Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade.
BACKGROUND
Sugammadex is the first selective relaxant binding agent that has been studied for reversal of neuromuscular blockade induced by rocuronium and other steroidal non-depolarizing neuromuscular blocking agents (NMBAs).


OBJECTIVE
To assess the efficacy and safety of sugammadex in reversing neuromuscular blockade induced by steroidal non-depolarizing NMBAs and in preventing postoperative residual neuromuscular blockade.


METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), and EMBASE (1980 to August 2008). In addition, we handsearched reference lists of relevant articles and meeting abstracts. Furthermore, we contacted the medication's manufacturer for more information.


METHODS
All randomized controlled trials (RCTs) on adult patients (>/= 18 years old) in which sugammadex was compared with placebo or other medications, or in which different doses of sugammadex were compared with each other. We excluded non-randomized trials and studies on healthy volunteers.


METHODS
We independently performed determination of trial inclusion, quality assessment, and data extraction. We applied standard meta-analytic techniques.


RESULTS
We included18 RCTs (n = 1321 patients). Seven trials were published as full-text papers, and 11 trials only as meeting abstracts. All the included trials had adequate methods of randomization and allocation concealment. The results suggest that, compared with placebo or neostigmine, sugammadex can more rapidly reverse rocuronium-induced neuromuscular blockade regardless of the depth of the block. We identified 2, 4, and 16 mg/kg of sugammadex for reversal of rocuronium-induced neuromuscular blockade at T(2) reappearance , 1 to 2 post-tetanic counts, and 3 to 5 minutes after rocuronium, respectively. The number of trials are very limited regarding vecuronium and pancuronium. Serious adverse events occurred in < 1% of all patients who received the medication. There was no significant difference between sugammadex and placebo in terms of the prevalence of drug-related adverse events (RR 1.20, 95% CI 0.61 to 2.37; P = 0.59, I(2) = 0%, 5 RCTs). Also, no significant difference was found between sugammadex and neostigmine for adverse events (RR 0.98, 95% CI 0.48 to1.98; P = 0.95, I(2) = 43%, 3 RCTs).


CONCLUSIONS
Sugammadex was shown to be effective in reversing rocuronium-induced neuromuscular blockade. This review has found no evidence of a difference in the instance of unwanted effects between sugammadex, placebo or neostigmine. These results need to be confirmed by future trials on larger patient populations and with more focus on patient-related outcomes.
Abrishami
Amir
A
Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, 2-241A McLaughlin Wing, Toronto, Ontario, Canada, M5T 2S8.
Ho
Joyce
J
Wong
Jean
J
Yin
Ling
L
Chung
Frances
F
D000328:Adult; D000732:Androstanols / Q000037:antagonists & inhibitors; D002800:Cholinesterase Inhibitors / Q000494:pharmacology; D006801:Humans; D009388:Neostigmine / Q000494:pharmacology; D019148:Neuromuscular Blockade; D009469:Neuromuscular Junction / Q000187:drug effects*; D003473:Neuromuscular Nondepolarizing Agents / Q000037:antagonists & inhibitors*; D010197:Pancuronium / Q000037:antagonists & inhibitors; D016032:Randomized Controlled Trials as Topic; D000077123:Rocuronium; D000077122:Sugammadex; D014673:Vecuronium Bromide / Q000037:antagonists & inhibitors; D047408:gamma-Cyclodextrins / Q000494:pharmacology*
D000732:Androstanols; D002800:Cholinesterase Inhibitors; D003473:Neuromuscular Nondepolarizing Agents; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D009388:Neostigmine; D014673:Vecuronium Bromide; D010197:Pancuronium; D000077123:Rocuronium