title: Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion.
abstract: BACKGROUND
  Acetylcholinesterase inhibitors (neostigmine, edrophonium) and encapsulating agents (sugammadex and calabadion) can be used to reverse residual neuromuscular blockade (NMB).
  
  
  METHODS
  This review provides information about efficacy, effectiveness, and side effects of drugs (acetylcholinesterase inhibitors and encapsulating agents) used to reverse neuromuscular blocking agents (NMBAs).
  
  
  CONCLUSIONS
  The therapeutic range of acetylcholinesterase-inhibitors is narrow and effectiveness studies demonstrate clinicians don't use these unspecific reversal agents effectively to increase postoperative respiratory safety. The encapsulating drugs sugammadex and calabadion reverse all levels of NMB, and complete recovery of muscle strength can be achieved almost immediately after administration. For this reason encapsulating agents can be used as a solution for "cannot intubate cannot ventilate"- situations. Poor binding selectivity of encapsulating agents carries the risk of displacement of the NMBA by a competitively binding drug, which may lead to recurarization. In order to avoid side-effects, related to unspecific binding of endogenous proteins and drugs administered perioperatively it is prudent to titrate the dose of reversal agents to the minimal effective dose, depending on the depth of neuromuscular transmission block identified by neuromuscular transmission monitoring. Calabadions provide a diversified (increased binding selectivity) and expanded (reversal of benzylisoquinolines) spectrum of possible indications.
authors.affiliation: a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA.
authors.forename: Friederike
authors.initials: F
authors.lastname: Haerter
authors.affiliation: a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA.|b Department of Anesthesia and Critical Care Medicine , University Hospital Essen, University Duisburg-Essen , Essen , Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Eikermann
mesh_terms: D000762:Anesthesia Recovery Period; D000768:Anesthesia, General; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use*; D055191:Delayed Emergence from Anesthesia / Q000188:drug therapy*; D004491:Edrophonium / Q000627:therapeutic use; D006576:Heterocyclic Compounds, 4 or More Rings / Q000627:therapeutic use*; D006801:Humans; D009388:Neostigmine / Q000627:therapeutic use; D019148:Neuromuscular Blockade; D003473:Neuromuscular Nondepolarizing Agents; D000077122:Sugammadex; D013451:Sulfonic Acids / Q000627:therapeutic use*; D047408:gamma-Cyclodextrins / Q000627:therapeutic use*
chemical_list: D002800:Cholinesterase Inhibitors; D006576:Heterocyclic Compounds, 4 or More Rings; D003473:Neuromuscular Nondepolarizing Agents; D013451:Sulfonic Acids; C583725:calabadion 1; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D009388:Neostigmine; D004491:Edrophonium
keywords: Respiratory complications; encapsulation; neuromuscular transmission block; reversal