Current Anesthesiology Reports

, Volume 6, Issue 2, pp 185–191 | Cite as

The Use of Sugammadex in Clinical Practice: Which Patients Are Most Likely to Benefit?

  • Thomas Fuchs-BuderEmail author
Neuromuscular Blockade (GS Murphy, Section Editor)
Part of the following topical collections:
  1. Neuromuscular Blockade


The main advantage of sugammadex-based reversal compared with the “classical” acetylcholinesterase inhibitor-based concept is that it achieves more rapid and more reliable recovery and has the unique ability to dose-dependently reverse any degree of neuromuscular block. Mainly because of economic reasons, sugammadex is often limited to patient groups or procedures that are most likely to benefit from its unique features. In this context, patients with myasthenia gravis, patients undergoing (abdominal) laparoscopic surgery, patients undergoing short-acting procedures that require neuromuscular blockade, obese, elderly, or patients undergoing rapid sequence induction are most often cited. However, at comparable costs, this arbitrary limitation of sugammadex could be abolished.


Sugammadex Neostigmine Rocuronium Neuromuscular blockade Residual paralysis Rapid sequence induction Train-of-four 


Compliance with Ethics Guidelines

Conflict of Interest

Thomas Fuchs-Buder has received compensation from Merck for service as a consultant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Murphy GS, Szokol JW, Marymont JH, et al. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107:130–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Murphy GS, Szokol JW, Avram MJ, et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115:946–54.CrossRefPubMedGoogle Scholar
  3. 3.
    Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98:1042–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. 2010;112:1013–22.CrossRefPubMedGoogle Scholar
  5. 5.
    Meistelman C, Fuchs-Buder T, Raft J. Sugammadex development and use in clinical practice. Curr Anesthesiol Rep. 2013;3:122–9.CrossRefGoogle Scholar
  6. 6.
    Zhang MQ. Drug-specific cyclodextrines: the future of rapid neuromuscular drug reversal? Drugs Future. 2003;28(347):54.Google Scholar
  7. 7.
    Bom A, Bradley M, Cameron K, et al. A novel concept of reversing neuromuscular block: chemical encapsulation of rocuronium bromide by a cyclodextrin-based synthetic host. Angew Chem Int Ed Eng. 2002;41:266–70.Google Scholar
  8. 8.
    Sorgenfrei IF, Norrild K, Larsen PB, et al. Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study. Anesthesiology. 2006;104:555–62.CrossRefGoogle Scholar
  9. 9.
    Gijsenbergh F, Ramael S, Houwing N, van Iersel T. First human exposure of Org 25969, a novel agent to reverse the action of rocuronium bromide. Anesthesiology. 2005;103:695–703.CrossRefPubMedGoogle Scholar
  10. 10.
    Groudine SB, Soto R, Lien C, Drover D, Roberts K. A randomized, dose-finding, phase II study of the selective relaxant binding drug, sugammadex, capable of safely reversing profound rocuronium-induced neuromuscular block. Anesth Analg. 2007;104:555–62.CrossRefPubMedGoogle Scholar
  11. 11.
    Vanacker BF, Vermeyen KM, Struys MM, et al. Reversal of rocuronium-induced neuromuscular block with the novel drug sugammadex is equally effective under maintenance anesthesia with propofol or sevoflurane. Anesth Analg. 2007;104:563–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Lee C, Jahr JS, Candiotti KA, et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology. 2009;110:1020–5.CrossRefPubMedGoogle Scholar
  13. 13.
    De Boer HD, van Egmond J, Driessen JJ, Booij LH. A new approach to anesthesia management in myasthenia gravis: reversal of neuromuscular blockade by sugammadex. Rev Esp Anesthesiol Reanim. 2010;57:181–4.CrossRefGoogle Scholar
  14. 14.
    Petrun AM, Mekis D, Kamenik M. Successful use of rocuronium and sugammadex in a patient with myasthenia. Eur J Anaesthesiol. 2010;27:917–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Naguib M, Flood P, McArdle JJ, Brenner HR. Advances in neurobiology of the neuromuscular junction. Implications for the anaesthesiologist. Anesthesiology. 2002;96:202–31.CrossRefPubMedGoogle Scholar
  16. 16.
    De Boer HD, Fuchs-Buder T. Residual neuromuscular blockade and myasthenia gravis. Acta Anaesthesiol Scand. 2012;56:932–3.CrossRefPubMedGoogle Scholar
  17. 17.
    de Boer HD, van Egmond J, Driessen JJ. Sugammadex in patients with myasthenia gravis. Anaesthesia. 2010;65:653.CrossRefPubMedGoogle Scholar
  18. 18.
    Fujimoto M, Teraski S, Nishi M, Yamamoto T. Response to rocuronium and its determinants in patients with myasthenia gravis: A case-control study. Eur J Anaesthesiol. 2015;32:672–80.CrossRefPubMedGoogle Scholar
  19. 19.
    • De Boer HD, Shields MO, Booij LH. Reversal of neuromuscular blockade with sugammadex in patients with myasthenia gravis: a case series of 21 patients and review of the literature. Eur J Anaesthesiol. 2014;31:715–21. The article gives a complete overview over the topic.Google Scholar
  20. 20.
    Yamaguchi S, Ohno G, Kitamura J. Successful anesthetic management of laparoscopic rectopexy using rocuronium and sugammadex in a patient with Becker muscular dystrophy. Masui. 2014;63:1131–4.PubMedGoogle Scholar
  21. 21.
    Matsuki Y, Hirose M, Tabata M, Nobukawa Y, Shigemi K. The use of sugammadex in a patient with myotonic dystrophy. Eur J Anaesthesiol. 2011;28:145–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Dell-Kuster S, Levano S, Burkhart CS, et al. Predictors of the variability in neuromuscular block duration following succinylcholine. A prospective, observational study. Eur J Anaesthesiol. 2015;32:687–96.CrossRefPubMedGoogle Scholar
  23. 23.
    Fuchs-Buder T, Schmartz D. The never ending story or the search for a nondepolarising alternative to succinylcholine. Eur J Anaesthesiol. 2013;30:583–4.CrossRefPubMedGoogle Scholar
  24. 24.
    Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2008. doi: 10.1002/14651858.CD002788.pub2.Google Scholar
  25. 25.
    Pühringer FK, Rex C, Sielenkämper AW, et al. Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points. An international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial. Anesthesiology. 2008;109:188–97.CrossRefPubMedGoogle Scholar
  26. 26.
    Sorensen MK, Bretlau C, Gätke MR, et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine. a randomised trial. Br J Anaesth. 2012;108:682–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Bisschops MMA, Hollemann C, Huitink JM. Can sugammadex save a patients in simulated „cannot intubate, cannot ventilate“situation? Anaesthesia. 2010;65:936–41.CrossRefPubMedGoogle Scholar
  28. 28.
    Fernando PU, Viby-Mogensen J, Bonsu AK, et al. Relationsip between posttetanic count and response to carinal stimulation during vecuronium-induced neuromuscular blockade. Acta Anaesthesiol Scand. 1987;31:593–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Blobner M, Frick CG, Stäuble RB, et al. Neuromuscular blockade improves surgical conditions (NISCO). Surg Endosc. 2015;29:627–36.CrossRefPubMedGoogle Scholar
  30. 30.
    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.CrossRefPubMedGoogle Scholar
  31. 31.
    De Souza CM, Tardelli MA, Tedesco H, et al. Efficacy and safety of sugammadex in the reversal of deep neuromuscular blockade induced by rocuronium in patients with end stage renal disease: A comparative prospective clinical trial. Eur J Anaesthesiol. 2015;32:681–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Mirzakhani H, Welch CA, Eikermann M, Nozari A. Neuromuscular blocking agents for electroconvulsive therapy: a systematic review. Acta Anaesthesiol Scand. 2012;56:3–16.CrossRefPubMedGoogle Scholar
  33. 33.
    Lu IC, Wu CW, Chang PY, et al. Reversal of rocuroniu-induced neuromuscular blockade by sugammadex allows for optimization of neural monitoring of the recurrent laryngeal nerve. Laryngoscope. 2016. doi: 10.1002/lary.25577.PubMedGoogle Scholar
  34. 34.
    Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13:4–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Gambee AM, Hertzka RE, Fisher DM, et al. Preoxygenation techniques: comparison of three minutes and four breaths. Anesth Analg. 1987;66:468–70.CrossRefPubMedGoogle Scholar
  36. 36.
    Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2009;110:253–60.CrossRefGoogle Scholar
  37. 37.
    Pansard JL, Chauvin M, Lebrault C, Gauneau P, Duvaldestin P. Effects of an intubating dose of succinylcholine and atracurium on the diaphragm and the adductor pollicis muscle in humans. Anesthesiology. 1987;67:326–30.CrossRefPubMedGoogle Scholar
  38. 38.
    Meistelman C, Plaud B, Donati F. Rocuronium (ORG 9426) neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis in humans. Can J Anaesth. 1992;39:665–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fast-track bariatric surgery. Obes Surg. 2013;23:1558–63.CrossRefPubMedGoogle Scholar
  40. 40.
    Monk TG, Rietbergen H, Woo T, Fennema H. Use of sugammadex in patients with obesity: a pooled analysis. Am J Ther. 2015. doi: 10.1097/MJT.0000000000000305.PubMedGoogle Scholar
  41. 41.
    • Murphy GS, Szokol JW, Avram MJ, et al. Residual neuromuscular block in the elderly: incidence and clinical implications. Anesthesiology 2015;123:1322–36. The article summarizes the risk of residual paralysis in the elderly.Google Scholar
  42. 42.
    • Hardemark Cedborg AI, Sundman E, Boden K, et al. Pharyngeal function and breathing pattern during partial neuromuscular block in elderly. Effects on airway protection. Anesthesiology 2014;120:12–25. Gives new insights in paryngeal function in elderly and expands our understanding.Google Scholar
  43. 43.
    Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015;115:743–51.CrossRefPubMedGoogle Scholar
  44. 44.
    Ledowski T, Falke L, Johnston F, et al. Retrospective investigation of postoperative outcome after reversal of residual neuromuscular blockade: sugammadex, neostigmine or no reversal. Eur J Anaesthesiol. 2014;31:423–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Kopman AF. Neostigmine versus sugammadex: which, when, and how much? Anesthesiology. 2010;113:1010–1.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media New York 2016

Authors and Affiliations

  1. 1.Anesthesia and Critical CareUniversité de Lorraine, Centre Hospitalier Universitaire de NancyVandoeuvres-Les-NancyFrance

Personalised recommendations