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Recovery from NMBA : problems and solutionsRecovery from NMBA : problems and solutions
Wirat WasinwongWirat WasinwongAnesthesia department
Faculty of MedicinePrince of Songkla University
Muscle relaxant
• 1912 : curare
• 1970s : pancuronium
• 1980s : vecuronium, cisatracurium, mivacurium, rocuronium
• rapacuronium
Ideal muscle relaxant
• Onset
• Duration
• Metabolite/accumulation
• Safety
• Reversibility
• Cost
Rocuronium
• Dose 0.6-0.9 mg/kg
• Onset 60-90 sec.
• Duration 20-40 min.
• Minimal cardiovascular effect
• Hepatorenal excretion
Dam and Goldman “ Today, the most common cause
of postoperative respiratory inadequacy is the use and misuse of muscle relaxant drugs”
Anesthesiology 1961; 22:699-707
Postoperative residual curarization (PORC)
• 1979– Residual postoperative weakness– Incomplete recovery– Ventilatory complications
Anesthesiology 1997; 86:765-71
• Kopman, Yee and Neuman
“ normal vital muscle function, including normal pharyngeal function, requires the TOF ratio at the adductor pollicis to recover to > 0.9 ”
relationship between receptor occupancy and neuromuscular monitoring
0
25
50
75
100
125
concentration
rece
pto
r o
ccu
pat
ion
(%
) no neuromuscular block block
A.H. Bom , Dept. Pharmacology, Organon Newhouse, Scotland, UK
Minimal residual paralysis
• Impair pharyngeal muscle function
• Reduce lower esophageal sphincter tone
• Increase risk – Aspiration– Upper airway obstruction– Impair hypoxic ventilatory response
Eriksson LI, et al. Anesthesiology 1997;87: 1035-43. Eikerman M, et al. Anesthesiology 2003; 98: 1333-7.Eriksson LI, et al. Anesthesiology 1993;78: 693-9.
Incidence of residual blockStudy year n TOF NDMR PORC
reverse
Cammu G 2002 30 <O.7 cisatracurium 40 % Y
rocuronium 47Gatke MR 2002 120 <0.8 roc with TOF 3 without TOF 16.7Hayes AH 2001 150 <0.8 vecuronium 64 atracurium 52 rocuronium 47Baillaed C 2000 568 <O.7 vecuronium 42
NBerg H 1997 691 <0.7 pancuronium 26 atr, vec
5.3Shorten GD 1992 panc with TOF 15 wthout TOF 47
Debeane B,et al. Anesthesiology,2003;98(5):1042-8
Naguib M, et al. Br J Anaesth 2007;98(3):302-16.
Murphy GS,et al. Anesth Analg 2004,98:193-200
Berg H,et al. Acta Anaesthesiol Scand 1997;41:1095
Pancuronium in cardiac surgery
• Increase duration of weaning and tracheal extubation
• Significant muscle weakness after tracheal extubation
Murphy GS, et al. Anesth Analg 2002;95:1534-9 Murphy GS, et al. Anesth Analg 2003;96:1301-7
Thomas R, et al. Anaesthsia 2003;58:265-70
How to avoid PORC
• Avoid long acting NMBA
• Avoid unnecessary deep block
• Antagonize block at the end
• Do not initiate reversal before– Spontaneous muscle activity presents– 3 or 4 response of TOF
• Use reliable clinical evaluation
• Objective neuromuscular monitoring
• Objective neuromuscular monitoring is evidence based practice
Ericksson LI. Anesthesiology
2003;98:1037-9.
Neuromuscular blockade reversal
Disadvantages of anticholinesterases
• Inability to antagonize profound block• Relatively slow onset of action to peak1
–neostigmine (7–11 min)–pyridostigmine (15–20 min)
• Muscarinic effects–bradycardia and hypotension–bronchoconstriction and excessive
secretions–nausea and vomiting
1. Bevan DR et al. Anesthesiology. 1992; 77:785–805
Sugammadex
top / bottom view side view
-cyclodextrin
6 glucose units
-cyclodextrin
7 glucose units
-cyclodextrin
8 glucose units
Hydrophilic exterior : polar hydroxyl group
O
S
OH
OH
O S
OH
OH
O
OS
OH O
O
S
OHOH OO
S
OH
OH
O
OS
OH
OH
O
OS
OH
OH
O
O
S
OHOHO
O
OH
CO2Na
CO2Na
NaO2C
NaO2C
NaO2C
NaO2C
CO2Na
CO2Na
Hydrophobic cavity
Carboxyethyl group
Quaternary nitrogen
Sugammadex• Water-soluble complex formation
1:1 ratio with steroidal muscle relaxants
• rocuronium > vecuronium >> pancuronium
Sugammadex• No effects on acetylcholinesterase or any
other receptors (nicotinic, muscarinic)
• Acid-base change: no effects on sugammadex efficacy
Pharmacokinetics
• Elimination half-life ≈100 min
• Clearance 120 mL/min– similar to normal glomerular filtration rate
• Volume of distribution 18 L– > blood volume, but substantially
< the volume of the extracellular space
• 59–80% of administered dose excreted in the urine over 24 h
Gijsenbergh F et al. Anesthesiology. 2005; 103:695–703
Sugammadex increases renal excretion of rocuronium• 14% of an administered rocuronium dose
is excreted in the urine within 0–24 h
• With concomitant administration of sugammadex (8.0 mg/kg at 3 min) renal excretion of rocuronium within 0–24 h increased to 39–68%
Gijsenbergh F et al. Anesthesiology. 2005; 103:695–703
Sugammadex
• Drugs that potentiate effects of neuromuscular blocking agents (Mg2+, aminoglycosides) may need higher sugammadex dose
• Other steroids– Cortisone, atropine, verapamil– 120-700 time < rocuronium– Clinical insignificant
Clinical studies
Reversal of Rocuronium-induced Neuromuscular Block by the Selective Relaxant Binding Agent Sugammadex : A Dose-finding and Safety StudySorgenfrei IF. Anesthesiology 2006 10466; :7 74–
• Randomized, placebo-controlled, assessor-blinded trial
• 27 male patients.
• 0.6 mg/kg rocuronium
• Sugammadex 0.5, 1, 2, 3 ,4 mg/kg at T2 of TOF
Reversal of Rocuronium-induced (1.2 mg/kg) ProfoundNeuromuscular Block by SugammadexA Multicenter, Dose-finding and Safety Study
de Boer, HD, et al. Anesthesiology 2007 107239; : –44
• phase II, multicenter,assessor-blinded, placebo-controlled, parallel study.
• 43 patients
• 5-min reversal after rocuronium
• Adverse effects : diarrhea, light anesthesia
Early Reversal of Profound Rocuronium-inducedNeuromuscular Blockade by Sugammadex in aRandomized Multicenter StudyEfficacy, Safety, and Pharmacokinetics
Sparr HJ , et al. Anesthesiology 2007 106935 4; : –3
• 98 male adult patients
• Reversal at 3,5 and 15 min
• After rocuronium 0.6 mg/kg.
• Adverse effect: sucking, moving, glimace, cough
Anesth Analg 2007;104(3):569-74
Sugammadex• 3 times more rapid than edrophonium
• 10 times more rapid than neostigmine
Side effects • Hypotension• Cough• Vomitting• Dry mouth• Abnormal smell• Sensation of a changed temperature
• Abnormal level of N-acetyl glucosaminidase in urine
Safety
• Biologically inactive• Not bind to plasma proteins • Sugammadex well tolerated in studies to date
Gijsenbergh F et al. Anesthesiology. 2005; 103:695–703
Limitation • succinylcholine, benzylisoquinolinium
– Ineffective– After reversing with sugammadex
: difficult ,unpredictable dose of rocuronium, vecuronium to re-establish block
: more intense block benzylisoquinolinium
: decrease dose
Limitation • Cost
• Sugammadex-rocuronium complex in renal disease : unclear
• Reverse profound block with inadequate dose : incomplete recovery
Approval of Sugammadex 11-Mar-08 07:05 pm • Schering-Plough announces the FDA Advisory
Committee unanimously recommends U.S. approval of sugammadex, the first and only selective relaxant binding agent (19.82 +0.17) -Update-
Co announced that the U.S. Food and Drug Administration (FDA) Advisory Committee on Anesthetics and Life Support has recommended sugammadex for approval. After reviewing data on the safety
Gantacurium• Lack of accumulation• Dose 2.5-3 x ED95
– Maximum block onset within 90 sec.
• 25-75% recovery index = 3 min.– 7 min. for mivacurium– 9 min. for rapacuronium– 14 min. for cisatracurium
• Clinical duration < 10 min.• Complete recovery to TOF>0.9 within 15 min.
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