Letters to the Editor: Letters & Announcements
I welcome the opportunity to respond to the concerns of Hemmerling and Geldner (1) and will specifically address those issues directed to my editorial. With regard to point Number 3, the characteristics of recurring neuromuscular paralysis have not changed in 40 yr. As with neostigmine, presumably, clinicians would be well versed on the dose-response relationship with sugammadex, which is increasingly well established and, undoubtedly, will be very clear upon Food and Drug Administration approval. As with any drug, extensive use by the clinicians, following Food and Drug Administration approval, will better define any problems related to the use of sugammadex. With respect to side effects following reversal of residual neuromuscular blockade, the numerous instances of residual neuromuscular blockade, some of which lead to postoperative morbidity, attests to the concept that neostigmine is certainly not a panacea and is associated with adverse effects (2–4). Preliminary evidence so far indicates that sugammadex is not associated with residual neuromuscular blockades in the postanesthesia care unit. Once again, widespread clinical use will eventually establish the resilience of such a conclusion.
In response to Item 5, I completely agree with Hemmerling and Geldner that the smallest dose that produces the most effective clinical result is the one that should be used and clinicians should not be giving doses in excess of that required for adequate surgical conditions.
Finally, all clinicians would agree that the best clinical practice possible should always be used and not compromised because the availability of a better antagonist or “reversal drug.” The conclusions stated in the last paragraph stated by Hemmerling and Geldner are indeed exciting and hopefully will be confirmed by widespread clinical use.
Ronald D. Miller, MD
Department of Anesthesia and Perioperative Care
University of California San Francisco
San Francisco, California
1. Hemmerling TM, Geldner G. Sugammadex: good drugs do not replace good clinical practice. Anesth Analg 2007;105:1506
2. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthetic unit. Anesth Analg. In press
3. Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, Vandenbrouche G, Deloof T. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg 2006;102:426–9
4. Berg H, Viby-Mogensen J, Roed J, Morteusen CR, Englbaek J, Skovgaard LT, Krintel JJ. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. Acta Anaesthiol Scand 1997;41:1095–103