effect of unrestricted access to sugammadex in an Australian teaching hospital with a retrospective observational audit.
Use of both sugammadex and amino steroid relaxants increased dramatically, with average reversal costs per case increasing by AUS$85.
Although there was no change in anaesthesia, surgical or PACU time, there was a statistically significant decrease in median time from surgery to hospital discharge (0.2 days shorter) after introduction of sugammadex. Do to the nature of the study, it is nevertheless impossible to infer a causal link.
Abrishami et al.'s Cochrane review of 18 RCTs totalling 1,300 patients confirmed the superiority of sugammadex compared with neostigmine at all studied levels of blockade. They identified sugammadex dosing of:
Importantly there was similar frequency of adverse events compared to neostigmine (< 1%), although overall small sample sizes mean no conclusion can be made regarding rare serious adverse events.
Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
Time to achieve full reversal (TOFR > 0.9) was significantly faster with sugammadex (107s ± 61) than neostigmine (1044 ±590s) or edrophonium (331s ± 27).
All sugammadex-reversed patients were completely reversed within 5 minutes, compared with no patients receiving neostigmine.
Reversal with sugammadex lead to less increase in heart-rate than when neostigmine-glycopyrrolate or edrophonium-atropine and almost total avoidance of the dry-mouth associated with the later (5% vs 85-95%)
An audit of pre-extubation residual paralysis before and after the introduction of sugammadex. Residual paralysis was significantly more common in those not reversed or reversed with neostigmine than in those reversed with sugammadex.
Patients receiving sugammadex were also less likely to desaturate in the PACU and had fewer post-operative chest x-ray changes.