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BMC Anesthesiology
Published in: BMC Anesthesiology 1/2015

Open Access 01-12-2016 | Research article

A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

Authors: Ralph P. Insinga, Cédric Joyal, Alexandra Goyette, André Galarneau

Published in: BMC Anesthesiology | Issue 1/2015

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Abstract

Background

The objective of this analysis is to explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex (Bridion™, Merck & Co., Inc., Kenilworth, NJ USA) versus neostigmine for neuromuscular block reversal in Canada.

Methods

A discrete event simulation (DES) model was developed to compare ORs using either neostigmine or sugammadex for NMB reversal over one month. Selected inputs included OR procedure and turnover times, hospital policies for paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use. Trials show sugammadex’s impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four ratio ≥0.9) is verified prior to extubation in the OR. Scenarios were therefore evaluated reflecting varied assumptions for neuromuscular reversal practices.

Results

With use of moderate neuromuscular block, when full neuromuscular recovery is verified prior to extubation (93 procedures performed with sugammadex, 91 with neostigmine), use of sugammadex versus neostigmine avoided 2.4 procedural cancellations due to OR time over-run and 33.5 h of paid staff overtime, while saving an average of 62 min per OR day. No difference was observed between comparators for these endpoints in the scenario when full neuromuscular recovery was not verified prior to extubation, however, per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 51 cases prevented), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (23 cases avoided).
Sugammadex impact in reversing deep neuromuscular block was evaluated in an exploratory analysis. When it was hypothetically assumed that 30 min of OR time were saved per procedure, the number of paid hours of staff over-time dropped from 84.1 to 32.0, with a 93% reduction in the per patient risk of residual blockade.

Conclusions

In clinical practice within Canada, for the majority of patients currently managed with moderate neuromuscular block, the principal impact of substituting sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications. For patients maintained at a deep level of block to the end of the procedure, sugammadex is likely to both enhance OR efficiency and reduce residual block complications.
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Literature
1.
2.
A randomized, safety-assessor blinded trial comparing 4.0 Mg.Kg-1 Sugammadex with placebo in adult subjects scheduled for surgery requiring profound neuromuscular blockade. Clinical Trial Report on Protocol 19.4.316. Merck & Co., Inc. 2010.
3.
Blobner M, Eriksson LI, Scholz J, Motsch J, Della RG, Prins ME. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol. 2010;27:874–81.CrossRefPubMed
4.
Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111:120–8.CrossRefPubMed
5.
Rex C, Bergner UA, Puhringer FK. Sugammadex: a selective relaxant-binding agent providing rapid reversal. Curr Opin Anaesthesiol. 2010;23:461–5.CrossRefPubMed
6.
Sabo D, Jones RK, Berry J, Sloan T, Chen JY, Morte JB, Groudine S. Residual neuromuscular blockade at extubation: a randomized comparison of sugammadex and neostigmine reversal of rocuronium-induced blockade in patients undergoing abdominal surgery. J Anesthes Clin Res. 2011;2:140.CrossRef
7.
Flockton EA, Mastronardi P, Hunter JM, Gomar C, Mirakhur RK, Aguilera L, Giunta FG, Meistelman C, Prins ME. Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine. Br J Anaesth. 2008;100:622–30.CrossRefPubMed
8.
Khuenl-Brady KS, Wattwil M, Vanacker BF, Lora-Tamayo JI, Rietbergen H, Alvarez-Gomez JA. Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg. 2010;110:64–73.CrossRefPubMed
9.
Geldner G, Niskanen M, Laurila P, Mizikov V, Hubler M, Beck G, Rietbergen H, Nicolayenko E. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia. 2012;67:991–8.CrossRefPubMed
10.
Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology. 2008;109:816–24.CrossRefPubMed
11.
Yang LP, Keam SJ. Sugammadex: a review of its use in anaesthetic practice. Drugs. 2009;69:919–42.CrossRefPubMed
12.
A multi-center, randomized, parallel group, comparative, active controlled, safety assessor blinded, anesthesiologist-TOF-Watch® SX blinded trial comparing T4/T1 ratio at time of tracheal extubation using 4 mg.kg-1 sugammadex administered at 1–2 PTCs or better after the last dose of rocuronium bromide to 50 ?g.kg-1 neostigmine administered as per standard of care in adult subjects undergoing elective open abdominal procedures requiring neuromuscular blockade reversal. Clinical Trial Report on Protocol 19.4.334. Merck & Co., Inc. 2009.
13.
A multi-center, randomized, parallel group, comparative, active controlled, safety assessor blinded trial in adult subjects comparing the efficacy and safety of sugammadex (SCH 900616, ORG 25969) administered at 1–2 PTC with neostigmine administered at reappearance of T2 in subjects undergoing laparoscopic cholecystectomy or appendectomy under propofol anesthesia. Clinical Trial Report on Protocol 19.4.318. Merck & Co., Inc. 2010.
14.
Effect of sugammadex compared with usual care for reversal of neuromuscular blockade induced by rocuronium on incidence of residual blockade at PACU entry (Phase 5, Protocol No. P07981 [also known as MK 8616–064]). 2012.
15.
A randomized, controlled, parallel-group, double-blind trial of sugammadex or usual care (neostigmine or spontaneous recovery) for reversal of rocuronium- or vecuronium-induced neuromuscular blockade in patients receiving thromboprophylaxis and undergoing hip fracture surgery or joint (hip/knee) replacement (P07038). 2014.
16.
Grintescu I, Mirea L, Ologoiu D, Ungureanu R, Mekauvar S, Vasilescu M. Comparison of the cost-effectiveness of sugammadex and neostigmine during general anesthesia for laparascopic cholecystectomy. Br J Anaesth. 2009;103:917.
17.
Partownavid P, Romito BT, Ching W, Berry AA, Barkulis CT, Nguyen KP, Jahr JS. Sugammadex: a comprehensive review of the published human science, including renal studies. Am J Ther. 2014;22:298–317.
18.
Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98:302–16.CrossRefPubMed
19.
Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, Nakatsuka I, Takeda J. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth Analg. 2013;117:345–51.CrossRefPubMed
20.
Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis at the time of tracheal extubation. Anesth Analg. 2005;100:1840–5.CrossRefPubMed
21.
Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia care unit recovery times and neuromuscular blocking drugs: a prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium. Anesth Analg. 2004;98:193–200. table.CrossRefPubMed
22.
Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, Krintel JJ. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095–103.CrossRefPubMed
23.
Ledowski T, Hillyard S, O’Dea B, Archer R, Vilas-Boas F, Kyle B. Introduction of sugammadex as standard reversal agent: impact on the incidence of residual neuromuscular blockade and postoperative patient outcome. Indian J Anaesth. 2013;57:46–51.CrossRefPubMedPubMedCentral
24.
Ledowski T, Falke L, Johnston F, Gillies E, Greenaway M, De Mel A, Tiong WS, Phillips M. Retrospective investigation of postoperative outcome after reversal of residual neuromuscular blockade: Sugammadex, neostigmine or no reversal. Eur J Anaesthesiol. 2014;31:423–9.CrossRefPubMed
25.
Rassam S, Sandbythomas M, Vaughan RS, Hall JE. Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland. Anaesthesia. 2005;60:995–1001.CrossRefPubMed
26.
Sakai T, Planinsic RM, Quinlan JJ, Handley LJ, Kim TY, Hilmi IA. The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis. Anesth Analg. 2006;103:941–7.CrossRefPubMed
27.
Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology. 1993;78:56–62.CrossRefPubMed
28.
Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, Vandenbroucke G, Deloof T. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102:426–9.CrossRefPubMed
29.
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, Gray J, Landry E, Gupta DK. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115:946–54.CrossRefPubMed
30.
Chambers D, Paulden M, Paton F, Heirs M, Duffy S, Craig D, Hunter J, Wilson J, Sculpher M, Woolacott N. Sugammadex for the reversal of muscle relaxation in general anaesthesia: a systematic review and economic assessment. Health Technol Assess. 2010;14:1–211.CrossRef
31.
Insinga RP, Konstantopoulou T, Athanasakis K, Argyris G. Budget impact of using sugammadex for the routine reversal of neuromuscular blockade in a Greek health care setting. ISPOR 15th Annual European Congress. Berlin, Germany, November 3–7, 2012.
32.
Eikermann M, Groeben H, Husing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade. Anesthesiology. 2003;98:1333–7.CrossRefPubMed
33.
Norton M, Xara D, Parente D, Barbosa M, Abelha FJ. Residual neuromuscular block as a risk factor for critical respiratory events in the post anesthesia care unit. Rev Esp Anestesiol Reanim. 2013;60:190–6.CrossRefPubMed
34.
Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111:110–9.PubMed
35.
Phillips S, Stewart PA, Bilgin AB. A survey of the management of neuromuscular blockade monitoring in Australia and New Zealand. Anaesth Intensive Care. 2013;41:374–9.PubMed
36.
37.
Jerico MC, Perroca MG, da Penha VC. Measuring quality indicators in the operating room: cleaning and turnover time. Rev Lat Am Enfermagem. 2011;19:1239–46.CrossRef
38.
Schofield WN, Rubin GL, Piza M, Lai YY, Sindhusake D, Fearnside MR, Klineberg PL. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005;182:612–5.PubMed
Metadata
Title
A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada
Authors
Ralph P. Insinga
Cédric Joyal
Alexandra Goyette
André Galarneau
Publication date
01-12-2016
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2015
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-016-0281-3

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