Linn, Dustin D

Abstract Purpose Sugammadex rapidly and effectively reverses aminosteroidal neuromuscular blocking agents and has largely replaced neostigmine in perioperative practice. Although its use is associated with faster recovery and a lower rate of residual neuromuscular blockade, clinically important limitations exist. This review summarizes the literature describing incomplete reversal, recurrence of neuromuscular blockade, adverse effects, drug interactions, and challenges in special populations, with a focus on the role of quantitative neuromuscular monitoring and pharmacist-led activities to optimize sugammadex use. Summary While sugammadex substantially reduces the risk of residual neuromuscular blockade compared to neostigmine, incomplete reversal and recurrence of neuromuscular blockade continue to occur, particularly when dosing is not guided by quantitative neuromuscular monitoring. Underdosing, redistribution of neuromuscular blocking agents, and altered pharmacokinetics can all contribute to inconsistent responses. Quantitative neuromuscular monitoring, rather than choice of reversal agent, is the main determinant of reliable neuromuscular recovery and reduced occurrence of postoperative complications. Sugammadex is associated with rare but potentially serious adverse effects, including hypersensitivity reactions and cardiovascular instability, highlighting the need for careful monitoring. Patent expiration and generic availability may expand access to sugammadex, and these limitations warrant continued attention. Conclusion Sugammadex represents a major advance in neuromuscular blockade reversal but remains an imperfect agent. Safe and effective use requires individualized dosing guided by quantitative neuromuscular monitoring and vigilance for adverse effects. Pharmacists are well positioned to lead education, dosing protocol development, and monitoring strategies that optimize patient safety while supporting adoption of quantitative neuromuscular monitoring.

Abstract Purpose To describe the systemic benefits of sugammadex as a reversal agent for neuromuscular blockade. Summary Sugammadex is the preferred reversal agent for neuromuscular blockade as recommended in guidelines from the American Society of Anesthesiology. This recommendation is primarily based on a faster time to recovery from neuromuscular blockade as compared to that seen with neostigmine. Systemic adverse effects of neostigmine are often mitigated by the administration of glycopyrrolate. However, glycopyrrolate is an antimuscarinic agent that may be associated with its own adverse effects when used as part of a reversal strategy for neuromuscular blockade. This review describes the potential systemic benefits of sugammadex, compared to an acetylcholinesterase/anticholinergic strategy, related to postoperative nausea and vomiting, urinary retention, bowel recovery, and cognitive dysfunction while also discussing its role in enhanced recovery after surgery protocols. Conclusion Sugammadex is associated with a reduction in systemic effects when compared to combinations of neostigmine and glycopyrrolate. Further research is needed on important clinical and economic outcomes associated with a reduction in these adverse effects.

Abstract Purpose To describe neuromuscular monitoring modalities and highlight the importance of neuromuscular monitoring to clinical pharmacy practice. Summary A growing body of literature and clinical practice guidelines have highlighted the importance of neuromuscular monitoring practices to ensure patient safety during surgery and in the intensive care unit. Understanding neuromuscular monitoring modalities can allow pharmacists to enhance participation in institutional discussions and optimization of neuromuscular blocker administration and reversal practices. We have described the various modalities of neuromuscular monitoring and considerations for using different modalities. Conclusion Neuromuscular monitoring should be performed whenever neuromuscular blocking agents are administered. This practice represents an evidence-based approach to minimizing the occurrence of residual neuromuscular blockade and its associated complications.

Abstract Purpose Neuromuscular blocking agents (NMBAs) are commonly used during surgery, and restoring neuromuscular function at the end of surgery is vital in preventing complications of residual paralysis. Recent guidelines from the American Society of Anesthesiology recommend using sugammadex over neostigmine; however, sugammadex is significantly more expensive than neostigmine and may increase drug expenditure for pharmacy departments. This review summarizes evidence evaluating sugammadex dose adjustments and the potential of these dose adjustments to lead to cost savings for pharmacy departments. Summary We found evidence suggesting that the manufacturer-recommended sugammadex dose may not be needed in many patients and that dosing based on an adjusted body weight or based on depth of neuromuscular blockade may lead to lower sugammadex usage. Combining sugammadex with neostigmine could also decrease the dose of sugammadex required. We have highlighted the importance of objective neuromuscular monitoring to guide sugammadex dosing and evaluation for residual neuromuscular blockade. Cost savings for pharmacy departments may be realized by these alternative dosing strategies and/or vial-splitting practices. Conclusion Implementing practices related to sugammadex vial splitting and dose adjustment based on body weight and depth of neuromuscular blockade shows potential benefits in terms of sugammadex cost savings.