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• W4234028305 abstract "We would like to thank Greenaway et al. for their contribution to recent correspondence discussing sugammadex 1-3. After administration of sugammadex, ventilation became significantly more difficult after ‘approximately 1 min’ with this impairment persisting for 3 min with associated oxygen desaturation to 80%, a similar time-scale to that which we encountered 3, and which concurs with other cases reports 4, 5. It is highly likely that the phenomenon we observed (with a flexible fibreoptic scope) of vocal cord opposition also occurred in Greenaway's case. We postulated this related to the rapid and complete return of muscle tone from a state of deep neuromuscular blockade (NMB), in the unconscious patient, with the airway not splinted by an tracheal tube. Greenway et al. state that “in all cases cited in the original editorial, and here, the hypoxaemic episode resolved without any adverse outcomes” and then surmise that perhaps awareness of the potential for this side effect is sufficient, rather than denying the use of sugammadex. We partly agree with this statement. The evidence from these case reports suggests the possibility of an ‘upper airway reactivity and closure’ that we believe is worth highlighting and sharing with colleagues. This is in the context of sugammadex reversal from deep levels of NMB in the ‘cannot intubate cannot oxygenate’ (CICO) situation. The important point is that, while correct dosage of sugammadex will rapidly (within 2–3 min) restore full NMB recovery, this may not result in restoration of a patent airway. This would occur at time of likely or impending hypoxia. In this situation, therefore, the choice is between sugammadex reversal, with possibility of this apparently transient airway obstruction, or maintaining NMB to best facilitate airway management attempts, including front-of-neck access 6. In a ‘cannot intubate, can ventilate’ situation, it concerns us that using sugammadex (with the potential side effect of laryngospasm) could convert a relatively controlled scenario into a potentially catastrophic one, whereby ventilation may become impossible. Our experience would prompt us to insert a supraglottic airway (SAD) and, if well positioned, monitor NMB with a quantitative nerve stimulator, and maintain anaesthesia and oxygenation while performing flexible endoscope guided intubation using an Aintree Intubation Catheter-technique. Other options would include continuing anaesthesia via the SAD, or waking the patient while monitoring NMB to a greater level of recovery (train of four count return 2–4 twitches) before reversal from intermediate block using neostigmine. In summary, while there is never likely to be a large randomised study to establish the exact nature of these events, we feel that awareness of (and planning for) the potential sequelae of giving sugammadex as part of airway rescue is essential." @default.
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• W4234028305 date "2017-03-13" @default.
• W4234028305 modified "2023-10-13" @default.
• W4234028305 title "Did sugammadex cause, or reveal, laryngospasm? A reply" @default.
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• W4234028305 doi "https://doi.org/10.1111/anae.13858" @default.
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