Table 2 Summary of case reports on the use of sugammadex in patients with myasthenia gravis (n = 15)
From: Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports
Author/year | Country | Patient characteristics | Disease | Type of surgery; Duration of surgery | Anesthetic agents | NMBA | NM monitoring | Dose of sugammadex & results of NM monitor | Postoperative course |
|---|---|---|---|---|---|---|---|---|---|
de Boer et al., 2010 | Netherlands | 2 patients-details not provided | Myasthenia gravis | Short procedures -details not provided; N.R. | N.R. | Rocuronium 0.15 mg/kg | Acceleromyography (TOF-Watch SX®) | Sugammadex 4 mg/kg; Pre reversal TOF count: 0 & PTC: 0; Post reversal TOF ratio: 0.9 (2.7 min for the first patient & 2.25 min for the second patient) | Uneventful extubation and recovery |
Petrun et al., 2010 | Slovenia | 44/F; 55 kg, 153 cm; BMI: 23.5 kg/m2 | Myasthenia gravis | Laparoscopic cholecystectomy; around 30 min | Propofol, sufentanil induction followed by maintenance with sevoflurane/ oxygen/air | Rocuronium 0.36 mg/kg, then 0.18 mg/kg | Acceleromyography (TOF watch S®) | Sugammadex 2 mg/kg; Pre reversal TOF ratio: 0.23; Post reversal TOF ratio: 1(4 min) | Uneventful extubation and recovery |
Unterbuchner et al., 2010 | Germany | 72/M; 88 kg, 172 cm; BMI: 29.7 kg/m2 | Myasthenia gravis | Elective radical prostatectomy; 210 min | Propofol, sufentanil induction followed by maintenance with propofol infusion and sufentanil bolus | Rocuronium 22 mg initial bolus and another 21 mg before intubation; followed by rocuronium infusion (cumulative rocuronium dose: 151 mg) | Electromyography (NM transmission module in GE Datex Light Monitor) | Sugammadex 2 mg/kg; Pre reversal TOF count:2; Post reversal TOF ratio: 0.9 (3.5 min) | Uneventful extubation and recovery in the intermediate care unit |
Argiriadou et al., 2011 | Greece | 31/F; 95 kg/ 160 cm; BMI: 37 kg/m2 | Myasthenia gravis | Transsternal thymectomy; 70 min | Propofol, fentanyl induction followed by propofol infusion | Rocuronium 0.5 mg/kg; no further dose | Acceleromyography (TOF-Watch SX®) | Sugammadex 2 mg/kg; Pre reversal TOF ratio: 0.3; Post reversal TOF ratio: 0.92 (3 min), 1.02 (7 min) | Uneventful extubation and recovery |
Mitre et al., 2011 | Romania | 56/F; 90 kg, 179 cm; BMI: 28.1 kg/m2 | Myasthenia gravis | Laparoscopic cholecystectomy; 40 min | Thiopentone, midazolam and fentanyl induction followed by maintenance with sevoflurane/oxygen/air | Rocuronium 0.6 mg/kg | Acceleromyography (TOF-Watch SX®) | Sugammadex 2 mg/kg; Pre reversal TOF ratio: 0.67; Post reversal TOF ratio: 0.96 (1 min) | Uneventful extubation and recovery |
Garcia et al., 2012 | France | 35/F: 80 kg; 34 weeks gestation | Myasthenia gravis | Emergency cesarean section; 90 min | Propofol, sufentanil induction followed by maintenance with propofol infusion | Rocuronium 8 mg (0.15 mg/kg), modified rapid sequence induction | Qualitative neuromuscular monitoring | Sugammadex 200 mg (4 mg/kg ideal body weight); Pre reversal TOF count: 1; Post reversal TOF count: 4 (4 min) | Artificial ventilation for 48 h due to failure to wean despite good motor response |
Jakubiak et al., 2012 | Poland | 38/F; 160 kg/ 181 cm; BMI: 48.8 kg/m2 | Myasthenia gravis | Elective laparoscopic adjustable gastric banding; 42 min | Propofol total intravenous infusion | Rocuronium 24 mg (0.15 mg/kg) | Acceleromyography | Sugammadex 200 mg (2 mg/kg corrected body weight) Pre reversal TOF count: 1; Post reversal TOF ratio: 1 (2.8 min) | Uneventful extubation and recovery in both the cases |
Üstün et al., 2012 | Turkey | 2 adult patients: Case 1:55/F; BMI 37 kg/m2; Case 2: 45/F; BMI 27 kg/m2 | Myasthenia gravis | Case 1: Disc Hernia repair; 135 min Case 2: Abdominal hysterectomy; 96 min | Propofol, remifentanil induction followed by maintenance with remifentanil infusion and sevoflurane/oxygen/air | Case1: Rocuronium 0.2 mg/kg for intubation followed by 1/8th of the dose as top up Case 2: Rocuronium 0.25 mg/kg | Acceleromyography (TOF-Watch SX®) | Case 1: Sugammadex 2 mg/kg; Pre reversal TOF: 0.15; Post reversal TOF ratio: 1 (2 min). Case 2: Sugammadex 2 mg/kg; Pre reversal TOF count: 2; Post reversal TOF ratio: 1 (5 min) | Uneventful extubation and recovery |
Iwasaki et al., 2013 | Japan | 2 patients. Case 1: 74/F; 54 kg/157 cm; BMI: 21.9 kg/m2. Case 2: 71/M, 72 kg/165 cm; BMI: 26.4 kg/m2 | Ocular myasthenia gravis | Case 1: Capsulosynovectomy left elbow; N.R. Case 2: Transcervical thymectomy; N.R. | Case 1: Propofol induction followed by maintenance with propofol and remifentanil Case 2: Propofol induction followed by maintenance with sevoflurane, remifentanil along with epidural anaesthesia (T5-T6 level) | Case 1: Rocuronium 0.5 mg/kg; additional 0.2 mg/kg if TOF count ≥2 Case 2: Rocuronium 0.3 mg/kg; additional 0.15 mg/kg if TOF count ≥2 | Acceleromyography (TOF-Watch SX®) | Case 1: Sugammadex 2 mg/kg followed by two additional boluses of 1 mg/kg; Pre reversal TOF ratio:0.2; Post reversal TOF 0.9 (1.5 min)a. Subsequently two additional boluses of 1 mg/kg sugammadex were administered Case 2: Sugammadex 1 mg/kg followed by two additional boluses of 1 mg/kg; Pre reversal TOF count: 2; Post reversal TOF ratio 0.9 (6.5 min)a (after 2 mg/kg sugammadex) | Uneventful extubation and recovery |
Kiss et al., 2013 | Switzerland | 25/F; BMI: 32.0 kg/m2 | Myasthenia gravis | Thymectomy; 120 min | Propofol infusion and sufentanil | Rocuronium 30 mg for intubation along with two 10 mg boluses (total 50 mg) | Datex Ohmeda M-NMT module and portable neuromuscular stimulator | Total dose of sugammadex: 17.34 mg/kg; Pre reversal TOF ratio: 0.36, Post reversal TOF ratio: 0.71 (after more than 8 min). | Pyridostigmine was given through nasogastric tube. Extubation after long waiting time, at the end of surgery |
Sugi et al., 2013 | Japan | 26 yr/F; 64 kg; 165 cm | Myasthenia gravis | Extended thymectomy; 155 min | Induction and maintenance with TCI propofol and remifentanil infusion supplemented with fentanyl boluses | Rocuronium 6 mg (0.09 mg/kg) for intubation; Total dose of rocuronium 28 mg. | Acceleromyography (TOF-Watch SX®) | Sugammadex 2 mg/kg. Post reversal TOF ratio: 0.55 (8.5 min). Additional 2 mg/kg sugammadex administered: No change in TOF ratio. Further supplemented with neostigmine 0.3 mg/kg; Post neostigmine TOF ratio: 0.86 (5 min). Post reversal TOF ratio (3 h & 7 h): 0.8 & 0.9 respectively. | Extubated after a delay at the end of surgery; Uneventful recovery |
Sungur Ulke et al., 2013 | Turkey | 10 patients: mean age: 31 ± 12 years; Weight: 68 ± 13 kg | Myasthenia gravis | Video thoracoscopic assisted thymectomy; mean surgical time: 62 +/−  16 min | Propofol, Fentanyl induction followed by propofol infusion & fentanyl boluses | Rocuronium 0.3 mg/kg; Mean total dose of rocuronium: 48+/−  16 mg | Acceleromyography (TOF-Watch S®) | Sugammadex 2 mg/kg; Pre reversal TOF ratio: ranged from 0 to 0.5; Mean time to TOF > 0.9: 1.85 min. | Uneventful extubation and recovery |
Casarotti et al., 2014 | Italy | 2 patients: Case 1: 48/M; BMI: 32.7 kg/m2. Case 2: 71/F | Myasthenia gravis | Case 1: Emergency laparotomy; 120 min Case 2: Emergency endoscopy for hemostasis; 60 min | Propofol, remifentanil induction followed by maintenance with propofol and remifentanil infusion | Case 1: Rocuronium 1.2 mg/kg ideal body weight. Rapid sequence induction Case 2: Rocuronium 1 mg/kg ideal body weight Rapid sequence induction | Acceleromyography (TOF-Watch SX®) | Case 1: Sugammadex 4 mg/kg actual body weight. Pre reversal PTC > 1. Post reversal TOF ratio: 0.9 (3 min) Case 2: Sugammadex 4 mg/kg actual body weight. Pre reversal TOF count: 1; Post reversal TOF ratio: 1 (2 min) | Intensive care unit monitoring; sedated for at least 30 min after sugammadex and then extubated; uneventful recovery. |
de Boer et al., 2014 | Netherlands, UK | 21 patients; M: 8; F: 13. Mean age: 56 years Average weight: 77.6 kg | Myasthenia gravis | Thymectomy: 10 Breast surgery: 3; Laparoscopic cholecystectomy: 1; Urological surgery: 2, Craniotomy: 1; Laminectomy: 1; Inguinal hernia repair: 1; Gastric surgery: 1; Skin lesions: 1; Duration: N.R. | Propofol, remifentanil induction and maintenance or propofol induction and sevoflurane for maintenance | Rocuronium: 13 patients: 0.1–1.0 mg/kg; Vecuronium: 8 patients: 0.1–0.2 mg/kg | Acceleromyography (TOF-Watch SX®) | a) Sugammadex 2 mg/kg for 12 patients. Pre reversal TOF count: ≥1 response; Post reversal TOF ratio: 0.9 (1.3 min) b) Sugammadex 4 mg/kg for 9 patients. Pre reversal TOF count: 0. Post reversal TOF ratio: 0.9 (2.75 min) | Uneventful extubation and recovery in all patients. |
Vymazal et al., 2015 | Czech Republic | 117 patients; M: 67, F: 50; Mean age: 41.6 years; Mean BMI: 24.2 kg/m2 | Myasthenia gravis | 105 patients: Surgical thymectomy, 12 patients: cholecystectomy; mean surgical time: 98.6 min | Propofol, sufentanil boluses; isoflurane/oxygen/air | Rocuronium 0.6 mg/kg for intubation with additional boluses of 0.15 mg/kg if required; Total dose of rocuronium: 72.5 mg. | Acceleromyography (TOF-Watch SX®) | Sugammadex 2 mg/kg (if pre reversal TOF count: ≥2) or 4 mg/kg (if pre reversal TOF count: 0–1); Post reversal TOF ratio: 0.9 (average 1.95 min) | Uneventful extubation and recovery |