PRO: Suddenly Sugammadex: Should Sugammadex Become the New ICU Standard for Reversalby Steve Gibson, MD, PhD Volume 28 | Issue 2 | Summer 2017 Sugammadex, which was approved by the FDA recently, is being integrated into anesthetic practices throughout the United States. Sugammadex is a superior reversal agent for intraoperative muscle relaxation compared to the standard regimen of Glycopyrrolate and Neostigmine (Glyco/Neo). It has a faster onset, reliably reverses deep blockade, can be redosed rapidly, and causes fewer side effects than alternative medications.1,2 Despite multiple recommendations favoring sugammadex reversal in the OR, there has been little discussion as to the role of sugammadex in the ICU. However, the same factors that make Sugammadex superior in the OR apply to the ICU as well. There are two general reasons to favor Sugammadex in the ICU- efficacy and safety. The greater efficacy of sugammadex would pay dividends in the most critically ill patients. Broadly speaking, intubated ICU patients have less functional reserve than patients intubated solely for a surgical procedure. Extubation may require several days and significant effort to optimize the patient. With less effective reversal (such as with neostigmine and glycopyrrolate), such extubations may fail where a sugammadex reversal would have succeeded. Sugammadex abolishes residual neuromuscular blockade, whereas glyco/neo reversal may leave residual blockade in up to a third of patients, which can lead to atelectasis and hypoxemia.3 Sugammadex reversal gives critically ill patient their best chance to be extubated and remain extubated. In addition to greater efficacy, sugammadex is the safer option for reversal of muscle relaxation. Adverse effects are rare in literature and clinical experience, and the initial concerns about frequent hypersensitivity reactions seem unrealized.4 Although glyco/neo is relatively safe when administered by knowledgeable providers, the potential deleterious effects of this combination should not be disregarded. After all, glycopyrrolate frequently causes tachycardia, and it must be given along with the neostigmine to prevent the latter’s muscarinic side effects, as unpleasant as diarrhea and as dangerous as asystole! These adverse effects are even less desirable in critically ill patients in the ICU. The benefits of sugammadex will become evident to ICU providers rapidly once they try this drug. It provides foolproof reversal of muscle relaxation and lesser risk of adverse effects. Studies directly comparing sugammadex and glyco/neo have yet to appear in critical care literature. Nonetheless, once mindful of the other robust data in favor of sugammadex, ICUs should adopt this drug as their reversal agent of choice. References:
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