Identifying a Minimal Sugammadex Dosing Strategy Ashlea C. Cantu, BSN, RN, SRNA, Eric A. Caron, BSN, RN, SRNA, Michelle L. Laginess, BSN, RN, SRNA Introduction Impact of Dosing Strategies on Tidal Volume Project Methodology • Neuromuscular blocking agents (NMBA) promote reversible skeletal muscle paralysis • Obtained permission from Michigan State University Institutional Review Board and facility to • Post-operative residual paralysis is a complication associated with the use of NMBA conduct this quality improvement project 12 • Residual paralysis from inadequate reversal of neuromuscular blockade is associated with • Project deemed non-research; quality improvement 11 adverse postoperative outcomes which include hypoxemia, hypercapnia, reduced hypoxic 10 • Provided a training session to all anesthesia providers during a staff meeting prior to project ventilatory drive, and an increased risk of aspiration 9 implementation regarding data collection and accurate measurement of NIF • Depending on how postoperative residual paralysis is defined, the incidence is reported to be 8 • Developed a data collection sheet that was placed in each operating rooms with instructions 16% to 88% post-endotracheal extubation1. Total Number 7 of Patients, n=36 6 • Three weeks of data collection using the facility's standardized dosing strategy • It is estimated that postoperative pulmonary complications lead to an additional 92,000 ICU 5 admissions and incur a cost of $3.42 billion each year2. • Three weeks of data collection for each proposed weight-based dosing strategy 4 • Neuromuscular recovery can be assessed using quantitative monitoring or qualitative 3 • Data was compiled using descriptive statistical analysis assessment 2 1 • Qualitative is subjective; quantitative is objective and more accurate 0 • In 2015, the Food and Drug Administration approved Sugammadex for reversal of steroid- Project Outcomes Tidal volume <6ml/kg (n=3) Tidal volume >6ml/kg (n=33) based NMBA 1 mg/kg 2 mg/kg 200 mg/kg Purpose • The clinical facility’s use of a one-size-fits all dosing strategy of 200 mg of Sugammadex produces comparable results of NIF and VT to the manufacture recommended 2mg/kg dosing strategy • The purpose of this project is to determine the impact that different Sugammadex dosing • 1 mg/kg dosing is as effective as 2 mg/kg strategies have on qualitative assessments specifically the negative inspiratory flow (NIF) and tidal volume (VT) prior to extubation • The single 200mg dosing strategy was equivalent to the 1mg/kg in the majority of study patients • Clinical Question: When comparing the facility's non-weight-based 200 mg Sugammadex dosing strategy, will administration of 1mg/kg or 2mg/kg dosing increase the NIF and VT prior Impact of Dosing Strategies on Negative Inspiratory Force • Many of the patients falling into the VT <6 ml/kg and NIF <-25 cm H2O categories had body to extubation in adult patients undergoing a general anesthetic with neuromuscular blockade? weights greater than 100 kg suggesting that weight-based dosing strategies may be more effective in this patient population Literature Summary Conclusions 12 11 10 9 • The manufacturer recommends a dose of 2mg/kg for moderate neuromuscular blockade 8 • All three dosing strategies used were effective in reversing neuromuscular blockade in the • Sources suggest that 0.5mg/kg and 1mg/kg Sugammadex dosing is as effective as 2mg/kg in 7 majority of patients Total Number of 6 reversing neuromuscular blockage 3 Patients, n=36 5 • More scientific studies are needed to establish dosing recommendations for this patient • There is currently no recommendation to support the use of a one-size-fits-all 200mg dosing 4 population 3 strategy for reversal in adult surgical patients 2 • Using actual body weight versus ideal body weight (IBW) produces faster recovery and 1 • NIF is subjective and should not be used as a criterion for assessment of residual paralysis fewer incidences of residual paralysis 0 <-25 cm H2O (n=2) >-25 cm H2O (n=34) • To assess for residual paralysis and readiness for extubation, NIF and VT were criteria most 1 mg/kg 2 mg/kg 200 mg frequently cited in the literature References Acknowledgements 1-Saager, L., Maiese, E. M., Bash, L. D., Meyer, T. A., Minkowitz, H., Groudine, S., Philip, B. K., Tanaka, P., Gan, T. J., Rodriguez-Blanco, Y., Soto, R., & Heisel, O. (2019). Incidence, risk factors, and This project would not be possible without the guidance and support of: consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study. Journal of clinical anesthesia, 55, 33–41. https://doi.org/10.1016/j.jclinane.2018.12.042 Dr. Gayle Lourens, DNP, MS, CRNA; John Gadwoord, CRNA; Tamara Lemons, CRNA; Sharee Doty, CRNA 2- Farhan, H., Moreno-Duarte, I., McLean, D., & Eikermann, M. (2014). Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery?. Current anesthesiology reports, 4(4), 290–302. https://doi.org/10.1007/s40140-014-0073-6 3- Duranteau, O., Fernandez, W., Tuna, T., Engelman, E., Van Obbergh, L., & Tabolcea, I. (2021). Earlier and lower dose administration of sugammadex: A randomised placebo-controlled trial. European journal of anaesthesiology, 38(8), 865–871. https://doi.org/10.1097/EJA.0000000000001502