New Perspectives on Neuromuscular Blockade and Reversal--A Relaxed Update
Presented by Sarah E. Giron, PhD, CRNAUniversity of Southern CaliforniaClinical Assistant Professor of AnesthesiologyEmail: [email protected]
¤W
hile this p
rese
ntatio
n wa
s de
velo
pe
d ind
ep
end
ently o
f influe
nce
s or fina
ncia
l ince
ntives fro
m M
erc
k, I do
d
isclo
se tha
t I have
co
nsulted
for M
erc
k Sharp
& D
ohm
e
Co
rpo
ratio
n in the p
ast a
nd c
ontinue
to p
rovid
e
ed
uca
tiona
l lec
tures fo
r them
. I do
not o
wn sto
ck, no
r ha
ve I re
ce
ived
any m
onie
s or b
ene
fits to p
rese
nt this info
rma
tion to
you to
da
y. If you ha
ve a
ny que
stions
ab
out m
y involve
me
nt with M
erc
k ple
ase
do
not he
sitate
to
co
ntac
t me
at sa
rah.g
iron@
me
d.usc
.ed
u.
My D
isclo
sure To
You:
Prese
ntatio
n Ob
jec
tives
¤Re
view
and
disc
uss the p
hysiolo
gic
and
p
harm
ac
olo
gic
al ro
les o
f neuro
musc
ular
blo
cka
de
in the c
are
of the
surgic
al
pa
tient.
¤Esta
blish the
imp
lica
tions o
f neuro
musc
ular
blo
cka
de
in curre
nt CRN
A p
rac
tice
.
¤C
om
pa
re a
lterna
tive, ne
w ne
urom
uscula
r b
loc
kad
e m
od
alitie
s.
¤Re
view
curre
nt neuro
musc
ular
blo
cking
ag
ents a
nd c
urrent re
versa
l o
ptio
ns for surg
ica
l pa
tients.
¤Pre
sent ne
urom
uscula
r blo
cka
de
m
onito
ring style
s and
co
mp
are
their
use in c
urrent C
RNA
pra
ctic
e.
http://w
ww
.ca
rtoo
nstoc
k.co
m/d
irec
tory/r/re
me
dia
l.asp
Prese
ntatio
n Ove
rview
¤N
euro
musc
ular Blo
cka
de
(NM
B)¤
Physiolo
gy a
nd Pha
rma
co
log
y of N
MB
¤D
ep
ola
rizing vs. N
on-D
ep
ola
rizing A
ge
nts
¤M
onito
ring o
f NM
B
¤Re
versa
l of N
MB
¤A
nticho
lineste
rase
s¤
Antic
holine
rgic
s¤
Suga
mm
ad
ex
(Bridio
n®)
¤O
ther A
ge
nts Being
De
velo
pe
d
Ne
urom
uscula
r Bloc
kad
e
¤A
Quic
k Ana
tom
ic a
nd
Physiolo
gic
Revie
w
¤The
Ne
urom
uscula
r Junc
tion (N
MJ)
¤M
oto
r Ne
rve Te
rmina
l (p
resyna
ptic
).
¤M
oto
r End Pla
te o
f M
uscle
Fibe
rs (p
ostsyna
ptic
).
¤A
s a m
oto
r nerve
p
ote
ntial re
ac
hes the
te
rmina
l, Ca
2+
cha
nnels o
pe
n and
c
ause
Ac
h filled
ve
sicle
s to fo
rm a
nd
op
en into
the syna
ptic
c
left.
http://mynotes4usm
le.tumblr.com
/post/34773331063/houseofmind-the-neurom
uscular-junction-nmj-is
Physiolo
gy o
f NM
B
¤O
nce
Ac
h co
mb
ines w
ith bo
tha
lpha
sub
units of the
nico
tinic re
ce
pto
r on
the p
ostsyna
ptic
me
mb
rane
, the
cha
nnel is o
pe
ned
ca
using K
+to
d
iffuse o
ut and
Na
+a
nd C
a2+
to
diffuse
in. This diffusio
n initiate
s a
de
po
lariza
tion w
hich (if it re
ac
hes the
thre
shold
po
tentia
l) initiate
s an a
ctio
n p
ote
ntial a
nd c
ause
s a m
uscle
c
ontra
ctio
n.
http://www.blobs.org/science/article.php?article=39
Ac
tion Po
tentia
l co
nt.
It All Sta
rted
with C
urare
http://he
rbo
laria
.wikia
.co
m/w
iki/Cura
rehttp
://ethno
bo
tany09.p
rovid
enc
e.w
ikispa
ce
s.net/C
urare
http://lisa
swrito
pia
.co
m/flying
-de
ath/
A Re
laxing
Histo
ry…
We
lliver. (2012). A
AN
A J, S11-17.
1884 First p
ublishe
d
study o
n C
urare
1941 C
urare
first used
in surg
ica
l pa
tients
1949 G
alla
mine
&
Me
toc
urine
de
velo
pe
d
1951 Suc
cinylc
holine
d
eve
lop
ed
1958 First ne
rve
stimula
tor
introd
uce
d
1964-68 The
first stero
ida
l N
MBA
s introd
uce
d:
Alc
uronium
and
Pa
ncuro
nium 1981
Ve
curo
nium
& A
trac
urium
introd
uce
d
1994 Ro
curo
nium &
C
isatra
curium
d
eve
lop
ed
1991 M
ivac
urium
introd
uce
d 2000
Rap
ac
uronium
intro
duc
ed
De
po
larizing
vs. No
n-De
po
larizing
M
uscle
Rela
xants
¤D
ep
ola
rizing M
uscle
Rela
xants: Suc
cinylc
holine
¤Sux is the
only d
ep
ola
rizing m
uscle
rela
xantin c
linica
l use. It
has a
rap
id o
nset (30-60se
c) a
nd sho
rtd
uratio
n(3-5min).
¤U
nlike N
on-D
ep
ola
rizers, Sux’s a
ctio
n in musc
le re
laxa
tion
oc
curs b
ec
ause
it mim
ics the
ac
tion o
f Ac
h . Ne
urom
uscula
r b
loc
kad
e d
eve
lop
s be
ca
use the
de
po
larize
d m
em
bra
ne
ca
nnot re
spo
nd to
subse
que
nt rele
ase
s of A
ch (Pha
se I
blo
cka
de
).
¤A
single
larg
e d
ose
, rep
ea
ted
do
ses o
r a c
ontinuo
us infusion
lea
ds to
po
stjunctio
nal m
em
bra
nes tha
t do
not re
spo
nd to
A
ch no
rma
lly. This ca
n be
ca
used
by re
ce
pto
r d
ese
nsitizatio
n, ion c
hanne
l blo
cka
de
or e
ntranc
e o
f Sux into
the ske
leta
l musc
le c
ytop
lasm
(Phase
II blo
cka
de
).
Side
Effec
ts of Suc
cinylc
holine
Why W
e Like
It:
¤Sp
onta
neo
us ventila
tion b
y the p
atie
nt resum
es ra
ther
quic
kly.
Why W
e D
on’t:
¤C
ard
iac
Dysrhythm
ias
¤Bra
dyc
ard
ia, junc
tiona
l rhythms a
nd sinus a
rrest.
¤H
ype
rkale
mia
¤Susta
ined
op
ening
of p
ostjunc
tiona
lrec
ep
tors a
re
asso
cia
ted
with le
aka
ge
of K+ o
n ave
rag
e 0.5
mEq
/liter. H
ype
rkale
mia
ma
y oc
cur in p
atie
nts with
musc
ular d
ystrop
hy, burns, a
nytime
there
’s skele
tal
musc
le a
trop
hy (96 hrsto
6 mo
nths afte
r injury), se
vere
traum
a a
nd up
pe
r mo
tor ne
uron le
sions.
¤M
yalg
ia¤
Fasic
ulatio
ns(o
uch!)
Side
Effec
ts of Suc
cinylc
holine
¤M
yog
lob
inuria¤
From
skele
tal m
uscle
da
ma
ge
.
¤Inc
rea
sed
Intrag
astric
Pressure
¤Se
co
nda
ry to inte
nsity of m
uscle
fasic
ulatio
ns.
¤Inc
rea
sed
Intrao
cula
r Pressure
¤M
axim
um inc
rea
ses se
en 2-4 m
in afte
r ad
ministra
tion a
nd c
an
last 5-10m
in.
¤Inc
rea
sed
ICP
¤Susta
ined
Skele
tal M
uscle
Co
ntrac
tion
¤Inc
om
ple
te ja
w re
laxa
tion a
nd m
asse
ter m
uscle
rigid
ity ca
n b
e se
en o
cc
asio
nally in c
hildre
n
¤M
alig
nant H
ype
rtherm
ia
No
n-De
po
larizing
Musc
le
Rela
xants
¤U
nlike Sux, N
on-D
ep
ola
rizing M
uscle
Rela
xants (N
DM
Rs) ac
t thro
ugh c
om
pe
titive a
ntag
onism
at the
NM
J. Only o
ne
alp
ha sub
unit on the
nico
tinic re
ce
pto
r nee
ds to
be
b
loc
ked
to p
reve
nt ac
tion p
ote
ntial p
rop
ag
atio
n.
http://www.sagentpharm
a.com/rocuroni
um-brom
ide-injection.html
http://www.bedfordlabs.com
/our_products/online_catalog/products/vecuronium
.html
http://hospira.com/products_an
d_services/drugs/PANCURONI
UM_BROMIDE
http://whataf
y.com/atracu
rium-
besylate-injection.html
https://www.anesthesio
logyhub.com/mivacron.
html
https://www.anesthesiologyh
ub.com/nim
bex.html
A Sum
ma
ry
Gustafson & Brow
n US Pharm
.2017;42(1):HS16-H
S20.
Spo
ntane
ous Re
versa
l of
ND
MRs
¤Sp
onta
neo
us reve
rsal is slo
w a
nd unp
red
icta
ble
.
¤Re
sidua
l blo
ck is a
ssoc
iate
d w
ith rare
but p
ote
ntially
serio
us risks: asp
iratio
n, imp
aire
d hyp
oxic
ventila
tory
resp
onse
, pulm
ona
ry co
mp
lica
tions (yuc
k!)Ca
rroll e
t al. (1998). A
naes, 53, 1169–1173.
Let’s Ta
lk Ab
out H
ow
We
Mo
nitor
Para
lysis
http://salestores.com/sunm
ed81053601.html
http://neuromuscular-m
onitoring.anesthesia-research.com/
http://en.wikipedia.org/w
iki/Neurom
uscular_monitoring
¤“W
hen ne
urom
uscula
r blo
cking
ag
ents a
re
ad
ministe
red
, mo
nitor ne
urom
uscula
r resp
onse
to
asse
ss de
pth o
f blo
cka
de
and
de
gre
e o
f re
co
very.”
¤A
AN
A Sta
nda
rds o
f Nurse
Ane
sthesia
Prac
tice
p.2
https://w
ww
.aa
na.c
om
/do
cs/d
efa
ult-sourc
e/p
rac
tice
-aa
na-c
om
-we
b-
do
cum
ents-(a
ll)/stand
ard
s-for-nurse
-ane
sthesia
-pra
ctic
e.p
df?sfvrsn=e
00049b1_2
Mo
nitoring
http://intra
op
era
tivene
urom
onito
ring.c
om
/train-o
f-four/
¤C
entra
l musc
les re
co
ver e
arlie
r than p
erip
hera
l musc
les (i.e
. your
dia
phra
gm
rec
ove
rs faste
r than yo
u ad
duc
tor p
ollic
is).¤
Ho
we
ver yo
ur co
rruga
tor sup
erc
iliirec
ove
rs faste
r than the
upp
er
airw
ay a
nd a
dd
ucto
r po
llicis
(i.e. o
vere
stima
tes the
de
gre
e o
f re
co
very).
¤A
TOF ra
tio ≥ 0.9 a
t the a
dd
ucto
r po
llicis
is co
nside
red
ad
eq
uate
re
co
very.
Subje
ctive
vs. Ob
jec
tive M
onito
ring
¤Sub
jec
tive M
onito
ring¤
Also
know
n as Q
ualita
tive
mo
nitoring
.¤
Usua
lly pe
rform
ed
with a
p
erip
hera
l nerve
stim
ulato
r and
visual o
r ta
ctile
asse
ssme
nt of
twitc
hes a
nd fa
de
.¤
Perfo
rme
d in le
ss than
40% o
f pa
tients. 1
¤O
nce
the TO
F ratio
e
xce
ed
s 0.40, mo
st c
linicia
ns ca
nnot d
ete
ct
eithe
r tac
tile o
r visual
fad
e. 2
1.Tho
mse
n et a
l. (2015). Br J Ana
esth, 115, i89-94.2.
Vib
y-Mo
ge
nsen
et a
l. (1985). Anesthesiol, 63, 440-443.
3.Phillip
s et a
l. (2013). Ana
esthIntensive C
are, 41, 374-379.
¤O
bje
ctive
Mo
nitoring
¤A
lso kno
wn a
s Q
uantita
tive m
onito
ring.
¤U
sually p
erfo
rme
d w
ith a
nerve
stimula
tor tha
t ca
n c
alc
ulate
TOF ra
tio.
¤Pe
rform
ed
in less tha
n 17%
of p
atie
nts. 3
http://fro
mne
wto
icu.c
om
/blo
g/2016/3/1
1/train-o
f-four
Ho
w d
o W
e M
ea
sure Re
versa
l in N
DM
Rs?
% o
f Rec
ep
tors
Bloc
ked
Twitc
hes
on TO
F
Clinic
al Re
spo
nse
99-1000 Tw
itche
s Fla
cc
id p
atie
nt
95D
iap
hrag
m M
ove
s
901 Tw
itch
Ab
do
mina
l rela
xatio
n
ad
eq
uate
for m
ost
ab
do
mina
l pro
ce
dure
s
754 Tw
itche
s Tid
al V
olum
e a
nd V
ital
Ca
pa
city N
orm
al
50Pa
ss inspira
tory p
ressure
test
30H
ea
d lift a
nd ha
nd-g
rip
sustaine
d
¤The
5-sec
hea
d lift
wa
s unab
le to
id
entify TO
F ratio
s a
s low
as 0.5 in
mo
re tha
n 70% o
f p
atie
nts. 1-2
¤5-se
c te
tanic
fad
e
ca
n only b
e
relia
bly d
ete
cte
d
whe
n the TO
F ratio
is ≤ 0.3. 3
1.Eike
rma
nne
t al. (2003). A
nesthesiol, 98, 1333-1337.
2.Pe
de
rsen e
t al.(1990). A
nesthesiol, 73, 835-839.3.
Ca
pro
n et a
l. (2006). Anesth
Analg, 102, 1578-
84.
Why Re
verse
Ne
urom
uscula
r Blo
cka
de
?¤
To fa
cilita
te sp
onta
neo
us resp
iratio
n and
ve
ntilatio
n.
¤Sho
rten tim
e in o
pe
rating
roo
m.
¤A
void
resid
ual b
loc
k and
its asso
cia
ted
risks.
¤Re
versa
l of N
DM
Rs is asso
cia
ted
with
de
cre
ase
d risk o
f po
stop
era
tive
mo
rtality a
nd c
om
a. 1
¤D
ec
rea
se the
risk of p
atie
nts e
xpe
rienc
ing the
very
unple
asa
nt effe
cts
of re
sidua
l blo
ck.
¤20-40%
of p
atie
nts exp
erie
nce
re
sidua
l NM
B in the PA
CU
2-3
1.A
rbo
usM
H e
t al. (2005). A
nesthesiol,102, 257–268.2.
He
iere
t al. (2012). Br J A
naesth, 108, 444-451.3.
Fortie
r et a
l. (2015). Anesth
Analg, 121, 366-372.
Disa
dva
ntag
es o
f Antic
holine
stera
ses
¤The
se a
ge
nts ca
nnot re
verse
pro
found
blo
cka
de
.
¤A
de
qua
te re
versa
l is not a
lwa
ys po
ssible
and
there
is alw
ays
a risk o
f resid
ual b
loc
kad
e (N
atio
nal A
vera
ge
s site 16-42%
ha
ve re
sidua
l blo
cka
de
in the PA
CU
). 1
¤M
urphy e
t al. sho
we
d 88%
of p
atie
nts have
resid
ual b
loc
kad
e
at e
xtuba
tion. 1
¤Ko
pm
an
et a
l. show
ed
that 50%
of p
atie
nts have
resid
ual
blo
cka
de
in PAC
U. 2
¤PA
CU
nurses re
po
rt that re
sidua
l NM
B is one
of the
three
mo
st c
ritica
l eve
nts that the
y fac
e tha
t req
uires e
me
rge
ncy
interve
ntion. 3
¤O
nset tim
es o
f antic
holine
stera
ses a
re d
iffere
nt:¤
Endro
pho
nium1-2 m
in¤
Ne
ostig
mine
7-11 min
1.A
nesAna
lg2005; 100:1840-1845.
2.A
nesAna
lg2004; 98: 102-106.
3.Stra
uss & Le
wis (2015). O
R Nurse, 9, 24-30.
Antic
holine
stera
ses c
ont.
Side
Effec
ts:
¤D
ec
rea
ses in b
loo
d p
ressure
se
co
nda
ry to d
ec
rea
ses in SV
R
¤Bra
dyc
ard
ia
¤Po
orly m
eta
bo
lized
by re
nal
failure
pa
tients (50%
of
Ne
ostig
mine
and
75% o
f End
rop
honium
and
Pyrid
ostig
mine
are
rena
llym
eta
bo
lized
)
¤Enha
nce
s ga
stric se
cre
tions
¤Inc
rea
ses m
otility o
f GI tra
ct
¤Inc
rea
sed
incid
enc
e o
f PON
V
¤Inc
rea
se p
rod
uctio
n of se
cre
tions
¤Bro
ncho
co
nstrictio
na
nd
incre
ase
d a
irwa
y resista
nce
¤M
iosis
¤D
ec
rea
sed
IOP
¤The
refo
re, the
se a
ge
nts should
be
a
dm
inistere
d w
ith an
Antic
holine
rgic
!!
Antic
holine
rgic
s
¤U
sed
for the
ir sed
ative
and
antisio
log
og
ue p
rop
ertie
s
¤Tre
atm
ent fo
r bra
dyc
ard
ia (A
trop
ine m
ore
so tha
n Glyc
op
yrola
te
or Sc
op
ola
mine
)
¤G
iven c
onc
om
itantly w
ith an a
nticho
lineste
rase
for re
versa
l of
musc
le b
loc
kad
e
¤Re
laxe
s bilia
ry and
urethra
l smo
oth m
uscle
¤Bro
ncho
dila
tion
¤Pre
ventio
n of m
otio
n sickne
ss
¤Sid
e Effe
cts:
¤C
entra
l Antic
holine
rgic
Syndro
me
: CN
S ma
nifesta
tions suc
h re
stlessne
ss, som
nole
nce
, halluc
inatio
ns and
unco
nscio
usness c
an
result.
Antic
holine
rgic
s co
nt.
Atro
pine
Sco
po
lam
ineG
lyco
pyrro
late
Sed
atio
n+
+++0
Antisia
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ase
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R+++
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xes Sm
oo
th M
uscle
+++
++
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riasis,
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Preve
nts Na
usea
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0
Ane
sthesio
log
y1 2018, V
ol.128, A
19. d
oi:10.1097/A
LN.0000000000002028 Info
gra
phic
c
rea
ted
by Jo
natha
n P. Wa
nde
rer &
Jam
es P.
Rathm
ell.
INFOGRAPHICS IN ANESTHESIOLOGY
411Innate
Imm
uneD
ysfunctionin
Trauma
Patients:From
Pathophysiology
toTreatm
ent(C
linicalConcepts
andC
omm
entary)R
ecentinsightsintoposttraum
aticim
mune
dysfunctionhave
definednew
targetsfor
imm
unointerventionthat
holdprom
iseforimproving
outcomesin
suchcriticallyill
patients.
271H
ighIntraoperative
InspiredO
xygenD
oesN
otIncrease
Postoperative
Supplem
entalO
xygenR
equirements
High
inspiredoxygen
may
bereasonable
inlow
errisk
surgeryto
improve
wound
oxygenation.
347A
ccuracyofU
ltrasound-guidedN
erveB
locksofthe
Cervical
ZygapophysialJointsU
ltrasoundim
agingw
asanaccurate
techniqueforcervi-
calzygapophysialjointnerveblocksinvolunteers.Seethe
accompanyingEditorialV
iewon
page236.
353E
stimation
oftheC
ontributionofN
orketamine
toK
etamine-
inducedA
cuteP
ainR
eliefandN
eurocognitiveIm
pairment
inH
ealthyVolunteers
Norketam
inehasan
effectoppositeto
thatofketamine
onpain
relief.
399S
evereE
mergence
Agitation
afterM
yringotomy
ina
3-yr-oldC
hild(C
aseS
cenario)Em
ergenceagitation,the
associatedrisk
factors,andits
preventionand
treatmentare
discussed.
243Factors
Affecting
Adm
issionto
Anesthesiology
Residency
inthe
United
States:C
hoosingthe
Futureof
Our
Specialty
The
proportionofanesthesiology
residentsfromU
.S.medicalschoolshasm
orethan
dou-bled
since1995.T
hisretrospective
cohortstudy
evaluatedthe
2010and
2011residency
applicantsto
determine
thefactorsassociated
with
asuc-cessful
admission
toresi-
dencytraining
programs.
The
sample
represented58%
ofthetotalnationalapplicantpool;66%
ofthe
applicantssuccessfully
matched
toanes-
thesiology.Theoddsforasuc-
cessfulmatch
were
higherforapplicantsfrom
U.S.m
edicalschools,
thosew
ithU
nitedStates
Medical
LicensingExam
inationscoresgreater
than210,
youngerappli-
cants,and
females.
Priorgraduate
educationor
peer-review
edpublicationsdid
notofferanyadvantage.T
hisstudysuggeststhe
potentialforageand
genderbiasinthe
selectionprocess.Seetheaccom
panyingEditorialView
onpage
230.
302W
hatFactors
Affect
IntrapartumM
aternalTemperature?
AP
rospectiveC
ohortS
tudy:MaternalIntrapartum
Temperature
The
causeofrises
inintrapartum
maternaltem
peratureis
notknown.In
thisprospective
studyof81
wom
enscheduled
forlaborinduction,hourlyoraltem
peratureswere
recordedand
analyzedbased
onrace,
bodym
assindex,
durationof
labor,and
time
toepidural.
Overall,tem
peratureroseina
significantlineartrendovertim
e.Positivetemperaturetrends
wereassociated
with
significantlylongertimefrom
mem
branerupturetodeliveryand
higherbody
mass
index.Tem
peratureslopes
didnot
differbefore
compared
with
afterepidural
analgesia.Thisstudy
suggeststhatepiduralanalgesiaalonedoesnotincreasetherisk
ofhightem
peraturesinintrapartum
wom
en.
321P
ostoperativeQ
TIntervalP
rolongationin
Patients
Undergoing
Noncardiac
Surgery
underG
eneralA
nesthesia
Electrocardiograms(EC
G)can
identifyabnorm
alcardiacrepolarization
byobservation
ofaprolonged
QT
interval.QT
intervalprolongationisoften
causedby
drugsandcan
resultinsudden
cardiacdeath.In
thisancillarystudy
tothe
Vitam
insinN
itrousOxide
trial,serialpostoperative
12-leadEC
Gw
ereobtained
from469
patientsundergoingm
ajornoncardiacsurgery
undergeneralanesthesia.Eighty
percentofpatientsexperienced
asignificantQ
Tintervalprolongation,and
approximatelyhalfhad
increasesgreaterthan440
msattheend
ofsurgery.O
nepatient
developedtorsade
depointes.D
rugsassociated
with
prolongedQ
Tintervalincluded
isoflurane,methadone,ketorolac,cefoxitin,zosyn,unasyn,epinephrine,
ephedrine,andcalcium
.Although
theexactcauseoftheassociationbetw
eenperioperatively
administered
drugsandQ
Tintervalprolongation
isnotknown,furtherstudyisw
arrantedto
determine
theclinicalrelevance.
THISM
ONTHIN
balt6/z7i-anesth/z7i-anesth/z7i00812/thismonth
panickesS!
2456/29/12
22:41Art:
Input-ebh
PACU
= postanesthesia care unit; TOF = train-of-four.
Infographic created by Jonathan P. Wanderer, Vanderbilt U
niversity Medical C
enter, and James P. Rathm
ell, Brigham and W
omen’s H
ealth Care/H
arvard Medical
School. Illustration by Annemarie Johnson, Vivo Visuals. Address correspondence to D
r. Wanderer: jonathan.p.w
1. Murphy G
S, Szokol JW, A
vram M
J, Greenberg SB
, Shear TD, D
eshur MA
, Benson J, N
ewm
ark RL, M
aher CE: N
eostigmine adm
inistration after spontaneous recovery to a train-of-four ratio of 0.9 to 1.0: A
randomized controlled trial of the effect on neurom
uscular and clinical recovery. AN
ESTHESIO
LOG
Y 2018; 128:27–37
2. Brull SJ, N
aguib M: H
ow to catch unicorns (and other fairytales). A
NESTH
ESIOLO
GY 2018; 128:1–3
3. Viby-Mogensen J, Jensen N
H, Engbaek J, O
rding H, Skovgaard LT, C
hraemm
er-Jørgensen B: Tactile and visual evaluation of the response to train-of-four nerve stim
ulation. A
NESTH
ESIOLO
GY 1985; 63:440–3
Anesth
esiology, V 128 •
No 1
January 2018
Com
plex Information for A
nesthesiologists Presented Q
uickly and Clearly
FREE
Dow
nloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/936634/ on 04/02/2018
Suga
mm
ad
ex
Bom
A e
t al. (2002). A
ngewC
hemIntEd
Engl,41, 266–270.
Wha
t is Suga
mm
ad
ex?
¤A
cyc
lod
extrin
¤C
yclic
olig
osa
cc
harid
e c
arb
ohyd
rate
s that a
re
ca
pa
ble
of e
nca
psula
ting ”g
uest” m
ole
cule
s.¤
Cyc
lod
extrin
pre
pa
ratio
ns are
curre
ntly used
in a
numb
er o
f ora
l me
dic
atio
ns from
Ibup
rofe
n to
Me
top
rolo
l to O
me
pra
zole
to e
nhanc
e so
lubility
and
stab
ility, incre
ase
bio
ava
ilab
ility and
d
ec
rea
se g
astric
ulce
ratio
n. 1
¤U
sually re
nally
exc
rete
d.
¤Su
refe
rs to the
suga
r co
mp
one
nt and
ga
mm
ad
ex
refe
rs to the
structura
l co
mp
one
nt γ-cyc
lod
extrin.
¤FD
A a
pp
rove
d fo
r use in U
S in De
ce
mb
er 2015.
¤First c
om
me
rcia
lly ava
ilab
le 2008
¤Kno
wn a
s Bridio
n® w
orld
wid
e.
1. Tiwa
ri, Tiwa
ri, & Ra
i (2010). J Pharm
acy a
nd Bioa
lliedSciences, 2, 72–79.
https://www.merckconnect.com
/bridion/dosing.htm
l?hcpUser=yes
Wha
t is Suga
mm
ad
ex c
ont.
¤V
ery w
ate
r solub
le (hyd
rop
hilic o
utside
, hyd
rop
hob
ic insid
e)
¤Fo
rms a
1:1 co
mp
lex w
ith Roc
or
Ve
c--Lo
w d
issoc
iatio
n rate
.
¤W
orks o
n Am
inoste
roid
alN
DM
Rs (Ro
c>V
ec
). 1
¤Is no
w re
ferre
d to
as a
Sele
ctive
Re
laxa
nt Binding
Ag
ent (SRBA
).
¤It is no
t a re
ce
pto
r drug
, it is a c
onta
iner
drug
.
¤C
ontra
indic
ate
d in se
vere
rena
l im
pa
irme
nt pa
tients.
1. SuyK e
t al. (2007). A
nesthesiol,106, 283-288.
Ad
ministra
tion
¤Sug
am
ma
de
xis a
NM
B reve
rsal a
ge
nt. ¤
For use
in ad
ult surgic
al p
atie
nts only.
¤Fo
r reve
rsal o
f only Ro
curo
nium a
nd V
ec
uronium
.
¤Is a
vaila
ble
as 100 m
g/c
c p
rep
ara
tion in 2 c
c a
nd 5 c
c via
ls.
¤Sug
am
ma
de
xis a
dm
inistere
d IV
.¤
Inco
mp
atib
le w
ith vera
pa
mil, o
nda
nsetro
n and
ranitid
ine.
¤The
me
cha
nism o
f ac
tion invo
lves e
nca
psula
ting, b
inding
and
ina
ctiva
ting Ro
c o
r Ve
c.
¤Thro
ugh ina
ctiva
tion, a
co
nce
ntratio
n gra
die
nt oc
curs shifting
the
NM
B aw
ay fro
m the
NM
J, reve
rsing p
ara
lysis.
¤The
spe
ed
in whic
h the re
versa
l take
s pla
ce
is de
pe
nde
nt on the
le
vel o
f rela
xatio
n and
do
se o
f Suga
mm
ad
ex. It is d
ose
d
ep
end
ent.
Ad
ministra
tion
¤H
orm
ona
l co
ntrac
ep
tives c
an b
ec
om
e le
ss effe
ctive
se
co
nda
ry to a
low
ering
of the
free
pla
sma
c
onc
entra
tions.
¤C
ounse
l your fe
ma
les p
atie
nts of c
hild b
ea
ring a
ge
to use
b
ac
k up c
ontra
ce
ptio
n 7 da
ys afte
r surge
ry.
Do
sing
¤N
o d
ose
ad
justme
nts nee
d to
be
ma
de
in ge
riatric
, ca
rdia
c o
r p
ulmo
nary p
atie
nts with no
rma
l rena
l functio
n.
¤N
o d
osa
ge
ad
justme
nt nec
essa
ry for m
ild to
mo
de
rate
rena
l im
pa
irme
nt.
¤H
ow
eve
r, it is co
ntraind
ica
ted
in seve
re re
nal im
pa
irme
nt p
atie
nts!!
Do
sing
¤D
osing
is ba
sed
on a
ctua
l bo
dy
we
ight , no
t ide
al b
od
y we
ight.
¤D
osing
is ba
sed
on the
de
gre
e o
f m
uscle
rela
xatio
n.
¤Fo
r 2/4 TOF tw
itche
s, the d
ose
is 2 m
g/kg
¤Fo
r 1-2 PTC tw
itche
s, the d
ose
is 4 m
g/kg
¤To
reve
rse RSI d
ose
of Ro
c, 16
mg
/kg sho
uld b
e a
dm
inistere
d 3
min a
fter the
RSI do
se.
¤Be
sure to
give
the re
co
mm
end
ed
d
ose
or yo
u ma
y run into
rec
urrenc
e o
f NM
B/rec
urariza
tion.
https://w
ww
.shuttersto
ck.c
om
/sea
rch/fa
t+thin
Do
sing c
ont.
¤If ne
urom
uscula
r blo
cka
de
wo
uld ne
ed
to b
e re
-e
stab
lished
afte
r a re
versa
l with Sug
am
ma
de
x, Sux, M
ivac
urium, C
isatra
curium
or A
trac
uriumc
ould
be
c
onsid
ere
d.
¤If a
n am
inoste
roid
alN
MB is use
d, fo
llow
the ta
ble
be
low
:
Minim
um W
aiting
Time
NM
BA &
Do
se to
be
A
dm
inistere
d
5 minute
s1.2 m
g/kg
Roc
uronium
4 hours
0.6 mg
/kg Ro
curo
nium0.1 m
g/kg
Ve
curo
nium
Re-A
dm
inistratio
n of Ro
c o
r Ve
cA
fter Re
versa
l with Sug
am
ma
de
x(up
to 4 m
g/kg
)
Pharm
ac
okine
tics
Bom
A e
t al (2003). A
nesthesiol, 99, A1158.
Gijse
nbe
rgh
et a
l. (2005). Anesthesiol,103, 695–703.
Ima
ge
from
http
s://en.w
ikipe
dia
.org
/wiki/Sug
am
ma
de
x#/m
ed
ia/File
:Sug
am
ma
de
x_sod
ium_3D
_front_vie
w.p
ng
¤Sug
am
ma
de
xis re
nally e
xcre
ted
.¤
The Et1/2
is 2 hours in a
n ad
ult with
norm
al re
nal func
tion.
¤>90%
is exc
rete
d in the
urine o
ver 24
hours.
¤V
Dis 11-14 lite
rs in ad
ults with no
rma
l re
nal func
tion.
¤Pla
sma
cle
ara
nce
is 88 cc
/min.
¤N
o m
eta
bo
lites.
¤N
o d
iffere
nce
in pha
rma
co
kinetic
s w
ith resp
ec
t to g
end
er o
r rac
e.
Ad
verse
Effec
ts
¤H
ype
rsensitivity re
ac
tions, inc
luding
a
nap
hylaxis, ha
ve b
ee
n rep
orte
d.
¤The
incid
enc
e c
ited
is 0.3% o
r 1/299 sub
jec
ts.
¤H
ype
rsensitivity o
cc
urred
with the
16 m
g/kg
do
se.
¤Bra
dyc
ard
ia ha
s be
en re
po
rted
.
¤W
hile no
antic
holine
rgic
nee
ds to
be
a
dm
inistere
d w
ith Suga
mm
ad
ex,
trea
t ap
pro
pria
tely.
¤Risk o
f pro
long
ed
NM
B.
¤Sug
am
ma
de
xm
ight no
t wo
rk on
ce
rtain p
atie
nts--Mo
nitor a
lwa
ys!http://forum
s-archive.secondlife.com/327/03/244341/1.htm
l
Tole
rab
ility
¤Risk o
f ble
ed
ing:
¤D
ose
s up to
16 mg
/kg ha
ve b
ee
n re
po
rted
to inc
rea
se c
oa
gva
lues b
y 25%
for 1 ho
ur.
¤H
ow
eve
r the c
linica
l trial d
id no
t show
a
n incre
ase
in blo
od
loss o
r ane
mia
.
¤Be
aw
are
, esp
ec
ially if yo
ur pa
tient
has a
know
n co
ag
ulop
athy, if the
y a
re re
ce
iving the
rap
eutic
a
ntico
ag
ulatio
n/throm
bo
pro
phyla
xis.
Gijse
nbe
rgh
et a
l. (2005). Anesthesiol,103, 695–703.
https://w
ww
.npg
.org
.uk/co
llec
tions/se
arc
h/po
rtrait/m
w62694
/Brea
thing-a
-vein
Just Ho
w Fa
st Is It?
NM
B Ag
ent
Suga
mm
ad
ex
(2 mg
/kg)
Ne
ostig
mine
/G
lyco
pyrro
late
(50 mc
g/kg
+ 10 mc
g/kg
)
Roc
uronium
1.4 minute
s21.5 m
inutes
Ve
curo
nium2.1 m
inutes
29 minute
s
Me
dia
n Time
to Full Re
versa
l (TOF ra
tio to
0.9) from
Mo
de
rate
Blo
cka
de
(T2 )
NM
B Ag
ent
Suga
mm
ad
ex
(4 mg
/kg)
Ne
ostig
mine
/G
lyco
pyrro
late
Roc
uronium
2.7 minute
sN
A
Ve
curo
nium2.1 m
inutes
NA
Me
dia
n Time
to Full Re
versa
l (TOF ra
tio to
0.9) from
De
ep
Blo
cka
de
(PTC 1-2)
Loo
king to
the Future
https://w
ww
.inde
pe
nde
nt.co
.uk/arts-e
nterta
inme
nt/tv/fea
tures/b
ac
k-to-the
-future-w
hy-the
-jetso
ns-is-the-m
ost-influe
ntial-tv-sho
w-o
f-the-20th-c
entury-8225272.htm
l
If I have
see
n further tha
n o
thers, it is b
y stand
ing up
on
the sho
ulde
rs of g
iants.
-Isaa
c N
ew
ton
Ga
ntac
urium¤
A ne
w c
lass o
f isoq
uinoline
NM
B know
n as
chlo
rofum
ara
tes.
¤D
eve
lop
ed
as a
n ultra
short a
cting
, rap
id o
nset
NM
B.
¤M
eta
bo
lized
by c
ysteine
a
dd
uctio
n and
pH
-se
nsitive hyd
rolysis.
¤M
eta
bo
lites ha
ve no
ne
urom
uscula
r pro
pe
rties.
¤N
o re
nal a
nd he
pa
tic
involve
me
nt in elim
inatio
n.
Pharm
ac
od
ynam
ics/Pha
rma
co
kinetic
s
¤In hum
an tria
ls, the ED
95o
f Ga
ntac
uriumw
as fo
und to
be
0.19 m
g/kg
¤O
nset tim
e is le
ss than 3 m
in, how
eve
r at 4 X ED
95d
ose
, onse
t tim
e c
an b
e sho
rtene
d to
1.5 min
¤D
uratio
n of a
ctio
n is ~10-15 min (sp
onta
neo
us reve
rsal to
TOF
≥ 0.9)
¤C
an b
e re
verse
d w
ith an a
nticho
lineste
rase
¤Pre
fera
bly e
dro
pho
niumw
ith it’s pe
ak e
ffec
t at 2 m
in.¤
In huma
ns, reve
rsed
to TO
F ≥ 0.9 in 3.8 min
¤C
an b
e re
verse
d w
ith L-cyste
ine¤
Cyste
ine is a
n am
ino a
cid
¤U
sed
in pa
renta
l nutrition
¤In a
bo
lus do
se o
f 10-50 mg
/kg fo
r reve
rsal, no
toxic
ity¤
De
pe
nding
on w
hen it is a
dm
inistere
d fo
r reve
rsal, c
an
shorte
n the d
uratio
n of a
ctio
n by 2-6 m
in
Side
Effec
ts
¤D
ose
de
pe
nde
nt transie
nt c
ard
iova
scula
r side
effe
cts
have
be
en o
bse
rved
in hum
ans.
¤U
sually re
po
rted
at d
ose
s o
f 3 X ED95
¤Evid
enc
ed
by hyp
ote
nsion
and
refle
x tac
hyca
rdia
¤H
uma
ns show
signific
ant
do
se d
ep
end
ent
histam
ine re
lea
se:
¤Pre
sent in d
ose
s of 4 X ED
95
¤A
t low
er d
ose
s (2.5 X ED95 )
no hista
mine
rele
ase
¤
Evide
nce
d b
y flushing
http://www.cfhi-fcass.ca/SearchR
esultsNews/2010/10/01/f1ca3fcf-f9aa-
4dcb-a64c-a95f2bbadd8d.aspx
Sunag
a &
Lien. (2013). C
urrAnesthesiolRep, 3, 105-113.
de
Boe
r & C
arlo
s. (2018). CurrA
nesthesiolRep Piublishe
dO
nline d
oi:10.1007/s40140-018-0262-9.
Othe
r Ne
w H
orizo
ns…
¤O
ther iso
quino
linefum
ara
te a
ge
nts¤
CW
002¤
CW
011
¤Re
verse
d b
y a
dm
inistratio
n of the
a
mino
ac
id c
ysteine
.
¤C
W002 a
nd C
W011
have
slow
er re
versa
l tim
e a
nd lo
nge
r d
uratio
n of a
ctio
n tha
n Ga
ntac
urium.
https://w
ww
.red
bub
ble
.co
m/p
eo
ple
/co
mp
ound
che
m/w
orks/1380542
8-20-am
ino-a
cid
s?p=p
oste
r
Othe
r Ne
w H
orizo
ns…
¤Tro
pinylD
ieste
r De
rivative
s
¤The
se a
re a
lkalo
ids sim
ilar in struc
ture
to a
trop
ine a
nd sc
op
ola
mine
.
¤G
-1-64¤
Rap
id o
nset (~1 m
in)¤
Short D
uratio
n (5-11min)
¤Re
verse
d w
ith an a
nticho
lineste
rase
¤So
me
ca
rdia
c sid
e e
ffec
ts¤
No
cum
ulative
effe
cts w
ith infusion
or re
pe
ate
d d
ose
s
¤TA
AC
3¤
Rap
id O
nset (45-60
sec
)¤
Short D
uratio
n (~half
to ¾
dura
tion o
f Ro
curo
nium)
¤So
me
ca
rdia
c e
ffec
ts¤
In anim
al stud
ies, d
ose
d
ep
end
ent
hypo
tensio
n
We
lliver(2012). A
AN
A J, S11-17.
Ca
lab
ad
ions
¤C
ala
ba
dio
n1 a
nd 2 a
re
pa
rt of the
mo
lec
ular
co
ntaine
r fam
ily C
ucurb
it[n]urils.
¤First re
versa
l ag
ents to
re
verse
bo
tha
mino
stero
ida
nd
be
nzylisoq
uinolinium
NM
Bs.
¤W
orks b
y flexing
its g
lyco
lurilba
ckb
one
to
ac
co
mm
od
ate
bo
th roc
a
nd c
is.
¤Be
nzylisoq
uinoline
sm
ake
up
1/3 of the
ma
rket
volum
e o
f NM
Bs.
¤N
o sig
ns of re
cura
rizatio
n.
¤In p
rec
linica
l trials, 90-150
mg
/kg o
f Ca
lab
ad
ion
1 w
as a
ble
to re
verse
ro
curo
niuma
nd
cisa
trac
uriumto
a TO
F ≥ 0.9 w
ithin 1-2 min (84 vs.
87 sec
).
¤N
o e
ffec
ts on he
art ra
te,
blo
od
pre
ssure o
r ABG
p
ara
me
ters.
¤Fa
st rena
l elim
inatio
n:¤
90-100% w
ithin 1 hour
¤Inte
resting
ly ma
y also
be
re
versa
l for lo
ca
l a
nesthe
tic to
xicity.
Ho
ffma
n et a
l., (2013). Anesthesiol, 119
(2), 317-325.
In Co
nclusio
n¤
Our c
urrent p
rac
tice
in NM
B is im
pro
ving, b
ut it is still far fro
m
pe
rfec
t.¤
Patie
nt safe
ty is of the
utmo
st p
riority.
¤W
e c
urrently a
dm
inister m
uscle
re
laxa
tion a
nd re
verse
it in a
very c
om
ple
x ma
nner.
¤O
bje
ctive
or q
uantita
tive
mo
nitoring
of N
MB ne
ed
s to b
e
utilized
.
¤M
any a
ge
nts, ma
ny side
e
ffec
ts.
¤Sug
am
ma
de
xo
ffers a
n new
w
ay to
reve
rse Ro
c a
nd V
ec
.
¤Pro
mising
new
drug
s for N
MB
and
reve
rsal a
re c
om
ing, a
re
we
rea
dy?
https://w
ww
.kee
pc
alm
-o-m
atic
.co
.uk/p/ke
ep
-c
alm
-its-the-c
onc
lusion/