Transcript Simplicity of NMTM with TOF

Bridion® in Clinical Practice:
Case Study
Dr Robin Duckworth
Consultant Anaesthetist
Ross Hall Hospital, Glasgow
The views and opinions expressed in this presentation are not those of Schering-Plough Corporation
SUG/09-183
Aims
• 2 case presentations
• commentary and impressions of using
sugammadex
Case Study 1
• elective admission for bilateral
thoracoscopic sympathectomy
• 21 year old female
• 5’3” and 65kg ( BMI 26 )
Case Study 1
• PMH
– Irritable bowel
– Asthma
– Tonsillectomy
• colonoscopy
• laryngoscopy
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non smoker
allergic to Penicillin
no medication
ASA grade 1
Case Study 1
anaesthesia:
– propofol 200mg
– alfentanil 1mg
– vecuronium 6mg
– oxygen/air mix
– sevoflurane
– fentanyl 50mcg
Case Study 1
• direct laryngoscopy – grade 1
• laryngoscopy demonstrated a large
exophytic friable lesion with surface
ulceration at the base of the tongue
• biopsies were taken
Case Study 1
Reversal
– a period of 15 minutes had elapsed
– sugammadex 200mg
Case Study 1
• spontaneous respiration returned over
the next minute
• patient extubated rapidly
• verbalising almost immediately
• no recall
Case Study 2
• 71 year old male
• elective admission for lumbar
decompression and Wallis stabilization
• 5’9” and 68kg (BMI 32)
• ASA 1
• No past medical history
• No known allergy
Case Study 2
anaesthesia
– propofol 180mg
– alfentanil 0.9mg
– N2O/O2/Desflurane
– vecuronium 6mg
– fentanyl 150mcg
– cefuroxime 1.5G
– ondansetron 8mg
– cyclimorph 7.5mg
– diclofenac 75mg
Case Study 2
reversal after 65 minutes
– neostigmine 3.75mg
– glycopyrrolate 0.75mg
Case Study 2
• extubated in recovery
• 5 minutes later patient now stridulous
and agitated
• not able to verbalise adequately
• appearance was of inadequate reversal
Case Study 2
what next ?
– wait
– monitor
– further reversal
– sugammadex...
Case Study 2
...within 30 seconds
– stridor abolished
– sitting up
– verbalising coherently
Scenarios
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a standard reversal
the special situation - eg ultra short
inadequate reversal
other possible benefits – real or
perceived
• relaxant anaphylaxis
Sugammadex
Standard reversal
• speed – rapid return of spontaneous respiration,
obviates the need for further doses of reversal
• head lift – as a monitor of recovery is a thing of the
past!
• cough reflex – never any apparent residual
curarization, if the correct dosing adhered to
• muscle tone – appears to return to preoperative levels
• re-animation occurs!
Sugammadex
Special situations
• short and ultra short, bariatric procedures
• surgical relaxation – optimizing relaxation eg for
closure or at specific times during surgery
• failed intubation – with or without airway
• expected and unexpected clinical scenario
Sugammadex
Inadequate reversal
• conventional failure
• PORC does not appear to occur clinically when
sugammadex is given in the recommended dose
• muscle power returns to pre-surgery levels
Sugammadex
Benefits – real and perceived
• aspiration less likely
• immediate post-operative pulmonary complications
less likely
• co-operative patients with excellent muscle tone
• calmer more “settled” patients possibly due to lack
of PORC
• lack of side effects such as tachycardia,
bronchospasm, nausea
Sugammadex
Benefits – cont.
• optimizing relaxation for closure – improves
surgical closure?, dehiscence less likely?,
herniation less?
• increased flexibility of technique
• pain control more manageable in immediate
recovery period
• happier surgeon
Sugammadex
Relaxant anaphylaxis
• Rocuronium or vecuronium – the concept of its
use as immediate, perhaps first line treatment
Sugammadex
Summary
Bridion is a new and novel drug which due its
unique pharmacology provides anaesthetists
with an agent which, in my view, surpasses our
present ability to reverse most levels of relaxant
blockade rapidly, safely, and in my view much
more effectively than ever before
Sugammadex
This results in a
happier surgeon
confident anaesthetist
much safer patient