Can sugammadex save a patient in a simulated ‘cannot intubate, cannot ventilate’ situation?

We read with interest the recent article by Bisschops et al. evaluating the use of sugammadex in a simulated emergency scenario [1]. It is well known that simulation used in this type of setting allows the educator to set the clinical agenda and practise rare scenarios that may be predicted to happen during regular clinical practice [2]. Simulation is invaluable in testing and improving standard operating procedures [3] in a safe environment [4]. Familiarisation with environment and standard operating procedures is also vital in the use of non-technical skills [5], particularly when using a new drug such as sugammadex. In our experience, requiring candidates to draw up their own drugs in real-time, such as dantrolene in a scenario involving malignant hyperthermia, supports the learning objectives by enhancing realism and providing time-sensitive goals. We strongly agree with the recommendations made for the use of high-dose rocuronium in combination with sugammadex for rapid sequence induction and would like to suggest some steps based on our own experience. The first step we suggest is to brief the team that rocuronium is to be used and that should an unanticipated difficult airway situation be encountered, then sugammadex will be used to reverse the effects of the rocuronium. This briefing could be included as part of the World Health Organization checklist, where anticipated airway problems are discussed [6]. The second step is to allocate the task of drawing up the sugammadex to a specific team member who has no additional role in the rapid sequence induction. Before induction, a calculation is made of the dose of sugammadex (16 mg.kg−1) that would be required and the volume of drug that should be drawn up. The instruction is given that should the anaesthetist not confirm intubation within 2 min, then the sugammadex is to be drawn up and handed to the anaesthetist for administration. Tasking one person with the responsibility of drawing up this emergency drug in a timely manner may avoid any loss of situational awareness, which may arise when dealing with a difficult airway. This has occurred in high-profile cases [7] and we suggest that patient safety would be improved by the introduction of this additional anticipation and planning. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.