Preparing for the unexpected: special considerations and complications after sugammadex administration

Abstract

Sugammadex, a modified gamma-cyclodextrin, has changed clinical practice of neuromuscular reversal dramatically. With the introduction of this selective relaxant binding agent, rapid and reliable neuromuscular reversal from any depth of block became possible. Sugammadex can reverse neuromuscular blockade without the muscarinic side effects typically associated with the administration of acetylcholinesterase inhibitors. However, what remained unchanged is the incidence of residual neuromuscular blockade. It is known that sugammadex cannot always prevent its occurrence, if appropriate dosing is not chosen based on the level of neuromuscular paralysis prior to administration determined by objective neuromuscular monitoring. Alternatively, excessive doses of sugammadex administered in an attempt to ensure full and sustained reversal may affect the effectiveness of rocuronium in case of immediate reoperation or reintubation. In such emergent scenarios that require onset of rapid and reliable neuromuscular blockade, the summary of product characteristics (package insert) recommends using benzylisoquinolinium neuromuscular blocking agents or a depolarizing agent. However, if rapid intubation is required, succinylcholine has a significant number of side effects, and benzylisoquinolinium agents may not have the rapid onset required. Therefore, prior administration of sugammadex introduces a new set of potential problems that require new solutions. This novel reversal agent thus presents new challenges and anesthesiologists must familiarize themselves with specific issues with its use (e.g., bleeding risk, hypermagnesemia, hypothermia). This review will address sugammadex administration in such special clinical situations.

Keywords: Anticholinesterase; Neostigmine; Neuromuscular block; Neuromuscular blocking drugs; Neuromuscular function; Pharmacologic reversal; Sugammadex.

Fig. 1

The relationship between the total dose of rocuronium (mg/kg) needed to re-establish neuromuscular blockade and time interval (minutes) between sugammadex administration and re-administration of rocuronium. It was adapted from Iwasaki et al. [7]. In this study, 0.6 mg/kg re-established neuromuscular blockade within 3 min when it was administered >3 h after sugammadex reversal. Larger doses (0.9 or 1.2 mg/kg) were necessary to re-establish neuromuscular blockade when sugammadex was administered less than 2 h previously

Fig. 2

The recommended algorithm to re-establish neuromuscular blockade after sugammadex administration [46, 51, 53]