Letters to the Editor: Letters & Announcements
Hemmerling and Geldner (1) raise a number of concerns related to two recent articles in the journal (2,3). Although the use of sugammadex does not obviate the need for neuromuscular monitoring altogether, I think it will decrease the need for routine objective monitoring. If one knows by palpation that the patient's train-of-four count is 2 during recovery from rocuronium-induced neuromuscular blockade, there is no doubt that administering 2 mg/kg of sugammadex will produce adequate neuromuscular recovery. Similarly, there is no doubt that 4 mg/kg of sugammadex would produce adequate neuromuscular recovery from a deeper block at a 1–2 posttetanic count. Furthermore, is objective neuromuscular monitoring really the current standard of care? Despite a plea by Eriksson (4) several years ago, one suspects that many North American anesthesiologists do not have access to objective neuromuscular function monitors and few use them routinely. No evidence suggests that such monitoring makes a difference (5,6). Many practitioners still do not know the current standards that define adequate recovery from neuromuscular blockade (7).
In my report (2), I addressed the interaction of sugammadex with other steroidal and nonsteroidal compounds, and I listed all the reported side effects. Additional data are needed but, as of now, we cannot predict other potential side effects.
The scenario described by Hemmerling and Geldner of subsequent muscle relaxation (8) is not unique to sugammadex. The 0.5 mg/kg dose of sugammadex at which reoccurrence of blockade was observed is (grossly) inadequate and is less than that shown to be appropriate in dose-finding studies (9,10). Inadequate recovery from neuromuscular-induced blockade due to inadequate reversal, among other factors, continues to occur in clinical practice. This scenario underscores why it is still necessary to know the patient's train-of-four count or posttetanic count before reversal.
Although Hemmerling and Geldner noted that a combination of neostigmine and glycopyrrolate has very few side effects when used properly, many anesthesiologists, especially in France and Germany, would disagree. The effects of such a combination have never been studied in conscious subjects.
I agree that the degree of neuromuscular blockade should not be increased because of the availability of sugammadex. Neuromuscular blockers, like any other drugs, should be used in doses required for the clinical situation. I maintain that introducing sugammadex into clinical practice would contribute to both increased patient safety and improved surgical conditions, which are the ultimate goals we all hope to accomplish.
Mohamed Naguib, MD
Department of Anesthesiology and Pain Medicine
The University of Texas M. D. Anderson Cancer Center
1. Hemmerling TM, Geldner G. Sugammadex: good drugs do not replace good clinical practice. Anesth Analg 2007;105:1506
2. Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology?. Anesth Analg 2007;104:477-8
3. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg 2007;104:575-81
4. Eriksson LI. Evidence-based practice and neuromuscular monitoring: it's time for routine quantitative assessment. Anesthesiology 2003;98:1037–9
5. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth 2007;98:302–16
6. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarization [letter]. Br J Anaesth 2007;99:297–9
7. Sorgenfrei IF, Viby-Mogensen J, Swiatek FA. [Does evidence lead to a change in clinical practice? Danish anaesthetists' and nurse anesthetists' clinical practice and knowledge of postoperative residual curarization]. Ugeskr Laeger 2005;167:3878–82
8. Eleveld DJ, Kuizenga K, Proost JH, Wierda JM. A temporary decrease in twitch response during reversal of rocuronium-induced muscle relaxation with a small dose of sugammadex. Anesth Analg 2007;104:582–4
9. Shields M, Giovannelli M, Mirakhur RK, Moppett I, Adams J, Hermens Y. Org 25969 (sugammadex), a selective relaxant binding agent for antagonism of prolonged rocuronium-induced neuromuscular block. Br J Anaesth 2006;96:36–43
10. Sorgenfrei IF, Norrild K, Larsen PB, Stensballe J, Ostergaard D, Prins ME, Viby-Mogensen J. Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study. Anesthesiology 2006;104:667–74