Sugammadex to Facilitate Neurologic Assessment in Severely Brain-Injured Patients: A Retrospective Analysis and Practical Guidance

Abstract

Background Widely used in anesthetic management, sugammadex is increasingly employed in the reversal of neuromuscular blocking agents (NMBAs) in the emergency department and critical care arena, where little evaluative data currently exists. This study explored the utility and safety of using sugammadex to facilitate neurologic assessments in critically ill, NMBA-exposed patients. Methods We pursued a retrospective case series and single-arm cohort analysis of all brain-injured patients receiving sugammadex to facilitate neurologic evaluation during one year at a high-volume Level 1 trauma center. The primary outcome was the qualitative impact of sugammadex administration on neurosurgeon decision-making. Secondary outcomes included the change to Glasgow Coma Scale (GCS) and hemodynamic parameters compared before and after sugammadex administration. Sugammadex dosing was also assessed across various weight scalars to explore dose-response trends and generate preliminary guidance for use in this setting. Results Our study criteria yielded 12 sugammadex administrations across 11 patients, the majority of whom had sustained a traumatic brain injury. All sugammadex administrations were adjudicated as beneficial to neurosurgeon decision-making and 50% were associated with a change to prognosis and plan. Sugammadex was associated with an increase in the GCS of 1-8 points among the 67% of patients who responded. Mean arterial pressure decreased significantly after sugammadex administration (median 94 vs. 104 mmHg, p=0.0215, median change of -8 mmHg [95%CI -25-3 mmHg]). No apparent dose-response trends were observed for changes to GCS or hemodynamic parameters. Conclusions The use of sugammadex to facilitate neurologic assessment after NMBA exposure in brain-injured patients was frequently associated with clinically meaningful changes to the neurologic exam and treatment plan. The risks of hemodynamic compromise and care complexity should be collaboratively weighed before pursuing this modality. An empiric sugammadex dose of 200 mg appears reasonable for this purpose, but further evaluation of NMBA reversal in the neurocritically ill outside of procedural settings is warranted.

Keywords: emergency neurosurgery; intracranial hemorrhage; neurologic assessment; neuromuscular blockade; neuroprognostication; non-depolarizing neuromuscular blocking agents; rapid sequence intubation; rocuronium; sugammadex; traumatic brain injury.

Figure 1. Population determination

ED=emergency department, FY20=fiscal year 2020 (July 1, 2019 to June 30, 2020), ICU=intensive care unit

Figure 2. GCS after sugammadex administration

All patients had a Glasgow Coma Scale (GCS) score of 3T prior to sugammadex administration. The distribution of GCS for the total population post-sugammadex is represented in the orange box-and-whiskers plot (n=11, p=0.0156 compared pre- vs. post-sugammadex), and for the sugammadex responders' subgroup in the yellow plot (n=7, p​​​​​​​=0.0156 compared pre- vs. post-sugammadex). Interpretation: Middle line inside box denotes median, x denotes mean, outer lines of box denote interquartile range, ends of whiskers denote total range (Note: values outside 1.5 times the interquartile range are considered outliers and instead represented by dots). P-values noted are from Wilcoxon Rank Sum Test (tests null hypothesis that the distribution of the differences has a median=0).

Figure 3. MAP and HR compared before and after sugammadex administration

HR=heart rate in beats per minute, MAP=mean arterial pressure in millimeters of mercury. Orange box-and-whisker plots include total population (n=11), red plots represent the sugammadex non-responder subgroup (n=4), and yellow plots represent the sugammadex responder subgroup (n=7). Within each pair of plots, the plot on the left represents pre-sugammadex administration and the plot on the right represents post-sugammadex administration. Interpretation: Middle line inside box denotes median, x denotes mean, outer lines of box denote interquartile range, ends of whiskers denote total range (Note: values outside 1.5 times the interquartile range are considered outliers and instead represented by dots). P-values noted are from Wilcoxon Rank Sum Test (tests null hypothesis that the distribution of the differences has a median=0).