Clinical Question: Should we routinely reverse paralytics in the immediate post-op period of neurosurgical patients?
- RSI sometimes leads to prolonged residual paralysis, and this may interfere with neurologic examination
- in one study, positive responders (improved exam after reversal) occurred after the oft-quoted 1-hour duration of paralytics
- a single dose of intermediate-acting NMBA during intubation can confer residual paralysis evenmore than 2 hours after administration
- this residual neuromuscular blockade is common, and often underestimated by clinicians
- improved GCS (as well as non-improvement) after complete reversal of paralysis may influence patient care
What is SUGAMMADEX?
- chelating medication for non-depolarizing aminosteroidal neuromuscular blocking agents (NMBAs), and can reverse paralysis caused by rocuronium or vecuronium.
- use may facilitate timely neurologic assessments in patients who have received NMBAs compared to delaying the exam for NMBA clearance.
- known to be well-tolerated, but may infrequently cause adverse reactions such as severe bradycardia, hypotension and even asystole.
Impact of reversal:
- facilitate post-operative neurologic assessment in the ICU
- detect change in neurologic exam
- change in neurologic prognosis
- change in certainty of prior neurologic prognosis
- change in decision to pursue further neuroimaging and/or other escalations of care
- change to neurosurgical treatment plan
- no impact?
CONS for reversing:
- Adverse Events:
- lower HR (55%)
- lower MAP (82%)
- new or worsening bradycardia or hypotension (27%)
- no major cardiopulmonary events
- Significant reduction in MAP – vital for post-op patients, especially those already with or at risk of significant reduction in brain perfusion
- if patient RTOR – subsequent need for paralysis may be more challenging, requiring larger doses of rocuronium or vecuronium to overcome recent sugammadex exposure
- alternatviely – can use cisatracurium (benzylisoguinolinium non-depolarizing NMBA)… but then again, sugammadex does not bind this drug, so direct/rapid reversal may not be achievable and will delay subsequent post-op neurologic assessments
- may interfere with coagulation assays (aPTT/PT/INR and R-time on TEG), may prolong bleeding times, team should be made aware
**RECOMMENDATION: Given possible adverse effects of sugammadex, and the effect on the efficacy of subsequent paralytics which may be needed if patient RTOR, routine reversal should not be recommended. In patients who are paralyzed, where there may be clinical concerns for neurologic deterioration masked by paralysis, or in patients who are still deeply paralyzed, may consider reversing paralytics. (Sy)
Dosing:
- Sugammadex 200mg IV push x1, may repeat after 15 minutes if incomplete reversal
- Uptodate:
- Deep block (at least 1 to 2 post-tetanic counts and prior to the second twitch following train-of-four [TOF] stimulation): 4 mg/kg as a single dose (Geldner 2012).
- Moderate block (after appearance of the second twitch following TOF stimulation): 2 mg/kg as a single dose.
- Readministration of rocuronium or vecuronium: waiting times for readministration of rocuronium or vecuronium vary greatly (5 minutes to 24 hours) depending on agent, dose, and renal function; if immediate neuromuscular blockade is needed, a nonsteroidal neuromuscular-blocking agent (eg, cisatracurium or atracurium) may be required.
- Note regarding dosing – manufacturer-recommended dosing of 2mg/kg and 4mg/kg ABW pertain to reversal of moderate and deep levels of NMB respectively. At time of ICU evaluation, NMB likely to have fallen to shallower levels.
- Doses of 0.25-2mg/Kg have been recommended for reversing lighter depths across minimal to moderate block range. 200mg dose achieves this range across diverse adult patient weights.
CHECKLIST:
[ ] sign-out from anesthesia:
- Which paralytic was used? (does not work for succinylcholine or atracurium or cisatraciurium, only works for rocuronium and vecuronium)
- When was paralytic given? (larger doses required if more recent)
- How was paralytic given? (may not reverse if given by continuous infusion but can still consider)
[ ] Will reversal potentially change management of the patient? or inform prognosis?
[ ] Is there a possibility that patient will RTOR? (subsequent rocuronium / vecuronium administration will be less effective for up to 4 hours [24hwith renal impairment])
[ ] if decision to proceed – train-of-four, give sugammadex 200mg IV, repeat after 5 minutes in select circumstances (e.g. patient received high doses of continuous NMBAs) if incomplete response
[ ] document dose given, make team aware
[ ] monitor patient
- continue train-of-four monitoring
- anticipate change in exam
- anticipate reduction in MAP, hypotension, bradycardia – be ready to intervene
- rare, but watch out for anaphylaxis events
- if paralyzed patient was undersedated – may potentially become agitated and pull at lines/tubes when reversed – ensure support is available
REFERENCE:
Hyland, S.J. et al. (2022) “Sugammadex to facilitate neurologic assessment in severely brain-injured patients: Retrospective analysis and practical guidance,” Cureus [Preprint]. Available at: https://doi.org/10.7759/cureus.30466.
Sugammadex: Drug information (no date) UpToDate. Available at: https://www.uptodate.com/contents/sugammadex-drug-information?sectionName=Adult&topicId=105866&search=sugammadex&usage_type=panel&anchor=F46021169&source=panel_search_result&selectedTitle=1~63&showDrugLabel=true&kp_tab=drug_general&display_rank=1#F46021169 (Accessed: November 23, 2022).
Peripheral Brain 