Dr Matthew Hart BM BCh BA (Oxon) FANZCA MRCA, Consultant Anaesthetist
The Children’s Hospital at Westmead, Sydney on the changing patterns of NMBs and sugammadex.
Despite a substantial drop in price and increase in availability, I have not adopted sugammadex into my routine clinical practice, and my primary reason for this is concerns around hypersensitivity.
Published data from Japan, where historically sugammadex usage has been high, suggest the incidence of anaphylaxis to sugammadex is as high as 1 in 5000. Add to this that using sugammadex infers an aminosteroid NMB (yet another anaphylaxis trigger) has also been utilised, then the combined usage of an NMB and sugammadex may expose children to a not insignificant risk of a life-threatening complication of anaesthesia. Additionally, many of our paediatric patient population attend for repeated procedures, and possibly risk sensitisation if given an NMB and sugammadex every time.
To my mind this means I need to have a very compelling reason to use this combination over a more traditional NMB free or NMB + anti-cholinesterase reversal technique if I am to justify the risk, and most cases I encounter in my routine practice simply do not meet this threshold. It is for similar reasons that I also do not view the need for tracheal intubation alone as an indicator to use a NMB.
Until there is strong evidence to suggest otherwise, for cases where an NMB is required, I will continue to reverse with neostygmine and an anticholinergic.
From Proshad Efune, MD, MSCS, Associate Professor, Department of Anesthesiology and Pain Management, Department of Pediatrics
Can neuromuscular blockade with sugammadex reversal alter our practice with resultant improvement in outcomes for the second most performed surgery in pediatric patients? This was the research question which formed the basis for a recent randomized, assessor blinded, controlled trial we performed at UT Southwestern Medical Center/Children’s Health Dallas. We hypothesized that children undergoing adenotonsillectomy who received neuromuscular blockade with sugammadex reversal at the end of surgery would consume less opioids perioperatively and have fewer respiratory events postoperatively. The basis of this hypothesis was alluded to in this week’s PAAD on how sugammadex has changed our practice as pediatric anesthesiologists. Adenotonsillectomies are short procedures with near constant painful stimulation from the time of mouth gag insertion until completion of surgery. The typical anesthetic regimen does not include neuromuscular blockade because of the short duration of the procedure and the concern that some recovery of neuromuscular function may not be achieved by the end of the procedure, even with low doses of neuromuscular blockade. This precludes the use of acetylcholinesterase inhibitors for reversal, unless waiting for some recovery could be tolerated (which it often is not because of the production pressure in these high turnover ENT rooms and expectation of highly efficient anesthetic management). Despite the introduction of sugammadex which requires only very little recovery of neuromuscular function for effective reversal, our practice has largely remained the same. Because of the near constant painful stimulation during these procedures, medications like fentanyl and propofol are administered to prevent non purposeful movement when neuromuscular blockade is not used. Consequently, children undergoing adenotonsillectomy are at risk for overdose with opioid analgesics. Our prior work demonstrated that opioid analgesia increases the number of episodes of hypoxemia after high-risk adenotonsillectomy.1 Therefore, we enrolled 172 children two to 12 years of age who were considered high risk i.e. less than three years of age, obese, or with severe OSA who underwent adenotonsillectomy. The participants were randomized to receive neuromuscular blockade at induction with sugammadex reversal upon completion of surgery or standard anesthesia without neuromuscular blockade. Study conditions were carefully controlled to prevent the influence of cointerventions on our outcomes. Children who received neuromuscular blockade were monitored with quantitative neuromuscular monitoring and were not extubated until the train of four ratio exceeded 90%. We used BIS guidance in both groups to ensure groups were under a similar depth of anesthesia during surgery. All patients were extubated awake. Opioid consumption was measured intra and postoperatively up to 24 hours following surgery and respiratory events were measured postoperatively up to 24 hours following surgery. Be on the lookout for our results.
1. Efune PN, Pinales P, Park J, Poppino KF, Mitchell RB, Szmuk P. Pediatric obstructive sleep apnea: a prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy. Anaesth Crit Care Pain Med. 2024;43(4):101385. doi:10.1016/j.accpm.2024.101385