Neuromuscular blockade rocuronium

A novel cyclodextrin reversal drug, sugammadex, has been submitted for FDA approval. It can rapidly inactivate steroidal neuromuscular blocking drugs by forming an inactive complex, which is excreted in the urine. This process allows the practitioner to rapidly reverse even profound degrees of neuromuscular blockade produced by rocuronium and vecuronium at the end of the surgical procedure. 

Sacan O, Klein K, White PF Sugammadex reversal of rocuronium-induced neuromuscular blockade A comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg 2007 104 569. [PMID 17312210]... 

Inhalation anaesthetics may impair the efficacy of anticholinesterases in reversing neuromuscular blockade. Propofol does not affect the reversal of rocuronium block by neostigmine. Physostigmine pre-treatment increased propofol requirements by 20% in one study. 

The inhalational anaesthetics increase the effects of the neuromuscular blockers to differing extents, but nitrous oxide appears not to interact significantly. Ketamine has been reported to potentiate the effects of atracurium. Propofol does not appear to interact with mivacurium or vecuronium. Xenon is reported not to interact with mivacurium or rocuronium, and has less effect than sevoflurane on vecuronium neuromuscular blockade. Bradycardia has been seen in patients given vecuronium with eto-midate or thiopental. Propofol can cause serious bradycardia if it is given with suxamethonium (succinylcholine) without adequate antimuscarinic premedication, and asystole has been seen when fentanyl, propofol and suxamethonium were given sequentially. 

A 71-year-old woman received a standard bowel preparation consisting of oral erythromycin and neomycin (a total of 3 g). Surgery was postponed for one day and she received a second similar bowel preparation pre-operatively. Anaesthesia was induced with sufentanil and etomidate and maintained with isoflurane and sufentanil. Rocuronium (total dose of 60 mg over 2 hours) was used to facilitate tracheal intubation and maintain muscle relaxation. Despite clinical appearance of a reversal of the neuromuscular blockade by neostigmine 3.5 mg and glycopyrrolate 400 micrograms, the patient complained of dyspnoea and required reintubation twice. The effects of additional doses of neostigmine were inconsistent and the use edrophonium 50 mg or calcium chloride 500 mg intravenously did not result in an improvement. ... 

Hasfurther DL, Bailey PL. Failure of neuromuscular blockade reversal after rocuronium in a patient who received oral neomycin. Can J/fnoesdi (1996) 43,617-20. 

Spacek A Neiger FX, Katz RL, Watkins WD, Spiss CK. Chronic carbamazepine therapy does not affect neuromuscular blockade by rocuronium. AnesthAnalg (1995) 80 (Suppl 2), S463,... 

Hem dez-Pala n J, Toitosa JA Maitinez-Lage JF, Perez-Ayala M. Rocuronium-induced neuromuscular blockade is affected chronic phenytoin therapy. J Neurosurg Anesthesiol... 

No change in neuromuscular blockade was seen in patients given intravenous cefuroxime shortly before pipecuronium or rocuronium in a controlled study. Similarly, intravenous cefoxitin given before, during and after surgery was not associated with a clinically important prolongation of vecuronium blockade. ... 

Duvaldestin P, Kuizenga K, Saldien V, Claudius C, Servin F, Klein J, Debaene B, Heeringa M. A randomized, dose-response study of sugammadex given for the reversal of deep rocuronium- or vecuronium-induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg 2010 110(1) 74-82. 

Dahl V, Pendeville PE, Hollmann MW, Heier T, Abels EA, Blobner M. Safety and efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in cardiac patients undergoing noncardiac surgery. Eur J Anaesthesiol 2009 26(10) 874-84. 

Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart PA, van Kuijk JH, Hermens Y, Mirakhur RK. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology 2009 110(2) 284-94. 

Systematic reviews The place of suxamethonium in pediatric practice has been reviewed It has significant adverse effects, some of which can be life-threatening. This is particularly relevant in pediatric anesthesia, because the spectrum of childhood diseases may expose susceptible individuals to an increased chance of adverse events compared with adults. The authors suggested that the rapidity of onset and offset of suxamethonium encourages its use by practitioners with only occasional experience of pediatric anesthesia. Rocuronium has a similar onset of action at a dose of 1.2 mg/kg, but sugammadex (a reversal agent specific to rocuronium) does not have a product licence for immediate reversal of neuromuscular blockade in children. 

This is a shghtly different conclusion from that reached in a Cochrane review of rocuronium versus suxamethonium for rapid-sequence intubation, which was that suxamethonium creates excellent intubation conditions more rehably than rocuronium [12 ]. However, the abihty of sugammadex to reverse deep neuromuscular blockade under rocuronium may alter the benefit to harm balance in comparison with suxamethonium. 

Puhringer FK, Rex C, Sielenkamper AW, Claudius C, Larsen PB, Prins ME, Eikermann M, Khuenl-Brady KS. Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points an international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial. Anesthesiology 2008 109(2) 188-97. 

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