Neuromuscular Blockade Clinical Trial
Official title:
The Use of Sugammadex as Rescue Therapy Following Inadequate Reversal With Neostigmine
Neuromuscular blocking agents (NMBAs) are commonly used in the practice of anesthesiology for skeletal muscle relaxation to facilitate tracheal intubation, mechanical ventilation, and to provide optimal surgical conditions. In order to prevent residual NMB, it is vital to adequately reverse any use of a non-depolarizing NMBA. This was historically done using an anticholinesterase such as neostigmine, which would increase the concentration of acetylcholine at the neuromuscular junction leading to the return of neuromuscular transmission. Unfortunately, there are disadvantages to the use of an anticholinesterase. It was in this context that sugammadex was found to be a valuable addition to the anesthesiologist's armamentarium. It is a modified γ-cyclodextrin that encapsulates the aminosteroid NMBAs rocuronium and vecuronium. This project is a double-blind randomized placebo-controlled dose-response trial that aims to determine the time taken to achieve adequate reversal comparing five doses of sugammadex as rescue therapy following inadequate reversal with neostigmine. The study team will recruit patients aged 18 years and above from the main operating room and outpatient surgery center at Grady Memorial Hospital who are undergoing elective surgery under general anesthesia, who has received NMB, received neostigmine for NMB reversal, and achieved a TOF count ≥ 3 twitches but not a TOF ratio of 0.9 fifteen minutes after neostigmine was given. Those with a TOF count < 3 twitches will drop out of the study as there are already specified doses of sugammadex for that level of NMB
Neuromuscular blocking (NMB) agents are commonly used in the practice of anesthesiology for skeletal muscle relaxation to facilitate tracheal intubation, and may require reversal in order to prevent residual NMB. This was historically done using an anticholinesterase such as neostigmine, which has many adverse effects and may not effectively reverse a deep NMB. However, the introduction of sugammadex was instrumental in allowing the rapid return of neuromuscular function. The FDA has only approved three doses of sugammadex (2 mg/kg, 4 mg/kg and 16 mg/kg) depending on the train of four (TOF) count, which is a qualitative measure of the depth of NMB and ranges from 0 to 4 twitches. Conversely, the TOF ratio is a quantitative measure, is calculated using the ratio of the amplitude of the fourth twitch to the first twitch, and ranges from 0 to 1. A TOF ratio of 0.9 is generally accepted as the minimum threshold to safely extubate a patient, but this information is not always readily accessible as many anesthesia providers do not have a quantitative NMB monitor. In 2020, Carvalho et al. conducted a meta-analysis of 53 studies (12,664 adult patients) where the pooled residual NMB incidence ranged from 0.115 when quantitative neuromuscular monitoring was used to 0.331 where no neuromuscular monitoring was used. Ravel et al. conducted a meta-analysis of 20 randomized controlled trials (1,923 adult patients), where residual NMB was found in 2.8% of patients who received sugammadex compared to 39% of those who received neostigmine 15 minutes post administration. Concerningly, 60 minutes after administration, 2.1% of the sugammadex group versus 19% of the neostigmine group still had NMB. When expanded to observational studies (58 studies with 25,277 adult patients), the incidence of residual NMB ranged from 0% to 90.5% (median 30%), which was significantly lower (0% to 16%) in the sugammadex group compared to 3.5% to 90.5% in the neostigmine group and 15% to 89% in the spontaneous recovery group. This project is a double-blind randomized placebo-controlled dose-response trial that aims to determine the time taken to achieve adequate reversal comparing five doses of sugammadex as rescue therapy following inadequate reversal with neostigmine. The study team will recruit patients aged 18 years and above from the main operating room and outpatient surgery center at Grady Memorial Hospital who are undergoing elective surgery under general anesthesia, who has received NMB, received neostigmine for NMB reversal, and achieved a TOF count ≥ 3 twitches but not a TOF ratio of 0.9 fifteen minutes after neostigmine was given. Those with a TOF count < 3 twitches will drop out of the study as there are already specified doses of sugammadex for that level of NMB. These patients will then be randomized to six groups: 2 mg/kg (the lowest dose approved by the FDA), 1 mg/kg, 0.5 mg/kg, 0.25 mg/kg, 0.125 mg/kg of sugammadex, and placebo. The time taken to reach a TOF ratio of 0.9 thereafter would be measured and compared for statistically significant differences. ;
Status | Clinical Trial | Phase | |
---|---|---|---|
Recruiting |
NCT05558969 -
The Effect of Magnesium Use in Reversal of Neuromuscular Block With Sugammadex
|
N/A | |
Completed |
NCT03168308 -
Sugammadex vs. Neostigmine for Neuromuscular Blockade Reversal in Thoracic Surgical Patients
|
Phase 4 | |
Not yet recruiting |
NCT03978780 -
Erector Spinae Block vs. Placebo Block Study
|
N/A | |
Completed |
NCT02892045 -
Mindray Neuromuscular Transmission Transducer
|
||
Completed |
NCT02912039 -
Electromyographic Assessment of the TetraGraph in Normal Volunteers
|
||
Completed |
NCT03427385 -
Minimum Local Anesthetic Dose for Adductor Canal Block
|
N/A | |
Completed |
NCT01450813 -
The Effect of Neuromuscular Blockade on the Composite Variability Index (CVI) During Laryngoscopy
|
N/A | |
Completed |
NCT00535496 -
Relation Between TOF-Watch® SX and a Peripheral Nerve Stimulator After 4.0 mg.Kg-1 Sugammadex (P05698)
|
Phase 3 | |
Recruiting |
NCT05794503 -
Postoperative Urinary Retention After Reversal of Neuromuscular Block by Neostigmine Versus Sugammadex
|
Early Phase 1 | |
Not yet recruiting |
NCT05993390 -
Pharmacological Reversal of Neuromuscular Blockade in Critically Ill Patients
|
N/A | |
Recruiting |
NCT04609410 -
Bleeding in Laparoscopic Liver Surgery
|
N/A | |
Terminated |
NCT03649672 -
The Validity and Tolerability of Awake Calibration of the TOF Watch SX Monitor
|
N/A | |
Completed |
NCT05687253 -
Evaluation of Intubation Conditions Following BX1000 or Rocuronium in Subjects Undergoing Surgery
|
Phase 2 | |
Completed |
NCT05474638 -
Comparison of Mechanomyographic 100 Versus 200 Hz 5 Second Tetanic Fade Ratios During Neuromuscular Block Recovery
|
N/A | |
Completed |
NCT05120999 -
Comparison of Onset of Neuromuscular Blockade With Electromyographic and Acceleromyographic Monitoring
|
||
Completed |
NCT03608436 -
The Effect of Low Pressure Pneumoperitoneum During Laparoscopic Colorectal Surgery on Early Quality of Recovery
|
Phase 4 | |
Completed |
NCT03572413 -
The Effect of Low Pressure Pneumoperitoneum During Laparoscopic Colorectal Surgery on Innate Immune Homeostasis.
|
Phase 4 | |
Recruiting |
NCT02930629 -
Residual Block in Postoperative Anaesthetic Care Unit
|
N/A | |
Completed |
NCT02932254 -
Magnesium Sulfate Effect Following the Reversal of Neuromuscular Blockade Induced by Rocuronium With Sugammadex
|
Phase 4 | |
Completed |
NCT01828385 -
Effect of Magnesium on the Recovery Time of Neuromuscular Blockade With Sugammadex
|
Phase 4 |