Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Comparison with Neostigmine???Glycopyrrolate and Edrophonium???Atropine

In Brief BACKGROUND: Sugammadex is a modified γ cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound residual rocuronium-induced blockade than the commonly used cholinesterase inhibitors, edrophonium and neostigmine. METHODS: Sixty patients undergoing elective surgery procedures with a standardized desflurane–remifentanil–rocuronium anesthetic technique received either sugammadex, 4 mg/kg IV (n = 20), edrophonium, 1 mg/kg IV and atropine, 10 μg/kg IV (n = 20), or neostigmine, 70 μg/kg IV and glycopyrrolate, 14 μg/kg IV (n = 20) for reversal of neuromuscular blockade at 15 min or longer after the last dose of rocuronium using acceleromyography to record the train-of-four (TOF) responses. Mean arterial blood pressure and heart rate values were recorded immediately before and for 30 min after reversal drug administration. Side effects were noted at discharge from the postanesthesia care unit. RESULTS: The three groups were similar with respect to their demographic characteristics and total dosages of rocuronium prior to administering the study medication. Although the initial twitch heights (T1) at the time of reversal were similar in all three groups, the time to achieve TOF ratios of 0.7 and 0.9 were significantly shorter with sugammadex (71 ± 25 and 107 ± 61 s) than edrophonium (202 ± 171 and 331 ± 27 s) or neostigmine (625 ± 341 and 1044 ± 590 s). All patients in the sugammadex group achieved a TOF ratio of 0.9 ≤5 min after reversal administration compared with none and 5% in the edrophonium and neostigmine groups, respectively. Heart rate values at 2 and 5 min after reversal were significantly higher in the neostigmine-glycopyrrolate group compared with that in sugammadex. Finally, the incidence of dry mouth was significantly reduced in the sugammadex group (5% vs 85% and 95% in the neostigmine and edrophonium groups, respectively). CONCLUSION: Sugammadex, 4 mg/kg IV, more rapidly and effectively reversed residual neuromuscular blockade when compared with neostigmine (70 μg/kg IV) and edrophonium (1 mg/kg IV). Use of sugammadex was associated with less frequent dry mouth than that with the currently used reversal drug combinations. IMPLICATIONS: Use of the cyclodextrin reversal drug, sugammadex, (4 mg/kg IV) was associated with a more rapid reversal of the train-of-four (TOF) to 0.9 after rocuronium-induced neuromuscular blockade (107 ± 61 s) when compared with edrophonium (331 ± 27 s) or neostigmine (1044 ± 590 s). More importantly, 75% of the patients in the sugammadex group achieved a TOF of 0.9 at 2 min after reversal compared with none in the two anticholinesterase groups. Sugammadex was also associated with less dry mouth than that with the conventional reversal drug combinations in the early postoperative period.