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BMC Anesthesiology
Published in: BMC Anesthesiology 1/2019

Open Access 01-12-2019 | Myasthenia Gravis | Research article

Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports

Authors: Usha Gurunathan, Shakeel Meeran Kunju, Lisa May Lin Stanton

Published in: BMC Anesthesiology | Issue 1/2019

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Abstract

Background

Sugammadex is a modified gamma-cyclodextrin that acts by selectively encapsulating free amino-steroidal neuromuscular relaxants. Several case reports have been published on the use of sugammadex in patients with neuromuscular disorders that include neuromuscular junction diseases, myopathies, neuropathies, and motor neurone disorders. The primary aim of this review is to systematically review the evidence on the use of sugammadex in patients with this heterogeneous group of diseases and provide recommendations for clinical practice.

Methods

A systematic electronic search of Medline, Embase and CINAHL databases was done until June 2019, to identify case reports describing the use of sugammadex in adult surgical patients with neuromuscular disorders.

Results

Of the 578 records identified through database searches, 43 articles were finally included for the systematic review. Of these, 17 reports were on patients with myopathy, 15 reports on myasthenia gravis, 9 reports on motor neuron diseases and 2 reports on neuropathies.

Conclusions

Majority of the articles reviewed report successful use of sugammadex to reverse steroidal muscle relaxants, especially rocuronium, in patients with neuromuscular diseases. However, with sugammadex, unpredictability in response and uncertainty regarding optimum dose still remain issues. Quantitative neuromuscular monitoring to ensure complete reversal and adequate postoperative monitoring is strongly recommended in these patients, despite the use of sugammadex.
Footnotes
1
Patients with neuromuscular disorders have a high risk of postoperative respiratory complications including respiratory failure.
 
2
Sugammadex should be strongly considered as a safer and effective alternative to neostigmine in the reversal of steroidal muscle relaxants.
 
3
Reduced dose of rocuronium has been used in these patients while the standard recommended dose of sugammadex has been successfully used to reverse muscle relaxants in the majority of the published case reports.
 
4
Variations from normal recovery patterns of muscle strength following administration of reversal agent have been observed in patients with neuromuscular diseases. In myasthenia gravis especially in ocular myasthenia, both spontaneously and with administration of sugammadex, earlier recovery of TOF ratio versus first twitch height and earlier recovery at corrugator supercilii muscle versus adductor pollicis muscle were observed. Hence, monitoring TOF ratio as well as the recovery of first twitch height to baseline at both the muscles is recommended.
 
5
Discordance between TOF ratios and clinical recovery have been reported in amyotrophic lateral sclerosis, which has been stated to be related to severity of disease and type of muscles involved.
 
6
Quantitative neuromuscular monitor is essential in the management of these patients with a TOF ratio of > 0.9 at peripheral muscles before extubation, to ensure adequate pharyngeal function and airway protection as well as to prevent complications such as atelectasis and pneumonia.
 
7
Since delayed or failed recurarisation and long recovery times have been reported with adequately dosed sugammadex reversal even in normal surgical patients, presence of additional factors such as renal dysfunction, temperature fluctuation, acid-base or electrolyte imbalances in these patients or interaction with other medications (i.e. magnesium, baclofen,) necessitate prolonged post-operative observation, especially for respiratory insufficiency in patients with neuromuscular diseases.
 
Literature
1.
Saez A, Acha B, Montero-Sanchez A, Rivas E, Escudero LM, Serrano C. Neuromuscular disease classification system. J Biomed Opt. 2013;18(6):066017.PubMedCrossRef
2.
Hauck LJ, White C, Feasby TE, Zochodne DW, Svenson LW, Hill MD. Incidence of Guillain-Barre syndrome in Alberta, Canada: an administrative data study. J Neurol Neurosurg Psychiatry. 2008;79(3):318–20.PubMedCrossRef
3.
Breiner A, Widdifield J, Katzberg HD, Barnett C, Bril V, Tu K. Epidemiology of myasthenia gravis in Ontario, Canada. Neuromuscul Disord. 2016;26(1):41–6.PubMedCrossRef
4.
Carr AS, Cardwell CR, McCarron PO, McConville J. A systematic review of population based epidemiological studies in myasthenia gravis. BMC Neurol. 2010;10:46.PubMedPubMedCentralCrossRef
5.
Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg. 2007;104(3):575–81.PubMedCrossRef
6.
Bom A, Bradley M, Cameron K, Clark JK, Van Egmond J, Feilden H, MacLean EJ, Muir AW, Palin R, Rees DC, et al. A novel concept of reversing neuromuscular block: chemical encapsulation of rocuronium bromide by a cyclodextrin-based synthetic host. Angew Chem Int Ed Engl. 2002;41(2):266–70.PubMedCrossRef
7.
8.
Karalapillai D, Kaufman M, Weinberg L. Sugammadex. Crit Care Res. 2013;15(1):57–62.
9.
Abrishami A, Ho J, Wong J, Yin L, Chung F. Cochrane corner: sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Anesth Analg. 2010;110(4):1239.PubMed
10.
Gold SJA, Harper NJN. The place of sugammadex in anaesthesia practice. Trends Anaesth Crit Care. 2012;2(1):4–9.CrossRef
11.
Stewart PA, Phillips S, de Boer HD. Residual neuromuscular blockade in myotonic dystrophy: lessons unlearned and sugammadex. Anaesth Intensive Care. 2011;39(4):756–7.PubMedCrossRef
12.
Petrun AM, Mekis D, Kamenik M. Successful use of rocuronium and sugammadex in a patient with myasthenia. Eur J Anaesthesiol. 2010;27(10):917–8.PubMedCrossRef
13.
Stewart PA, Phillips S, De Boer HD. Sugammadex reversal of rocuronium-induced neuromuscular blockade in two types of neuromuscular disorders: Myotonic dystrophy and spinal muscular atrophy. Rev Esp Anestesiol Reanim. 2013;60(4):226–9.PubMedCrossRef
14.
Racca F, Mongini T, Wolfler A, Vianello A, Cutrera R, Del Sorbo L, Capello EC, Gregoretti C, Massa R, De Luca D, et al. Recommendations for anesthesia and perioperative management of patients with neuromuscular disorders. Minerva Anestesiol. 2013;79(4):419–33.PubMed
15.
Madsen MV, Staehr-Rye AK, Gatke MR, Claudius C. Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review. Acta Anaesthesiol Scand. 2015;59(1):1–16.PubMedCrossRef
16.
Dubois PE, Putz L, Jamart J, Marotta ML, Gourdin M, Donnez O. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial. Eur J Anaesthesiol. 2014;31(8):430–6.PubMedCrossRef
17.
18.
19.
Claudius C, Karacan H, Viby-Mogensen J. Prolonged residual paralysis after a single intubating dose of rocuronium. Br J Anaesth. 2007;99(4):514–7.PubMedCrossRef
20.
Shimauchi T, Yamaura K, Sugibe S, Hoka S. Usefulness of sugammadex in a patient with Becker muscular dystrophy and dilated cardiomyopathy. Acta Anaesthesiol Taiwanica. 2014;52(3):146–8.CrossRef
21.
Buzello W, Krieg N, Schlickewei A. Hazards of neostigmine in patients with neuromuscular disorders. Report of two cases. Br J Anaesth. 1982;54(5):529–34.PubMedCrossRef
22.
Ren WH, Jahr JS. Reversal of neuromuscular block with a selective relaxant-binding agent: sugammadex. Am J Ther. 2009;16(4):295–9.PubMedCrossRef
23.
Hristovska AM, Duch P, Allingstrup M, Afshari A. The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta-analysis and trial sequential analysis. Anaesthesia. 2018;73(5):631–41.PubMedCrossRef
24.
25.
Eisenkraft JB, Book WJ, Papatestas AE. Sensitivity to vecuronium in myasthenia gravis: a dose-response study. Can J Anaesth. 1990;37(3):301–6.PubMedCrossRef
26.
Casarotti P, Mendola C, Cammarota G, Della Corte F. High-dose rocuronium for rapid-sequence induction and reversal with sugammadex in two myasthenic patients. Acta Anaesthesiol Scand. 2014;58(9):1154–8.PubMedCrossRef
27.
Blichfeldt-Lauridsen L, Hansen BD. Anesthesia and myasthenia gravis. Acta Anaesthesiol Scand. 2012;56(1):17–22.PubMedCrossRef
28.
Sungur Z, Senturk M. Anaesthesia for thymectomy in adult and juvenile myasthenic patients. Curr Opin Anaesthesiol. 2016;29(1):14–9.PubMedCrossRef
29.
De Boer HD, Van Egmond J, Driessen JJ, Booij LHJD. Sugammadex in patients with myasthenia gravis: correspondence. Anaesthesia. 2010;65(6):653.PubMedCrossRef
30.
31.
Sungur Ulke Z, Yavru A, Camci E, Ozkan B, Toker A, Senturk M. Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy. Acta Anaesthesiol Scand. 2013;57(6):745–8.PubMedCrossRef
32.
Garcia V, Diemunsch P, Boet S. Use of rocuronium and sugammadex for caesarean delivery in a patient with myasthenia gravis. Int J Obstet Anesth. 2012;21(3):286–7.PubMedCrossRef
33.
Vymazal T, Krecmerova M, Bicek V, Lischke R. Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patients undergoing surgery - a series of 117 cases. Ther Clin Risk Manag. 2015;11:1593–6.PubMedPubMedCentralCrossRef
34.
Kiss G, Lacour A, d'Hollander A. Fade of train-of-four ratio despite administration of more than 12 mg kg (−1) sugammadex in a myasthenia gravis patient receiving rocuronium. Br J Anaesth. 2013;110(5):854–5.PubMedCrossRef
35.
Sugi Y, Nitahara K, Shiroshita T, Higa K. Restoration of train-of-four ratio with neostigmine after insufficient recovery with Sugammadex in a patient with myasthenia gravis. A A Case Rep. 2013;1(3):43–5.PubMedCrossRef
36.
O'Leary RA, C MC. Stopped short: Sugammadex in undiagnosed Myasthenia gravis [Conference Abstract]. Eur J Anaesthesiol. 2013;30:26.CrossRef
37.
Iwasaki H, Takahoko K, Otomo S, Sasakawa T, Kunisawa T, Iwasaki H. Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis. Can J Anaesth. 2013;60(12):1222–7.PubMedCrossRef
38.
39.
Matsumura T, Saito T, Yonemoto N, Nakamori M, Sugiura T, Nakamori A, Fujimura H, Sakoda S. Renal dysfunction can be a common complication in patients with myotonic dystrophy 1. J Neurol Sci. 2016;368:266–71.PubMedCrossRef
40.
41.
42.
Imison AR. Anaesthesia and myotonia--an Australian experience. Anaesth Intensive Care. 2001;29(1):34–7.PubMedCrossRef
43.
Wefki Abdelgawwad Shousha AA, Sanfilippo M, Sabba A, Pinchera P. Sugammadex and reversal of neuromuscular block in adult patient with duchenne muscular dystrophy. Case Rep Anesthesiol. 2014;2014:680568.PubMedPubMedCentral
44.
Baumgartner P, Baumgartner P. Rocuronium and sugammadex in myotonic dystrophy. Anaesth Intensive Care. 2010;38(5):959–60.PubMed
45.
Matsuki Y, Hirose M, Tabata M, Nobukawa Y, Shigemi K. The use of sugammadex in a patient with myotonic dystrophy. Euro J Anaesth. 2011;28(2):145–6.CrossRef
46.
Mavridou P, Dimitriou V, Margaritis A, Manataki A. Anesthesia for laparoscopic surgery in a patient with myotonic dystrophy (Steinert's disease): beneficial use of sugammadex, but incorrect use of pethidine: a case report. Acta Anaesthesiol Belg. 2011;62(2):101–4.PubMed
47.
Petrovski J. The use of sugammadex to reverse rocuronium in a patient with myotonic dystrophy. Anaesth Intensive Care. 2011;39(3):505–6.PubMed
48.
Teixeira J, Matias B, Ferreira I, Taleço T, Duarte JS. Sugammadex is changing the paradigm in neuromuscular blockade in patients with myotonic dystrophy. J Perioper Pract. 2019;29(10):337–40.PubMedCrossRef
49.
Mangla C, Bais K, Yarmush J. Myotonic dystrophy and anesthetic challenges: a case report and review. Case Rep Anesthesiol. 2019;2019:4282305.PubMedPubMedCentral
50.
Kashiwai A, Suzuki T, Ogawa S. Sensitivity to rocuronium-induced neuromuscular block and reversibility with sugammadex in a patient with myotonic dystrophy. Case Rep Anesthesiol. 2012;2012:107952.PubMedPubMedCentral
51.
Stourac P, Krikava I, Seidlova J, Strazevska E, Huser M, Hruban L, Janku P, Gal R. Sugammadex in a parturient with myotonic dystrophy. Br J Anaesth. 2013;110(4):657–8.PubMedCrossRef
52.
Kosinova M, Stourac P, Harazim H, Janku P, Huser M, Vohanka S. Anaesthesia and orphan disease: rocuronium and sugammadex in the anaesthetic management of a parturient with Becker's myotonia congenita. Euro J Anaesthesiol. 2016;33(7):545–7.CrossRef
53.
Kendigelen P, Tutuncu AC, Ashyralyyeva G, Hamamcioglu EA, Kaya G. Sugammadex usage in a patient with dermatomyositis. J Clin Anesth. 2015;27(5):438–9.PubMedCrossRef
54.
Suzuki T, Nameki K, Shimizu H, Shimizu Y, Nakamura R, Ogawa S. Efficacy of rocuronium and sugammadex in a patient with dermatomyositis. Br J Anaesth. 2012;108(4):703.PubMedCrossRef
55.
Staikou C, Rekatsina M. Use of rocuronium and sugammadex under neuromuscular transmission monitoring in a patient with multiple sclerosis. Saudi J Anaesth. 2017;11(4):472–5.PubMedPubMedCentralCrossRef
56.
Weekes G, Hayes N, Bowen M. Reversal of prolonged rocuronium neuromuscular blockade with sugammadex in an obstetric patient with transverse myelitis. Int J Obstet Anesth. 2010;19(3):333–6.PubMedCrossRef
57.
Tiryaki E, Horak HA. ALS and other motor neuron diseases. Continuum (Minneap Minn). 2014;20(5 Peripheral Nervous System Disorders):1185–207.
58.
Kelsaka E, Karakaya D, Zengin EC. Use of sugammadex in a patient with amyotrophic lateral sclerosis. Med Princ Pract. 2013;22(3):304–6.PubMedCrossRef
59.
Chang YJ, Jung WS, Son WR, Jo YY. Discordance between train-of-four response and clinical symptoms in a patient with amyotrophic lateral sclerosis. Acta Med Okayama. 2014;68(2):125–7.PubMed
60.
Chang TB, Huh J. Delayed neuromuscular recovery after use of sugammadex in a patient with amyotrophic lateral sclerosis: a case report. Anaesth Pain Intensive Care. 2017;21(4):475–8.
61.
Kelsaka E, Karakaya D, Zengin EC, Zengin EC. Use of sugammadex in a patient with amyotrophic lateral sclerosis. Med Principles Pract. 2013;22(3):304–6.CrossRef
62.
Suzuki T. A train-of-four ratio of 0.9 may not certify adequate recovery after sugammadex. Acta Anaesthesiol Scand. 2011;55(3):368–9.PubMedCrossRef
63.
Yoo JH, Kim SI, Park SY, Jun MR, Kim YE, Kim HJ. Use of sugammadex in a patient with progressive muscular atrophy and in a patient with amyotrophic lateral sclerosis. Medicine (United States). 2017;96(23):e7098.
64.
Sperfeld AD, Hanemann CO, Ludolph AC, Kassubek J. Laryngospasm: an underdiagnosed symptom of X-linked spinobulbar muscular atrophy. Neurology. 2005;64(4):753–4.PubMedCrossRef
65.
Takeuchi R, Hoshijima H, Doi K, Nagasaka H. The use of sugammadex in a patient with Kennedy's disease under general anesthesia. Saudi J Anaesth. 2014;8(3):418–20.PubMedPubMedCentralCrossRef
66.
Vilela H, Santos J, Colaço J, Oliveira E, Canas-da-Silva P. Reversal of neuromuscular blockade with sugammadex in a patient with spinal muscular atrophy type III (Kugelberg-Welander syndrome). J Anesth. 2012;26(2):306–7.PubMedCrossRef
67.
de Boer HD, van Egmond J, van de Pol F, Bom A, Booij LH. Sugammadex, a new reversal agent for neuromuscular block induced by rocuronium in the anaesthetized rhesus monkey. Br J Anaesth. 2006;96(4):473–9.PubMedCrossRef
68.
McDonagh DL, Benedict PE, Kovac AL, Drover DR, Brister NW, Morte JB, Monk TG. Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients. Anesthesiology. 2011;114(2):318–29.PubMedCrossRef
69.
Yoshida F, Suzuki T, Kashiwai A, Furuya T, Konishi J, Ogawa S. Correlation between cardiac output and reversibility of rocuronium-induced moderate neuromuscular block with sugammadex. Acta Anaesthesiol Scand. 2012;56(1):83–7.PubMedCrossRef
70.
Cammu GV, Smet V, De Jongh K, Vandeput D. A prospective, observational study comparing postoperative residual curarisation and early adverse respiratory events in patients reversed with neostigmine or sugammadex or after apparent spontaneous recovery. Anaesth Intensive Care. 2012;40(6):999–1006.PubMedCrossRef
71.
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(3):582–4.PubMedCrossRef
72.
Hunter JM. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation. Br J Anaesth. 2017;119(suppl_1):i53–62.PubMedCrossRef
73.
Menéndez-Ozcoidi L, Ortiz-Gómez JR, Olaguibel-Ribero JM, Salvador-Bravo MJ. Allergy to low dose sugammadex. Anaesthesia. 2011;66(3):217–219 213.PubMedCrossRef
74.
Takahiro T, Haruyama N, Mae T, Doi K, Ozaki M. Be careful about anaphylactic shock by antagonism of the neuromuscular blockade ∼cases of anaphylactic shock induced by Sugammadex. Crit Care Med. 2012;40(12):291.
75.
76.
Cammu G, Van Vlem B, van den Heuvel M, Stet L, el Galta R, Eloot S, Demeyer I. Dialysability of sugammadex and its complex with rocuronium in intensive care patients with severe renal impairment. Br J Anaesth. 2012;109(3):382–90.PubMedCrossRef
77.
Metadata
Title
Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports
Authors
Usha Gurunathan
Shakeel Meeran Kunju
Lisa May Lin Stanton
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2019
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-019-0887-3

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