During invasive surgical procedures, muscle relaxants are often used to make endotracheal intubation easier, as well as ensuring patients remain immobile during the operation. They can also help to improve surgical exposure. The use of these medicines is widespread, although in some instances a reversal agent is required to bring the patient's muscular ability back to normal levels after an invasive procedure has been carried out – which is where Sugammadex comes in.
Sugammadex is a fast-acting synthetic cyclodextrin molecule which works by encapsulating rocuronium, a muscle relaxant commonly used to promote skeletal muscle relaxation during surgeries or mechanical ventilation. Sugammadex is currently regarded by many healthcare professionals as the most ideal reversal agent available in modern medicine and can be used in everything from minor procedures to serious operations performed in the intensive care unit.
The medication is often marketed under the trade name Bridion, and the patent is currently owned by Merck. It is currently approved for use in the European Union, Australia, New Zealand, Iceland, and Norway. It is the very first selective relaxant binding agent to have been discovered.
Along with the required effects, Sugammadex can also cause some unwanted side effects. The most common side effects reported by patients undergoing treatment with this medication include blurred vision, headache, nervousness, dizziness or light-headedness when suddenly getting up from a prone position, sweating, unusual weakness or tiredness, slow or fast heartbeat.
As the patient continues with administration of Sugammadex as prescribed by a doctor, these side effects should begin to lessen. If side effects persist over a prolonged period of time or appear to get worse, the patient is advised to follow this up with his or her doctor as soon as possible. Some of these side effects may only cause mild discomfort, and a pharmacist or healthcare professional might be able to advise the patient on ways to alleviate these effects using over-the-counter products or natural remedies.
The majority of patients who undergo treatment with Sugammadex will only experience minimal side effects during and after the drug is administered. In many instances, the benefits of the drug outweigh the potential risk of experiencing minor side effects.
Other side effects which are experienced rarely, albeit often enough to warrant mentioning, include the following: chills, chest pain or discomfort, shortness of breath, fever, coughing, confusion, blue lips and/or fingernails, wheezing, difficulty swallowing, hives or welts, itching, hoarseness, irritation, increased sweating, joint pain, puffiness or swelling of the eyelids and general eye area, redness in the face or neck, swelling the ankles or legs and/or unusual bleeding or bruising. Many of these effects will not require medical attention, although patients are advised to contact their doctor if they experience prolonged discomfort after this medicine is administered.
Because Sugammadex has the propensity of cause confusion, patients are advised to refrain from driving or operating heavy machinery immediately after this medicine has been administered. This is because this side effect could affect the ability of the patient to make accurate judgments, therefore putting their own life and the lives of other road users at risk.
As with all medicines, it is imperative that Sugammadex is only administered in a clinical setting, as prescribed by a physician. This means that the team of healthcare providers should avoid injecting the patient with more of the drug than advised – either in terms of dose size or frequency. Additionally, patients should not be administered with Sugammadex if their doctor decides it is in their best interests to cease treatment with the drug.
For the routine reversal of non-depolarizing muscle relations such as rocuronium or vecuronium, the patient should be administered with 4mg/kg of Sugammadex intravenously on a one-off basis, provided recovery has reached 1-2 posttetanic counts (PTC), with no twitch responses to train-of-four stimulation.
For the immediate reversal or rocuronium, 16/kg of Sugammadex should be administered via IV, once.
Healthcare professionals who are administering Sugammadex intravenously should pay incredibly close attention to the instructions of the surgeon, doctor or operating practitioner. Although there are guidelines as to the amount of Sugammadex to use, it should be reiterated that these recommendations can be altered by the patient’s doctor based on their body weight as well as the anesthetic regimen.
To determine that satisfactory recovery has taken place, skeletal muscle tone assessments and respiratory measurements should be taken alongside the response to peripheral nerve stimulation. If the doctor is not convinced that recovery has taken place as expected, they may, with caution, proceed to administer another dose of Sugammadex at their discretion.
It is important for doctors and healthcare providers to get the initial dose right in cases where the patient requires re-administration with rocuronium or vecuronium (as part of a two-stage operation, for example), as the use of lower doses than recommended can increase the risk of the recurrence of neuromuscular blockade after initial reversal. In the event of a patient requiring re-administration with muscle relaxants, the minimum wait times apply:
When rocuronium 1.2mg/kg is administered within 30 minutes of reversal with Sugammadex, the onset of neuromuscular blockade can potentially be delayed by approximately 4 minutes, with the duration of neuromuscular blockade shortened approximately 15 minutes.
All drugs have the potential to interact with other drugs or chemicals within the body, and these interacts can change the way each medicine works. In some cases, it can make one or more medicines become ineffective. In other cases, the patient can experience potentially harmful side effects. Because of this, it is imperative that the patient keeps a detailed list of all medicines they are currently taking. This includes vitamin pills, complementary medicines and over the counter remedies as well as prescribed drugs.
Below is a list of medications known to interact negatively with Sugammadex. If the patient is currently undergoing treatment with any of these drugs, they should inform their doctor or healthcare provider prior to undergoing treatment with Sugammadex:
Hypersensitivity reactions have been reported in some patients undergoing treatment with Sugammadex, including anaphylaxis. Clinicians should therefore be prepared for the possibility of hypersensitive reactions and take precautions by having the right medicines nearby for the treatment of hypersensitivity.
Ventilation support for patients undergoing treatment with Sugammadex is mandatory until spontaneous respiration and the ability to maintain the airway is assured. A small number of patients have previously experienced minimal or delayed responses to Sugammadex – it is therefore pertinent to monitor ventilation until recovery has occurred.
Marked bradycardia has been reported in some patients, often resulting in cardiac arrest, minutes after Sugammadex was administered. Resuscitation devices should therefore be kept close to hand in a clinical setting to counteract this.
Use of Sugammadex is not recommended in patients who have severe renal impairment, or those on dialysis. This is because the risk of adverse reaction may be greater in those with liver or kidney issues. Patients with these conditions should consult with their doctor, who may be able to offer an alternative treatment.
Women who undergo treatment with Sugammadex should be aware that the efficacy of hormone-based contraceptives can be reduced for a period of up to 7 days after administration. It is therefore advisable to use non-hormonal contraceptives, such as condoms, for a 7-day period post-Sugammadex treatment.
Sugammadex is available only as an IV formulation, in 200mg or 500mg vials. It should be stored at room temperature – it is not suitable for freezing or refrigerating.
Because this drug should only be administered in a clinical setting, it is the responsibility of the patient’s healthcare provider to ensure the correct storage, administration, and disposal of Sugammadex.
Sugammadex is a well-tolerated medication which is relatively free of dangerous side-effects. It is particularly useful in the reversal of neuromuscular blockade (some clinicians consider it the best medicine of its type).
However, it can be quite an expensive drug to administer. Despite this, many physicians will still advocate its use, as it can be cost-effective in terms of reducing the amount of time a patient needs to stay in bed in a clinical setting, therefore promoting much faster convalescence in a home setting as opposed to having to stay in a hospital for a prolonged period.
To get the most out of this medication, patient and doctor must work together in order to ascertain the right dosage based on body weight, surgical procedure and any tolerances or interactions which may arise.