Reversal of Pipecuronium-Induced Moderate Neuromuscular Block with Sugammadex in the Presence of a Sevoflurane Anesthetic: A Randomized Trial.
BACKGROUND
Pipecuronium is a steroidal neuromuscular blocking agent. Sugammadex, a relaxant binding γ-cyclodextrin derivative, reverses the effect of rocuronium, vecuronium, and pancuronium. We investigated whether sugammadex reverses moderate pipecuronium-induced neuromuscular blockade (NMB) and the doses required to achieve reversal.


METHODS
This single-center, randomized, double-blind, 5-group parallel-arm study comprised 50 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch SX) according to international standards. When the NMB recovered spontaneously to train-of-four count 2, patients randomly received 1.0, 2.0, 3.0, or 4.0 mg/kg of sugammadex or placebo. Recovery time from sugammadex injection to normalized train-of-four (TOF) ratio 0.9 was the primary outcome variable. The recovery time from the sugammadex injection to final T1 was the secondary end point. Postoperative neuromuscular functions were also assessed.


RESULTS
Each patient who received sugammadex recovered to a normalized TOF ratio of 0.9 within 5.0 minutes (95% lower confidence interval for the lowest dose 70.1%; for all doses 90.8%) and 79% of these patients reached a normalized TOF ratio 0.9 within 2.0 minutes (95% lower confidence interval for the lowest dose 26.7%; for all doses 63.7%). T1 recovered several minutes after the TOF ratio. No residual postoperative NMB was observed.


CONCLUSIONS
Sugammadex adequately and rapidly reverses pipecuronium-induced moderate NMB during sevoflurane anesthesia. Once the train-of-four count has spontaneously returned to 2 responses following pipecuronium administration, a dose of 2.0 mg/kg of sugammadex is sufficient to reverse the NMB.
From the *Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary; and †Department of Ecology, Hungarian Academy of Sciences, Centre for Ecological Research, Debrecen, Hungary.
Edömér
E
Tassonyi
Adrienn
A
Pongrácz
Réka
R
Nemes
László
L
Asztalos
Szabolcs
S
Lengyel
Béla
B
Fülesdi
D000328:Adult; D000368:Aged; D000762:Anesthesia Recovery Period; D000768:Anesthesia, General / Q000379:methods*; D018685:Anesthetics, Inhalation; D000931:Antidotes / Q000627:therapeutic use*; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006814:Hungary; D008297:Male; D008738:Methyl Ethers; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000009:adverse effects / Q000379:methods*; D009466:Neuromuscular Blocking Agents / Q000009:adverse effects / Q000627:therapeutic use*; D009469:Neuromuscular Junction / Q000187:drug effects* / Q000503:physiopathology; D020511:Neuromuscular Junction Diseases / Q000139:chemically induced / Q000175:diagnosis / Q000503:physiopathology / Q000517:prevention & control*; D061886:Neuromuscular Monitoring; D017300:Pipecuronium / Q000009:adverse effects / Q000627:therapeutic use*; D020127:Recovery of Function; D000077149:Sevoflurane; D000077122:Sugammadex; D013997:Time Factors; D016896:Treatment Outcome; D047408:gamma-Cyclodextrins / Q000627:therapeutic use*
D018685:Anesthetics, Inhalation; D000931:Antidotes; D008738:Methyl Ethers; D009466:Neuromuscular Blocking Agents; D047408:gamma-Cyclodextrins; D017300:Pipecuronium; D000077122:Sugammadex; D000077149:Sevoflurane