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The Effect of Intravenous Dexamethasone on Sugammadex Reversal Time in Children Undergoing Adenotonsillectomy

Gulec, Ersel MD; Biricik, Ebru MD; Turktan, Mediha MD; Hatipoglu, Zehra MD; Unlugenc, Hakki MD

doi: 10.1213/ANE.0000000000001142
Pediatric Anesthesiology: Research Report

BACKGROUND: Dexamethasone has been shown to cause inhibition of sugammadex reversal in functionally innervated human muscle cells. In this prospective, double-blind, randomized, controlled study, we evaluated the effect of dexamethasone on the reversal time of sugammadex in children undergoing tonsillectomy and/or adenoidectomy.

METHODS: We recruited 60 patients with ASA physical status I to II, between the ages of 3 and 8 years, scheduled for elective tonsillectomy and/or adenoidectomy. After the induction of anesthesia, patients in group D received IV dexamethasone at a dose of 0.5 mg/kg within a total volume of 5 mL saline, whereas patients in group S received only 5 mL IV saline as the control group. At the end of surgery, all patients were given a single bolus dose (2 mg/kg) of sugammadex at reappearance of T2. Demographic data, hemodynamic variables, time to recovery (a train-of-four ratio of 0.9), time to tracheal extubation, and adverse effects were recorded.

RESULTS: There was no statistical significance between 2 groups in time to recovery and time to extubation. Time to recovery was 97.7 ± 23.9 seconds in group D and 91.1 ± 39.5 seconds in group S (P = 0.436; 95% confidence interval, −10.3 to 23.5). Time to extubation was 127.9 ± 23.2 seconds and 123.8 ± 38.7 seconds in group D and in group S, respectively (P = 0.612; 95% confidence interval, −11.9 to 20.05).

CONCLUSIONS: IV dexamethasone, given after induction of anesthesia, at a dose of 0.5 mg/kg, does not substantively affect the reversal time of sugammadex in pediatric patients undergoing adenoidectomy and/or tonsillectomy.

Published ahead of print January 14, 2016

From the Department of Anesthesia, Cukurova University Faculty of Medicine, Balcalı Hospital, Adana, Turkey.

Accepted for publication November 16, 2015.

Published ahead of print January 14, 2016

Funding: Institutional and departmental.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Ersel Gulec, MD, Department of Anesthesia, Cukurova University Faculty of Medicine, Balcalı Hospital, 01130, Adana, Turkey. Address e-mail to gulecersel@yahoo.com.

To decrease the potential risk of adverse respiratory complications after surgery, the prevention of residual neuromuscular blockade is an important issue that is frequently neglected.1–6 Currently, sugammadex has been widely used to reduce the risk of residual neuromuscular blockade after surgery.7–11 Sugammadex, a modified γ-cyclodextrin, reverses neuromuscular blockade by encapsulating steroidal neuromuscular-blocking drugs (NMBDs) and reducing their free concentration at the neuromuscular junction.12–15

Dexamethasone has frequently been used to treat the inflammatory response during surgery and subsequently reduce postoperative edema, pain, nausea, and vomiting after tonsillectomy and/or adenotonsillectomy.16–19

Recently, in an in vitro study, dexamethasone was reported to cause the inhibition of sugammadex reversal in a dose-dependent manner in functionally innervated human muscle cells.20 Therefore, in this prospective, double-blind, randomized, controlled study, we investigated the effect of dexamethasone on the reversal time of sugammadex in pediatric patients undergoing adenoidectomy and/or tonsillectomy.

The hypothesis was that in patients who underwent adenoidectomy and/or tonsillectomy, dexamethasone, given after the induction of anesthesia, would prolong the reversal time of sugammadex compared with saline. A train-of-four (TOF) ratio of ≥0.9 is generally accepted as the end point of adequate recovery after the administration of NMBD reversal agents.21 Thus, the primary end point was the time to recovery (the time to recovery of the TOF ratio to 0.9 after sugammadex administration), and the secondary end point was the time to tracheal extubation (the time between sugammadex administration and extubation). An adequate spontaneous minute ventilation, regular breathing pattern, the presence of swallowing reflex, 5-second head lift or hand grip, and eye opening either on command or spontaneously were our clinical criteria to determine the appropriate time of tracheal extubation.

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METHODS

Our study protocol was registered at ClinicalTrials.gov (principal investigator’s name: EG, and identifier: NCT02137395) on July 1, 2014, and approved by the ethics committee of Cukurova University (decision number: 31/7 and Date: June 19, 2014). This prospective, randomized, double-blind controlled study was performed between July 1, 2014, and May 12, 2015. After obtaining written informed parental consent, 60 pediatric patients with ASA physical status I to II, between the ages of 3 and 8 years, scheduled for elective adenoidectomy and/or tonsillectomy were recruited. Exclusion criteria were the presence of respiratory, hepatic, renal, and cardiovascular disease; oropharyngeal or facial pathology; neuromuscular disorder; hypertension; diabetes mellitus; and the use of preoperative corticosteroids. Children were admitted to the preoperative unit 30 minutes before the operation. No premedication was given to children before surgery. All patients were monitored by noninvasive arterial blood pressure, electrocardiogram, and peripheral oxygen saturation (SpO2) (Draeger-Primus Anesthesia Device Monitor, Draeger Medical Systems, Inc., Denver, MA). Anesthesia was induced with 4% to 5% sevoflurane by facemask. An IV cannula (22G) was inserted after ensuring an adequate depth of anesthesia. Patients were randomly allocated into 2 groups in a 1:1 ratio by a computer-generated randomization list.

Immediately before neuromuscular monitoring, the first group of patients (group D) received IV dexamethasone at a dose of 0.5 mg/kg within a total volume of 5 mL saline, and the second group of patients (group S) received only 5 mL IV saline without dexamethasone as the control group. The majority of studies used a dose of 0.5 mg/kg dexamethasone for tonsillectomy and/or adenoidectomy.16 An anesthesiologist blinded to the groups performed the injections.

Neuromuscular monitoring was initiated with an acceleromyograph (TOF-Watch® S; Organon Ireland Ltd., Dublin, Ireland) measuring the function of the adductor pollicis muscle after the induction of anesthesia. A transducer was attached over the thumb. Two electrodes were placed on cleaned skin corresponding to the ulnar nerve trajectory at the wrist. Stabilization and calibration were performed for TOF-Watch S according to the good clinical research practice in pharmacodynamic studies of NMBDs.22 After calibration, TOF stimulations were applied repetitively every 15 seconds. Rocuronium was administered IV at a dose of 0.6 mg/kg followed by a 5-minute period of stabilization of TOF stimulations. Tracheal intubation was performed after obtaining the adequate neuromuscular blockade (TOF = 0). TOF stimulation was maintained every 15 seconds until the end of anesthesia or at a 0.9 TOF ratio. Heart rate and systolic and diastolic blood pressure measurements were recorded at 10-minute intervals. IV tramadol was administered at a dose of 1 mg/kg for postoperative analgesia. At the end of surgery, anesthesia was terminated, and when T2 of the TOF reappeared, all patients were administered a single bolus injection of sugammadex at a dose of 2 mg/kg. We assessed the time between dexamethasone and sugammadex administrations. The time to achieve a TOF ratio of 0.9 after sugammadex administration was recorded for all patients.

After reversal of neuromuscular block, patients were tracheally extubated when the following criteria were fulfilled: providing 100% oxygen through the breathing system; suctioning of the oropharyngeal secretions; the presence of swallowing reflex; facial grimacing; coughing; spontaneous purposeful movements of the arms (i.e., reaching for the endotracheal tube); sustaining hip flexion for 10 seconds; 5-second head lift or hand grip; eye opening either on command or spontaneously; normally dilated and central pupils; regular breathing pattern without retraction and an adequate spontaneous minute ventilation (tidal volumes >6 mL/kg, respiratory rate 15 to 40 breaths/min, end-tidal CO2 <45 mm Hg, and SaO2 >95% with 100% oxygen); change in arterial blood pressure; and heart rate within 20% of baseline. The time from sugammadex administration to extubation was also recorded for all patients. After extubation, patients were transferred to the postoperative care unit. SpO2, respiratory rate, heart rate, noninvasive arterial blood pressure, and clinical evaluation of recovery (5-second head lift test, the absence of diplopia, tongue depressor test, and general muscle weakness) were observed during the first 2 hours in the postanesthesia care unit. Any adverse effect was also recorded during the surgery and postoperatively for 8 hours. An anesthesiologist, blinded to the groups, performed all recording and drug administration.

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Statistical Analysis

The primary end point of the study was the time to recovery (the time to recovery of TOF ratio to 0.9 after sugammadex administration). Dexamethasone has been reported to decrease the recovery of contractions by equimolar sugammadex by 26%.20 In addition, the time to recovery of the TOF ratio to 0.9 after sugammadex administration has been reported as 1.2 ± 0.4 minutes for children undergoing surgery.12 Therefore, the sample size calculation was estimated to detect a 0.3-minute difference in the duration of residual neuromuscular blockade when used with dexamethasone. We calculated that 28 patients in each group were necessary to differentiate recovery time with 80% power at the 5% significance level. To compensate for loses, we recruited 30 patients for each group.

Statistical analyses were performed using IBM SPSS software version 22.0 (IBM SPSS Statistics for Windows, Version 22.0; IBM Corp., Armonk, NY). The variables were investigated using visual (histograms and probability plots) and analytical methods (Kolmogorov-Simirnov with Lilliefors Significance Correction) to determine whether or not they were normally distributed. Categorical measurements as number and percentage and continuous measurements as mean and SD (if necessary, median and minimum − maximum) were evaluated. The χ2 test or Fisher exact test, whichever was appropriate, was used to compare the categorical measurements between the 2 groups. To evaluate the change in measurements obtained in the time interval, repeated-measurements analysis was performed. The independent samples t test was used for weight, surgery time, intraoperative and postoperative hemodynamic data, time to recovery of the TOF ratio to 0.9, and the time between sugammadex administration and tracheal extubation, which were normally distributed. We found that measurements were normally distributed (P = 0.200 for all measurements in both groups) and the results of the Levene test based on the mean were P = 0.013 for the time to recovery of the TOF ratio to 0.9 and P = 0.006 for the time to extubation. The time to recovery and the time to extubation were presented as means with 95% confidence interval (CI). The Mann-Whitney U test was used if variables had an abnormal distribution. The level of statistical significance was 0.05 in all tests.

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RESULTS

Sixty-four patients were eligible for the study. Because of protocol violations, there were 4 withdrawals; 2 were because of short surgery time in group D and 2 because of prolonged surgical hemostasis in group S. Overall, data on 60 patients were used in statistical analysis (Fig. 1). No statistical significance was found in demographic and hemodynamic (heart rate and systolic and diastolic blood pressures) data between the 2 groups (Tables 1 and 2).

Table 1

Table 1

Table 2

Table 2

Figure 1

Figure 1

Figure 2

Figure 2

The time from dexamethasone to sugammadex administration was 39.6 ± 17.2 minutes in group D and 36.6 ± 14.6 minutes in group S. We found no significant difference in the time from dexamethasone to sugammadex administration. The time to recovery of the TOF ratio to 0.9 after sugammadex administration was 97.7 ± 23.9 (95% CI, 88.8–106.7) seconds in group D and 91.1 ± 39.5 (95% CI, 76.3–105.8) seconds in group S. The time to extubation after sugammadex administration was 127.9 ± 23.2 (95% CI, 119.2–136.6) seconds and 123.8 ± 38.7 (95% CI, 110.0–137.6) seconds in group D and in group S, respectively. There was no significant difference between groups in time to recovery and time to extubation (P = 0.436; 95% CI, −10.3 to 23.5 and P = 0.612; 95% CI, −11.9 to 20.05 in group D and in group S, respectively) (Fig. 2). One patient in group D and 4 patients in group S experienced nausea. These patients did not require any antiemetic therapy, and their symptoms resolved spontaneously. No side effects were recorded except laryngospasm in 1 patient in group S.

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DISCUSSION

In the present study, we evaluated the reversal time of sugammadex in children administered dexamethasone or saline after the induction of anesthesia. We found that dexamethasone given as a single dose (0.5 mg/kg) does not significantly affect the reversal time of sugammadex in children undergoing adenoidectomy and/or tonsillectomy.

Sugammadex acts by forming a complex with steroidal NMBDs such as rocuronium and vecuronium and reduces their concentrations in the neuromuscular junction. Because of its inert structure, direct drug interactions are rarely expected with sugammadex. Two types of drug interactions may occur with sugammadex by displacement or capturing. Drugs interacting with sugammadex by displacement (i.e., toremifene, fusidic acid, and flucloxacillin) could potentially affect the efficacy of sugammadex due to rocuronium or vecuronium being displaced from sugammadex.23 Capturing interactions may occur if sugammadex binds with other drugs (i.e., hormonal contraceptives), thus sugammadex reduces their free plasma concentration. In addition, sugammadex might have decreased efficacy for rocuronium or vecuronium due to it binding with another drug.24 Therefore, a pharmacokinetic and pharmacodynamic interaction is possible.

Cyclodextrins have been reported to form inclusion complexes with other compounds.23 Zwiers et al.23 investigated clinically relevant displacement interactions between sugammadex and 300 commonly prescribed drugs by using the pharmacokinetic-pharmacodynamic model. The drugs included both steroidal and nonsteroidal drugs acting on steroidal receptors such as the corticosteroids hydrocortisone, prednisolone, and dexamethasone. In that study, dexamethasone was reported to have the lowest association rate constant compared with other corticosteroids used. Furthermore, its low association rate constant showed a small possibility of displacement of the NMBD from sugammadex when using dexamethasone. However, in an in vitro experimental study of innervated human muscle cells, the possible chemical interaction between dexamethasone and sugammadex was documented.25 Recently, in an in vitro experimental model of functionally innervated human muscle cells, Rezonja et al.20 investigated the influence of dexamethasone on sugammadex reversal of rocuronium-induced neuromuscular block and found that dexamethasone led to a dose-dependent inhibition of sugammadex reversal. Considering these data, we also expected that children who receive dexamethasone might show a delayed recovery from rocuronium when receiving sugammadex. However, we failed to demonstrate any inhibitory effect of dexamethasone (0.5 mg/kg) on the reversal time of sugammadex in children. The clinical relevance of the interaction between dexamethasone and sugammadex has not been investigated in humans, and as far as we know, this is the first clinical study evaluating the effect of dexamethasone on sugammadex reversal time.

Another issue that must be further investigated is the dose and the time of administration of dexamethasone. In the literature, there is no reliable way to determine which dose of dexamethasone is required to inhibit sugammadex reversal. In the present study, a single bolus dose of dexamethasone was used intraoperatively to prevent postoperative nausea and vomiting and to improve postoperative pain control at a total dose of 0.5 mg/kg.16 In most studies, although the same dose of dexamethasone was used to treat the inflammatory response during surgery, similar effects have been achieved with a smaller dose of dexamethasone.17,26–32

Time to administration of dexamethasone is also an important issue when rocuronium is used to induce neuromuscular blockade. It is clearly demonstrated that dexamethasone attenuates rocuronium-induced neuromuscular blockade when administered 2 to 3 hours before the induction of anesthesia.33 However, when dexamethasone is given at induction, the duration of neuromuscular blockade is not affected.33 In the present study, this was the main reason why we used dexamethasone at the induction of anesthesia.

The timing of dexamethasone administration may interact with and change the reversal time of sugammadex. Corticosteroids are extensively bound to plasma proteins.34 Thus, sugammadex is probably unable to bind proteins before a rapid distribution to peripheral compartments. Thereby, the inhibitory effect of dexamethasone on sugammadex reversal would be more pronounced when used simultaneously. Further studies are needed to reveal this relation between dexamethasone and sugammadex.

Our study has a number of limitations. First, the study lacks concentration measurements of dexamethasone in the plasma. Second, postoperative side effect assessment was limited to 8 hours because of outpatient conditions. Therefore, we could not show any side effects from the interaction between sugammadex and dexamethasone over a long period of time. Third, the current study was unable to analyze the potential of a dose-response relation of dexamethasone with sugammadex. Fourth, possible age-related differences in this drug-drug interaction were not addressed in this study. Fifth, the study has the possibility of a type II statistical error. Sixth, the lack of T1-25%, T1-75%, and TOF ratio at 80% data limits our study regarding comprehensive evaluation of neuromuscular recovery.

In conclusion, the dose of 0.5 mg/kg dexamethasone during the induction of anesthesia does not substantially affect the reversal time of sugammadex on rocuronium-induced neuromuscular blockade in children.

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DISCLOSURES

Name: Ersel Gulec, MD.

Contribution: This author helped design and conduct the study.

Attestation: Ersel Gulec approved the final manuscript, attests to the integrity of the original data and the analysis reported in this manuscript, and is the archival author.

Name: Ebru Biricik, MD.

Contribution: This author helped conduct the study and collect the data.

Attestation: Ebru Biricik approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

Name: Mediha Turktan, MD.

Contribution: This author helped conduct the study and collect the data.

Attestation: Mediha Turktan approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

Name: Zehra Hatipoglu, MD.

Contribution: This author helped collect and analyze the data of the study.

Attestation: Zehra Hatipoglu approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

Name: Hakki Unlugenc, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Hakki Unlugenc approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

This manuscript was handled by: James A. DiNardo, MD.

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ACKNOWLEDGMENTS

The authors thank the American Journal of Experts (Certificate Verification Key: 0FD1-F218-BFCA-FB32-C14D) for English editing of this study.

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