- Email: [email protected]
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prevention of postherpetic neuralgia in patients with acute herpes zoster. Anesth Analg 2009; 10: 1651–5 2. Naja ZM, Maaliki H, Al-Tannir MA, El-Rajab M, Ziade F, Zeidan A. Repetitive paravertebral nerve block using a catheter technique for pain relief in post-herpetic neuralgia. Br J Anaesth 2006; 96: 381–3 3. Rho RH, Brewer RP, Lamer TJ, Wilson PR. Concise review for clinicians—complex regional pain syndrome. Mayo Clin Proc 2002; 77: 174–80
doi:10.1093/bjaceaccp/mkr001 Advance Access Publication 11 March 2011
Editor—I read with interest the article on Anaesthesia for bariatric surgery by Drs Sabharwal and Christelis in Volume 10, number 4 of August 2010. As an anaesthetist with a regular commitment for both laparoscopic gastric bands and for gastric bypass operations, it is always useful to refresh one’s knowledge on this sometimes very challenging anaesthesia. I would like to agree with the authors that induction of anaesthesia is a particularly hazardous period for this group of patients, for a variety of reasons which are highlighted in the article. The reversal of neuromuscular block with rocuronium using sugammadex has been demonstrated to be more rapid than the spontaneous recovery of succinylcholine and therefore an inherently safer technique, in my opinion, where difficulty in tracheal intubation is a real possibility. However, I would also suggest that additionally and of equal importance in my view is the immediate postoperative recovery period. In this regard, I would now suggest that it should be mandatory, where neuromuscular block has been achieved and maintained using either of the aminosteroids, rocuronium or vecuronium, that this is reversed at the conclusion of the procedure with sugammadex. This statement is made based on my own experience of sugammadex as a reversal agent in over 1500 patients. It is also well recognized that residual curarization is prevalent in between 10% and 40% of patients reversed with neostigmine and an anticholinergic agent, as quoted in many published peerreviewed studies. It is crucial that we maximize neuromuscular recovery in the immediate postoperative period, particularly in the context of the bariatric patient. An often awkward airway and the additional possibility of an underlying obstructive sleep apnoea, commonly associated with these patients, add further to potential morbidity which may be circumvented by the routine use of sugammadex.
Conflict of interest None declared.
doi:10.1093/bjaceaccp/mkq049
Reply from the authors Editor—We would like to thank Dr Duckworth for his interest in our article. He raises two interesting points; the use of sugammadex in patients undergoing bariatric surgery and the potential role that sugammadex has in anaesthesia practice. Sugammadex is currently licensed for use in the reversal of rocuronium- or vecuronium-induced moderate or deep muscle relaxation. Clinical trials in surgical patients show that sugammadex provides a rapid reversal of rocuronium- or vecuroniuminduced neuromuscular block with a low incidence of residual or recurrent neuromuscular block and was generally well tolerated.1 Dr Duckworth, and others, advocate the use of sugammadex as ‘mandatory’ where either rocuronium or vecuronium has been used for neuromuscular block. They also suggest it be routinely used in patients undergoing bariatric surgery. Appraising the evidence as it currently stands, all we can conclude is that clinical trials have demonstrated promising results and sugammadex will almost certainly be a useful addition to the reversal agents commonly used in anaesthetic practice. However, we must stress that there are several factors associated with the use of sugammadex that have yet to be determined before its use should be considered mandatory, which are given below: † Its efficacy and safety in patients with poor health or in those with neuromuscular disorders. Most studies to date have been undertaken in healthy individuals. Although a fairly recent study showed large differences in the pharmacokinetics of sugammadex and rocuronium between patients with renal failure and healthy controls, the significance of this is unclear.2 † Studies of sugammadex generally have small numbers, which may fail to show the incidence of infrequent adverse events in large patient populations. † The evidence base for modelling cost effectiveness is very limited. The high cost of sugammadex warrants its cost effectiveness to be considered before it is rolled out into routine practice. † There are no studies investigating the use of sugammadex for patients having bariatric surgery. We would urge Dr Duckworth to publish his results. A final point is that a number of authors advocate the use of remifentanil in the bariatric population, thereby negating the need for high or repeated doses of neuromuscular blocking agents.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 3 2011
109
Downloaded from http://ceaccp.oxfordjournals.org/ at Oakland University on June 6, 2015
Feedback
Robin A. Duckworth* BMI Ross Hall Hospital Glasgow, UK *E-mail: [email protected]
Feedback
Conflict of interest
References
None declared.
1. Yang LP, Keam SJ. Sugammadex: a review of its use in anaesthetic practice. Drugs 2009; 69: 919– 42
N. Christelis* Melbourne, Australia *E-mail: [email protected]
2. Staals LM, Snoeck MMJ, Driessen JJ et al. Reduced clearance of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth 2010; 104: 31–9
A. Sabharwal London, UK
doi:10.1093/bjaceaccp/mkq050
Downloaded from http://ceaccp.oxfordjournals.org/ at Oakland University on June 6, 2015
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Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 3 2011
prevention of postherpetic neuralgia in patients with acute herpes zoster. Anesth Analg 2009; 10: 1651–5 2. Naja ZM, Maaliki H, Al-Tannir MA, El-Rajab M, Ziade F, Zeidan A. Repetitive paravertebral nerve block using a catheter technique for pain relief in post-herpetic neuralgia. Br J Anaesth 2006; 96: 381–3 3. Rho RH, Brewer RP, Lamer TJ, Wilson PR. Concise review for clinicians—complex regional pain syndrome. Mayo Clin Proc 2002; 77: 174–80
doi:10.1093/bjaceaccp/mkr001 Advance Access Publication 11 March 2011
Editor—I read with interest the article on Anaesthesia for bariatric surgery by Drs Sabharwal and Christelis in Volume 10, number 4 of August 2010. As an anaesthetist with a regular commitment for both laparoscopic gastric bands and for gastric bypass operations, it is always useful to refresh one’s knowledge on this sometimes very challenging anaesthesia. I would like to agree with the authors that induction of anaesthesia is a particularly hazardous period for this group of patients, for a variety of reasons which are highlighted in the article. The reversal of neuromuscular block with rocuronium using sugammadex has been demonstrated to be more rapid than the spontaneous recovery of succinylcholine and therefore an inherently safer technique, in my opinion, where difficulty in tracheal intubation is a real possibility. However, I would also suggest that additionally and of equal importance in my view is the immediate postoperative recovery period. In this regard, I would now suggest that it should be mandatory, where neuromuscular block has been achieved and maintained using either of the aminosteroids, rocuronium or vecuronium, that this is reversed at the conclusion of the procedure with sugammadex. This statement is made based on my own experience of sugammadex as a reversal agent in over 1500 patients. It is also well recognized that residual curarization is prevalent in between 10% and 40% of patients reversed with neostigmine and an anticholinergic agent, as quoted in many published peerreviewed studies. It is crucial that we maximize neuromuscular recovery in the immediate postoperative period, particularly in the context of the bariatric patient. An often awkward airway and the additional possibility of an underlying obstructive sleep apnoea, commonly associated with these patients, add further to potential morbidity which may be circumvented by the routine use of sugammadex.
Conflict of interest None declared.
doi:10.1093/bjaceaccp/mkq049
Reply from the authors Editor—We would like to thank Dr Duckworth for his interest in our article. He raises two interesting points; the use of sugammadex in patients undergoing bariatric surgery and the potential role that sugammadex has in anaesthesia practice. Sugammadex is currently licensed for use in the reversal of rocuronium- or vecuronium-induced moderate or deep muscle relaxation. Clinical trials in surgical patients show that sugammadex provides a rapid reversal of rocuronium- or vecuroniuminduced neuromuscular block with a low incidence of residual or recurrent neuromuscular block and was generally well tolerated.1 Dr Duckworth, and others, advocate the use of sugammadex as ‘mandatory’ where either rocuronium or vecuronium has been used for neuromuscular block. They also suggest it be routinely used in patients undergoing bariatric surgery. Appraising the evidence as it currently stands, all we can conclude is that clinical trials have demonstrated promising results and sugammadex will almost certainly be a useful addition to the reversal agents commonly used in anaesthetic practice. However, we must stress that there are several factors associated with the use of sugammadex that have yet to be determined before its use should be considered mandatory, which are given below: † Its efficacy and safety in patients with poor health or in those with neuromuscular disorders. Most studies to date have been undertaken in healthy individuals. Although a fairly recent study showed large differences in the pharmacokinetics of sugammadex and rocuronium between patients with renal failure and healthy controls, the significance of this is unclear.2 † Studies of sugammadex generally have small numbers, which may fail to show the incidence of infrequent adverse events in large patient populations. † The evidence base for modelling cost effectiveness is very limited. The high cost of sugammadex warrants its cost effectiveness to be considered before it is rolled out into routine practice. † There are no studies investigating the use of sugammadex for patients having bariatric surgery. We would urge Dr Duckworth to publish his results. A final point is that a number of authors advocate the use of remifentanil in the bariatric population, thereby negating the need for high or repeated doses of neuromuscular blocking agents.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 3 2011
109
Downloaded from http://ceaccp.oxfordjournals.org/ at Oakland University on June 6, 2015
Feedback
Robin A. Duckworth* BMI Ross Hall Hospital Glasgow, UK *E-mail: [email protected]
Feedback
Conflict of interest
References
None declared.
1. Yang LP, Keam SJ. Sugammadex: a review of its use in anaesthetic practice. Drugs 2009; 69: 919– 42
N. Christelis* Melbourne, Australia *E-mail: [email protected]
2. Staals LM, Snoeck MMJ, Driessen JJ et al. Reduced clearance of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth 2010; 104: 31–9
A. Sabharwal London, UK
doi:10.1093/bjaceaccp/mkq050
Downloaded from http://ceaccp.oxfordjournals.org/ at Oakland University on June 6, 2015
110
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 3 2011