2 Bridion® in Clinical Practice: Case Study Dr Robin DuckworthConsultant AnaesthetistRoss Hall Hospital, GlasgowSUG/09-183The views and opinions expressed in this presentation are not those of Schering-Plough Corporation
3 Aims 2 case presentations commentary and impressions of using sugammadex
4 Case Study 1elective admission for bilateral thoracoscopic sympathectomy21 year old female5’3” and 65kg ( BMI 26 )
5 Case Study 1 PMH non smoker allergic to Penicillin no medication Irritable bowelAsthmaTonsillectomycolonoscopylaryngoscopynon smokerallergic to Penicillinno medicationASA grade 1
6 Case Study 1 anaesthesia: propofol 200mg alfentanil 1mg vecuronium 6mg oxygen/air mixsevofluranefentanyl 50mcg
7 Case Study 1 direct laryngoscopy – grade 1 laryngoscopy demonstrated a large exophytic friable lesion with surface ulceration at the base of the tonguebiopsies were taken
8 Case Study 1 Reversal a period of 15 minutes had elapsed sugammadex 200mg
9 Case Study 1 spontaneous respiration returned over the next minute patient extubated rapidlyverbalising almost immediatelyno recall
10 Case Study 2 71 year old male elective admission for lumbar decompression and Wallis stabilization5’9” and 68kg (BMI 32)ASA 1No past medical historyNo known allergy10
11 Case Study 2 anaesthesia fentanyl 150mcg propofol 180mg alfentanil 0.9mgN2O/O2/Desfluranevecuronium 6mgfentanyl 150mcgcefuroxime 1.5Gondansetron 8mgcyclimorph 7.5mgdiclofenac 75mg11
12 Case Study 2 reversal after 65 minutes neostigmine 3.75mg glycopyrrolate 0.75mg12
13 Case Study 2 extubated in recovery 5 minutes later patient now stridulous and agitatednot able to verbalise adequatelyappearance was of inadequate reversal13
14 Case Study 2what next ?waitmonitorfurther reversalsugammadex...
15 Case Study 2 ...within 30 seconds stridor abolished sitting up verbalising coherently
16 Scenarios a standard reversal the special situation - eg ultra short inadequate reversalother possible benefits – real or perceivedrelaxant anaphylaxis
17 Sugammadex Standard reversal speed – rapid return of spontaneous respiration, obviates the need for further doses of reversalhead lift – as a monitor of recovery is a thing of the past!cough reflex – never any apparent residual curarization, if the correct dosing adhered tomuscle tone – appears to return to preoperative levelsre-animation occurs!
18 Sugammadex Special situations short and ultra short, bariatric proceduressurgical relaxation – optimizing relaxation eg for closure or at specific times during surgeryfailed intubation – with or without airwayexpected and unexpected clinical scenario
19 Sugammadex Inadequate reversal conventional failure PORC does not appear to occur clinically when sugammadex is given in the recommended dosemuscle power returns to pre-surgery levels
20 Sugammadex Benefits – real and perceived aspiration less likely immediate post-operative pulmonary complications less likelyco-operative patients with excellent muscle tonecalmer more “settled” patients possibly due to lack of PORClack of side effects such as tachycardia, bronchospasm, nausea
21 Sugammadex Benefits – cont. optimizing relaxation for closure – improves surgical closure?, dehiscence less likely?, herniation less?increased flexibility of techniquepain control more manageable in immediate recovery periodhappier surgeon
22 Sugammadex Relaxant anaphylaxis Rocuronium or vecuronium – the concept of its use as immediate, perhaps first line treatment
23 SugammadexSummaryBridion is a new and novel drug which due its unique pharmacology provides anaesthetists with an agent which, in my view, surpasses our present ability to reverse most levels of relaxant blockade rapidly, safely, and in my view much more effectively than ever before
24 Sugammadex This results in a happier surgeon confident anaesthetist much safer patient
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