In this episode, I’ll discuss the Management of muscle relaxation with rocuronium and reversal with neostigmine or sugammadex guided by quantitative neuromuscular monitoring.
Sugammadex is an effective but expensive neuromuscular blocking reversal agent compared with the previous standard of care, neostigmine. In many cases neostigmine will work adequately, but if a patient does not have effective reversal of neuromuscular blockade with neostigmine the consequence can be an expensive and unexpected extended stay in the recovery unit or even overnight stay in an intensive care unit while the neuromuscular blockade wears off and the patient can be weaned from a ventilator. This uncommon but significant consequence naturally leads providers to want to use sugammadex exclusively and abandon neostigmine.
A group of authors recently published a study in Anesthesia and Analgesia that evaluated a protocol for managing rocuronium blockade and reversal, using quantitative monitoring to guide choice of reversal agent and to confirm full reversal before extubation.
This was a prospective cohort study that used electromyography-based quantitative monitoring and enrolled 200 patients scheduled for elective surgery involving the intraoperative use of rocuronium. Neuromsucular blockade reversal was accomplished with neostigmine if the train-of-four (TOF) ratio was 0.40 to 0.89 and with sugammadex for deeper levels of neuromuscular blockade. The primary endpoint was the incidence of postoperative residual neuromuscular blockade (PRNB), defined as TOF ratio <0.9 at the time of extubation. Using this protocol, the overall incidence of residual paralysis was 0% and the drug acquisition cost was 40% lower than it would have been if sugammadex was used exclusively. This protocol represents a successful implementation of selective use of sugammadex that can lower drug costs while still achieving zero residual paralysis and avoid prolonged stays in PACU or intensive care. To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
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