Now that sugammadex has made it to the US market, the push to add it to formulary has begun. I discussed the approval of sugammadex in episode 33. Sugammadex may have a role in the OR/PACU setting – I’ll leave that to others to determine.
One argument I’ve heard for adding sugammadex to formulary is for reversal of rocuronium or vecuronium if rapid sequence intubation unexpectedly fails and the patient cannot be intubated or ventilated.
Context for determining whether sugammadex might work in this scenario is important. For the purpose of this episode, the context is in a critically ill patient undergoing non-elective intubation for actual or impending respiratory failure.
Imagine that rapid sequence intubation was performed using rocuronium and etomidate. An airway could not be established, and the patient’s oxygen saturation is falling rapidly despite attempts at bagging the patient. There are just moments left before the patient experiences severe hypoxia and anoxic injury.
I think it is risky to say that sugammadex is the treatment that should be relied on to save such a patient from anoxic injury.
The hope is that reversing the paralytic will allow the patient to be ventilated with a bag-valve mask. But it is also possible that airway edema from the failed attempt at intubation is responsible for the “can’t oxygenate” part of this scenario. If so, sugammadex would be of no help and precious time would be wasted preparing and administering the medication instead of securing the airway.
If the patient needed an airway, even after rocuronium is reversed with sugammadex, they will still need an airway. Instead of using sugammadex, the next step in the provider’s failed airway algorithm (such as cricothyrotomy) should be initiated.
Some published case studies illustrate how sugammadex may not be able to reverse a “can’t intubate can’t oxygenate” scenario:
After induction of anaesthesia and three attempts at intubation, a “can’t intubate, can ventilate” situation deteriorated to a “can’t intubate, can’t ventilate” (CICV) situation in a 78 year old female. Rocuronium-induced neuromuscular block was successfully reversed with sugammadex however, ventilation was still not possible. A cricothyroid puncture was performed successfully to provide emergency oxygenation. The authors stated:
The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation.
A “can’t intubate, can’t oxygenate” airway crisis occurred as a result of an asymptomatic vallecular cyst. Rocuronium was used as the muscle relaxant for rapid sequence induction. Despite the use of sugammadex, the “can’t intubate, can’t oxygenate” situation failed to resolve.
In a manikin-based “can’t intubate, can’t oxygenate” simulation, the total time taken for anaesthetic teams to prepare and administer sugammadex from the time of their initial decision to use the drug was studied. The mean total time to administration of sugammadex was 6.7 min, following which an additional 2.2 min (total 8.9 min) would need to be allowed to achieve a train-of-four ratio of 0.9. Only 22% of the teams studied gave the right dose of sugammadex, with 56% of teams giving a dose that was too low. The author’s concluded:
Our simulation highlights that sugammadex might not have saved this patient in a “cannot intubate, cannot ventilate” situation, and that difficulties and delays were encountered when identifying, preparing and administering the correct drug dose.
In addition, the Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults have this to say about sugammadex:
The ability to antagonize the effect of rocuronium rapidly with sugammadex may be an advantage, although it should be remembered that this does not guarantee airway patency or the return of spontaneous ventilation.
In an emergent situation, don’t count on sugammadex to rescue a paralyzed patient from a “can’t intubate, can’t oxygenate” scenario.
For a compendium of successful case reports of sugammadex use in a different context (planned intubation of patients for OR procedures) go here.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.