Rev. Bras. Anestesiol. vol.65 número4

RevBrasAnestesiol.2015;65(4):240---243

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

SCIENTIFIC

ARTICLE

Use

of

sugammadex

on

burn

patients:

descriptive

study

Eduardo

Rodríguez

Sánchez

M.

_,

_Concepción

_Martínez

_Torres,

_Pablo

_Herrera

_Calo,

Ignacio

Jiménez

AnesthesiologyandReanimation,HospitalesUniversitariosVirgendelRocío,Sevilla,Spain

Received13August2014;accepted8October2014 Availableonline7June2015

KEYWORDS

Sugammadex; Cyclodextrin; Burninjury; Rocuronium;

Neuromuscularblock; Neostigmine

Abstract

Objectives:Aburnpatientisachallengeforanyanesthesiologist,undergoingseveralsurgeries duringadmission,andrequiringgeneralanesthesiaandmusclerelaxationmostofthetimes. Thevictimmayhaverespiratorysystemimpairmentandaresponsetomusclerelaxantsthat differsfromthehealthypatient,thuspropermonitoringandreversaliscrucial.Weanalyzed sugammadexeffectivenessandsafetyinthispopulation.

Materialsandmethods: Itwasaprospectivelydescriptivestudy,including4patients,andall ofthemwereconsideredmajorburnpatients,whounderwentescharotomywithgeneral anes-thesiaandneuromuscularrelaxation.Themainvariablewasthetimefor recoveryofaTOF higherthan0.9aftertheadministrationofsugammadexbeforeextubation.

Results:MeantimeofrecoveryfromaTOFratiohigherthan0.9followingtheadministration ofSugammadexwasof4.95min95%CI(3.25---6.64,p=.53).

Conclusions:Thereversionofneuromuscularrelaxationwithsugammadexappearstobe effec-tiveandsafeintheburnpatient.Moreanalytical,comparativestudiesoflargerpopulations wouldbenecessarytoconfirmthesedata.

©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.

PALAVRAS-CHAVE

Sugammadex; Gama-Ciclodextrinas; Queimaduras; Rocurônio; Bloqueio neuromuscular; Neostigmina

Usodesugamadexnopacientequeimado:estudodescritivo

Resumo

Objetivos: Opacientequeimadorepresentaumdesafioparaoanestesiologista,pois submete-seaváriasintervenc¸õescirúrgicasdurantesuahospitalizac¸ão,necessitandodeanestesiageral erelaxamentomuscularnamaiorpartedelas.Apresentasistemarespiratóriocomprometido eumarespostaaosrelaxantesmuscularesquediferedopacientesadio;portanto,um moni-toramentocorretoereversãotornam-seimprescindíveis.Avaliamosaeficáciaeseguranc¸ado sugamadexnestapopulac¸ão.

∗_{Correspondingauthor.}

E-mail:edurodriguez87@yahoo.es(E.RodríguezSánchezM.).

http://dx.doi.org/10.1016/j.bjane.2014.10.001

Sugammadexinthemajorburnpatient:descriptivestudy 241

Materialemétodos: Estudodescritivocomcaráter prospectivoque incluiquatro pacientes, todoselesconsideradosgrandesqueimados,submetidosaescarectomiacomanestesiagerale relaxamentoneuromuscular.Comovariávelprincipaltomou-seotempoderecuperac¸ãodeTOF superiora0,9apósaadministrac¸ãodesugamadexantesdeextubac¸ão.

Resultados: O tempo médio de recuperac¸ão de uma razão TOF superior a 0,9 após a administrac¸ãodesugamadexfoide4,95min(IC95%3,25-6,64;p=0,53).

Conclusões: A reversãodo relaxamentoneuromuscular comsugamadex parece sereficaz e seguranopacientequeimado.Seriamnecessáriosmaisestudosanalíticos,comparativosede maiorpopulac¸ãoparaconfirmaressesdados.

©2015SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Burnsaretissueinjuriesproduced byskinaggression from anysourceofenergy.Theseveritycriteriawouldbe involve-ment of more than 25% of totalbody surface, burns that follow inhalation syndrome, involvement of face, eyes, hands,feetandperineum.1_{Mortalityofmajorburnpatients} is approximately13.9%.2,3 _{In our unit, 174 patients were} attendedintheyearof2012.Thesepatientsunderwent sev-eralsurgicalinterventionsduringtheirstayinthehospital, withmost of them under general anesthesia, orotracheal intubation,andneuromuscularrelaxation.

Sugammadexisamodifiedcyclodextrinusedforreversion of rocuronium- and vecuronium-induced nondepolarizing muscle block.4,5 _{The dose of sugammadex varies} depend-ingonthelevel ofmusclerelaxation,withmeantimefor recoveryof aTOFratiohigherthan 0.9of3min.(min).6,7 Several studies demonstrated the superiority of this drug comparedtoneostigmine8---10 _{regardingsafetyandtimefor} recovery.Itwassuccessfullyusedinthe obesepatient,in the elderly, and also in children older than two years.11 However,its use in the major burn patienthad not been studied.Themainobjectiveofthisworkwastoanalyzethe efficacyofsugammadexinthispatientprofileinwhomthe metabolic-hemodynamicchanges mayalterits pharmacol-ogyandinwhom,duetorespiratorysysteminvolvement(if constant),anappropriatereversalofneuromuscular block-ersiscrucial.Secondaryobjectivesarethemeasurementof neuromuscularrelaxation recovery timeafterits adminis-tration,thecomparisonoftheseresultswiththoseexisting in the literaturein other types of patients, report of the emergenceofadverseeffectsrelatedtoitsadministration, andreportofmainanestheticconsiderationsofmajorburn patient.

Materials

and

methods

Aprospectivedescriptivestudyoffourcaseswasconducted overtwomonths.Inclusioncriteriawereasfollows:major burn patient who underwent escharotomy under general anesthesia and orotracheal intubation. Exclusion criteria were: allergy to sugammadex, severe renal impairment

(creatinine clearance below 30mLmin−1_{, intraoperative}

hemodynamicinstabilityrequiringadministrationofamines, or the need for blood transfusions. All patients were monitoredwithelectrocardiogram,oxygensaturation, non-invasive blood pressure and monitoring of neuromuscular blockadebyaccelerometry(TOFwatch).Inductionwas con-ductedwithpropofol(2.5mgkg−1_{),fentanyl(2␮gkg}−1_)and

rocuronium(0.6mgkg−1_{).Maintenancewasperformedwith}

sevofluraneat1CAM,withtheadministrationofabooster doseofrelaxant(30%theinitialdose)onthosewhoshowed recoveryfromblock(emergenceof2responsesinTOF).At theendofthesurgery,andbeforeextubation,sugammadex wasadministeredin allcases,withthe dose according to thelevelneuromuscularblock(deepblock4mgkg−1_,

moder-ateblock2mgkg−1_{,recoveryphasewith4responsestoTOF}

ratio1mgkg−1_{).Thepatientswereextubatedafterrecovery}

ofTOF higherthan0.9.The variableconsidered wastime in minutes since the administration of sugammadexuntil recoveryofTOFhigherthan0.9.Allthetimewefollowedthe ethicalstandardsofthehumanexperimentationcommittee ofourcenter.Fordataanalysis,weusedthesoftwareIBM SPSSStatistics22.0.

Results

Four patients with ages between 69 and 76 years were included. The clinical characteristics of the patients are summarizedinTable1,andFig.1showsoneofthepatients includedinthestudy.Theaveragepercentageofbody sur-faceareaburnedwas17.25%.Twoofthepatientsreceived aboosterdoseofrocuronium(20and25mgrespectively). The averagerecovery timefrom aTOF ratiogreater than 0.9 after sugammadex administration before extubation was4.95min witha 95% confidence intervalof 3.25---6.64 (p=0.53).Themedianofthesamevariablewasof4.65min. Typicaldeviationwasof1.06.

Discussion

242 E.RodríguezSánchezM.etal.

Table1 Patients’clinicalcharacteristics.

Case Patient1 Patient2 Patient3 Patient4

Age(years) 76 77 69 72

Gender Female Female Male Female

Comorbidity Hypertension,

dyslipidemia, depression

Hypertension, osteoporosis

Dementia, blindness

Hypertension

Burnbodysurface(%) 18 12 25 14

TimeforrecoveryofTOFhigherthan0.9min 4.2 5.1 4.1 6.4

Boosterdoseofrocuronium(mg) No 20 No 25

lung capillaries,12 _{and therefore thecontrol of lung} func-tionshallbeourpriority.Insevere burnpatients,thereis aproliferationofimmatureacetylcholinereceptorsonboth neuromuscularplateandextra-synapticsites.Thisleadsto anincreasedsensitivitytodepolarizingrelaxants (succinyl-choline),withriskofseverehyperkalemiaandaresistance tonon-depolarizingneuromuscularblockingagents, increas-inginstaurationlatency,andreducingthetimeofaction13_; this,alongwithapossiblerenalimpairmentmayresultin itsaccumulationafterreadministration,withriskofresidual curarization.Theuseofmusclerelaxationreversionagents, anditsmonitoringareeffectivemeasurestoprevent pare-sis;thepresenceofTOFratiogreaterthan0.9isconsidered safetoperformextubation.14 _{Theanticholinesterasedrugs} (neostigmine,edrophonium)areroutinelyusedforreversal ofneuromuscular relaxationin burn patients; thesedrugs produceadverseeffectsderivedfromtheincreaseof acetyl-cholineanditsinteractionwithmuscarinicreceptorsoutof intersynapticsite.Theaverage timetoreacha TOFvalue higherthan0.9afterthereappearanceofthe2responses toTOFisof18.5minafterneostigmineadministration.15_Itis shownineffectivetoreversedeepblock.Theemergenceof sugammadexassumedtobearevolutioninthisregard,but ithasnotbeenstudiedinburnpatients,withamorerapid andpredictablebeginningofactionbeingdemonstratedin severalstudies,comparedtoneostigmine,andbeing effec-tive in a deep block.8---11 _{In our study the mean time to} recoveryof TOF ratiogreater than 0.9after sugammadex

Figure1 Apatientincludedinthestudy.

administrationwas4.95min, timethat is lowerthan that of neostigminein other populations.None ofthe patients showedcomplicationsrelatedtotheadministrationof sug-ammadex. These data, although preliminary, have shown thatsugammadexcanbeusedinthesepatients,with recov-erytimesformuscleactivitysimilartothatinother types ofpatients.Moreprospectivecomparativeanalytical stud-ieswithmorepatientsarenecessarytoconfirmtheresults ofthiswork.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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