LECTURES ABOUT NMB MONITORING AND SUGAMMADEX PROMOTED BY MSD ... Contribution of sugammadex for the safety of neuromuscular blockade.
Simão Esteves@
SAFETY IN THE MANAGEMENT OF NEUROMUSCULAR BLOCKADE SIMÃO ESTEVES SERVIÇO DE ANESTESIOLOGIA CHP - PORTO
DISCLOSURE MSD
CONSULTANT
L ECTURES ABOUT
NMB MONITORING AND SUGAMMADEX PROMOTED BY
MSD
Simão Esteves@
OVERVIEW • Use of neuromuscular blockers • Safety in the management of neuromuscular blockade • Side effects of neuromuscular blockers • Residual neuromuscular blockade • Contribution of sugammadex for the safety of neuromuscular blockade management
Simão Esteves@
CLASSIC INDICATIONS • Facilitate intubation
• Facilitate ventilation • Facilitate surgery
Simão Esteves@
FACILITATE INTUBATION
Simão Esteves@
Simão Esteves@
FACILITATE SURGERY
Simão Esteves@
WHERE ARE THE DIFFERENCES…
Simão Esteves@
FACILITATE SURGERY
Simão Esteves@
Simão Esteves@
ADVANTAGES OF NMB OPTIMIZATION • Assurance of immobility • Neurosurgery, microsurgery (ENT), ophthalmology
1-3
• Less abdominal muscle tone • Better conditions for laparoscopic surgery→ GI surgery, gynecology 2,4,5,6
• Lower abdominal pressure→ NMB may limit insufflation pressure 7
• Lower incidence of some complications
3,4,7,8
• Cough, higher abdominal and intrathecal pressures, upper airway lesions
1. Lemmens HJM et al. BMC Anesthesiol. 2010;10:15; 2. Meretoja OA. Paediatr Anaesth. 2010;20:591-604; 3. Rossiter JD et al. Eye (Lond). 2006;20:55-58; 4. Welliver M et al. Drug Des Devel Ther. 2008;2:49-59; 5. Ogunnaike BO et al. Anesth Analg. 2002;95:1793-1805; 6. Chassard D et al. Ann Fr Anesth Réanim. 1996;15:1013-1017. 7. Chui PT et al. Anaesth Intensive Care. 1993;21:163-171; 8. Mencke T et al. Anesthesiology. 2003;98:1049-1056
Simão Esteves@
SAFETY IN THE MANAGEMENT OF NEUROMUSCULAR BLOCKADE •
Side effects of neuromuscular blockers • Autonomic effects • Cardiovascular • Dysrhythmias, tachycardia, hypotension • Respiratory • Bronchospasm • Histamine release
• Hypotension, cutaneous rash • Alergic reactions • Anaphylaxis
Simão Esteves@
ANAPHYLAXIS
•
Quaternary ammonia ions seems to be related
•
Cross reactivity between different muscle relaxants and other daily life products
•
Rocuronium and sux are the drugs most related with anaphylaxis and anesthesia in Françe1
•
Rocuronium and atracurium were considered as drugs with moderate risk of anaphylaxis compared with sux (high risk) and vecuronium (low risk) 2
•
The higher incidence of anaphylaxis with rocuronium may only reflect it’s large use 2,3
•
Although relatively rare anaphylaxis related with rocuronium may be serious even fatal
1. Mertes PM, Laxenaire MC, Alla F: Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology 2003; 99:536-545; 2. Rose M, Fisher M: Rocuronium: High risk for anaphylaxis?. Br J Anaesth 2001; 86:678-682; 3. Watkins J: Incidence of UK reactions involving rocuronium may simply reflect market use. Br J Anaesth 2001; 87:522
Simão Esteves@
SAFETY IN THE MANAGEMENT OF NEUROMUSCULAR BLOCKADE •
Side effects of neuromuscular blockers antagonists • Neostigmine • Bradycardia, hypersalivation, bronchospasm, increased bronchial secretions, urinary frequency, nausea and vomiting • Atropine • Tachycardia, dryness of mouth and nose, mydriasis, urinary retention, delirium • Sugammadex • Allergy and anaphylaxis
Simão Esteves@
ANAPHYLAXIS AND SUGAMMADEX •
Some cases described (< 10) mainly in Japan
•
Several grades of severity (mild allergic reaction to anaphylactic shock)
•
Cause-effect relationship only in some cases
•
Possible causes – sugammadex as an antigen, sugammadex-rocuronium complex as an antigen, sugammadex structural changes mediated by light exposures an antigen
Simão Esteves@
SAFETY IN THE MANAGEMENT OF NEUROMUSCULAR BLOCKADE •
Residual neuromuscular blockade – presence of signals and symptoms of muscle weakness following the use of neuromuscular blockers
•
The diagnosis implies the use of quantitative monitors and a TOF R < 0.9 (although there are some studies that states that a TOF R =1.0 should be obtained when using the TOF Watch monitor)
•
Residual neuromuscular blockade may have harmful consequences for patients suffering this complication
Simão Esteves@
(Anesth Analg 2010;111:120–8)
Simão Esteves@
Simão Esteves@
Simão Esteves@
RECOVERY FROM NMB All patients (n = 526) 1.0 0.9
TOF Ratio
0.8 0.7 0.6
0.5 0.4 0.3 0.2 0.1 0.0 0
50
100
150
200
250
300
350
400
Time (min)
Debaene B et al. Anesthesiology. 2003;98:1042-1048
Simão Esteves@
(Anesth Analg 2010;111:120–8)
Simão Esteves@
ROLE OF SUGAMMADEX • Sugammadex may increase safety in the management of neuromuscular blockade: • Allowing a rapid and complete reversal of neuromuscular blockade, independent of the depth of blockade • Allowing an optimized use of neuromuscular blockade – deeper blockade until the end of surgery • Allowing the use of neuromuscular blockers in clinical situations where they were previously contra-indicated or pose difficulties in management - myopathies, myasthenia gravis
• Contributing as an adjunct therapy in anaphylactic reactions associated to amino steroid muscle relaxants • Contributing to a reduction in the incidence of residual neuromuscular blockade
Simão Esteves@
RAPID REVERSAL Reversão mais rápida com Sugamadex vs. Neostigmina (após reaparecimento de T2) Recuperação da razão TOF para 0,9 Rocurónio 0,6 mg/kg
Vecurónio 0,1 mg/kg
Sugamadex 2 mg/kg
NEO 50 µg/kg
Sugamadex 2 mg/kg
n = 48
n = 48
n = 48
95% IC (1,2-1,5 min)
95% IC (12,7-26,4min)
95% IC (1,9-3,0 min)
NEO 50 µg/kg n = 45 95% IC (12,2-25,5 min)
Dados do ensaio Aurora.
Simão Esteves@
RAPID REVERSAL INDEPENDENT OF DEPTH
Reversão mais rápida com Sugamadex vs. Neostigmina (após Rocurónio 0,6 mg/kg e a partir de 1-2 CPTs)
Reversão mais rápida com Sugamadex vs. Neostigmina (após Rocurónio 0,6 mg/kg e a partir de 1-2 CPTs) Os doentes tratados com Sugamadex atingiram mais cedo uma razão T4/T1 de 0,9
75 doentes ASA classe 1-4 Idade: 19-85 Anos
Sugamadex 4 mg/kg
n = 37
95% IC (2,3-3,3 min)
95% IC (35,7-59,5 min)
80 60
Sugamadex4 mg/kg
40
NEO 70 µg/kg
20 0
NEO 70 µg/kg
n = 37
Doentes que atingiram uma razão T4 /T1 de 0,9 (%)
100
0
20
40
60
80
100
120
140
160
Tempo (min) Dados do ensaio Signal.
Dados do ensaio Signal.
Simão Esteves@
USE IN SPECIAL CIRCUMSTANCES
Simão Esteves@
ANAPHYLAXIS TREATMENT (ROCURONIUM)
Br. J. Anaesth. (2011) 107 (2): 275-276.
Simão Esteves@
RESIDUAL BLOCKADE AND SUGAMMADEX What contribution ?
Simão Esteves@
Simão Esteves@
Simão Esteves@
Simão Esteves@
Simão Esteves@
Simão Esteves@
Simão Esteves@
CLOSING REMARKS • Contributions for neuromuscular blockade management safety: • Being aware of clinical importance of residual neuromuscular blockade
• Use of intermediate neuromuscular blockers • Systematic utilization of neuromuscular monitoring (quantitative if possible) • Regular use of neuromuscular reversal • Use of sugammadex when considered clinically indicated