Since its introduction, sugammadex showed marked efficacy and safety, ringing in a new era of patient safety in anaesthesiology [7]. However, since its dosing regimen necessitates the use of neuromuscular monitoring, the use of this agent may be limited in certain situations, particularly where such monitoring devices are not routinely used. Several surveys have shown that this is not uncommon, worldwide [2–5]. Hence, we here performed a retrospective study on the efficacy and safety of using sugammadex in the absence of guidance provided by neuromuscular monitoring. We considered that this study could show whether sugammadex reduces anaesthesia and extubation times, as well as recovery time in the PACU, facilitating early recovery after surgery, even in the absence of neuromuscular monitoring, in a routine clinical anaesthesia setting, without any intervention.
The results of the present study showed that sugammadex shortened anaesthesia time, extubation time, and recovery time, without increasing the incidence of postoperative adverse events. The effect of sugammadex in shortening anaesthesia time, extubation time, and recovery time has been clearly demonstrated by many previous studies performed around the globe in settings using appropriate neuromuscular monitoring. The result of the present study further showed that the efficacy of sugammadex remains firm, even in the absence of proper neuromuscular monitoring [9–11].
Sugammadex not only enabled shorter extubation time even with larger dose of rocuronium but also, though not given at the dose guided by proper neuromuscular monitoring, reversed the neuromuscular block within relatively constant time in our study. In group P, the extubation time was longer and the variation in this time was larger. There was a positive correlation between anaesthesia time and extubation time in group P, but not in group S, which indicated that extubation time in group P functioned as a key component influencing the anaesthesia time, whereas the relatively constant extubation time in group S was not a main determinant of anaesthesia time, even in the absence of neuromuscular monitoring.
The shortened anaesthesia time, extubation time, and recovery time in group S may allow faster operating room turnover, and this can allow better patient prognosis in terms of overall safety and recovery. ERAS has recently gained increasing attention. Enhanced recovery protocols for perioperative care have been proven to reduce complications after surgery, improve overall outcomes, and shorten the length of hospital stay, thus saving on resources [12]. Thus, guidelines for specific fields are being formulated and are being published throughout the world [13–16]. According to the ERAS protocol developed by the ERAS society, using short-acting anesthetic agents is one of the elements comprising the intraoperative component of the protocol [17]. Due to its ability to reverse rocuronium-induced neuromuscular blockade quickly, sugammadex combined with rocuronium can work as a short-acting agent, even capable of substituting for succinylcholine [18, 19]. Hence, sugammadex combined with rocuronium can reduce anaesthesia time, recovery time, and length of hospital stay, making it recommendable as a short-acting anesthetic agent in the ERAS protocol [20, 21]. Based on the results of the present study, we strongly recommend use of sugammadex combined with rocuronium even in a clinical anaesthesia setting without neuromuscular monitoring as a new element in the ERAS protocol.
As for the adverse events, although not statistically significant, there was one case of incomplete reversal in group P, which can cause detrimental complications, whereas no such case was found in group S [22, 23]. As is known from several previous studies and surveys, anaesthesiologists in our hospital tend also to use larger doses of rocuronium to achieve a theoretical deeper blockade when sugammadex is planned for use at the end of surgery; although obtaining a deeper block in group S was not proven by neuromuscular monitoring, this trend is clearly reflected in our study, as the total amount of rocuronium used in group S was significantly larger than that used in group P [24]. This trend for obtaining a theoretical deeper block, associated with sugammadex in group S, highlights another benefit of sugammadex, in that there were only two cases that needed additional rocuronium during the surgery in group S, whereas group P required this in 14 cases. It can be assumed that additional rocuronium was needed because of incomplete or insufficient neuromuscular block, in order to achieve optimal surgical conditions, resulting in the possibility of elongated anaesthesia time, a shorter time between the last injection of rocuronium and the injection of the reversal agent, and a consequently higher risk of incomplete reversal of neuromuscular block or recurarization [8, 25]. Postoperative haemodynamic values were found to be better in group S, and the incidence of tachycardia was less. Glycopyrrolate injected along with pyridostigmine in order to block its cholinergic adverse effects may explain the significantly higher incidence of tachycardia in group P [26].
The limitation of this study is that it was a retrospective study. We plan a randomized controlled trial on this subject, to further assess its implications for the ERAS protocol and the possible use of sugammadex in combination with rocuronium in the ERAS protocol, in the near future.