|Year : 2016 | Volume
| Issue : 2 | Page : 80-85
Sugammadex and its effect on respiratory outcome in obstructive sleep apnea patients undergoing laproscopic bariatric surgery
Mohamed S Elhadidi
Department of Anesthesia and Surgical Intensive Care, Alexandria University Hospital, Alexandria, Egypt
|Date of Submission||09-Nov-2015|
|Date of Acceptance||24-May-2016|
|Date of Web Publication||6-Sep-2016|
Mohamed S Elhadidi
Department of Anesthesia and Surgical Intensive Care, Alexandria University Hospital, Alexandria, 21648
Source of Support: None, Conflict of Interest: None
Background Obesity has clearly emerged as a worldwide epidemic, and because obesity is a well-recognized risk factor for the development of obstructive sleep apnea (OSA), physicians will undoubtedly encounter patients with OSA undergoing surgery. The increased incidence of postoperative respiratory problems in patients with OSA could be explained by the depressive effects of narcotics as well as other anesthetic drugs on the function of the upper airway muscles. Anesthesia may also attenuate the ventilatory response to airway obstruction and abolish normal response to hypoxia and hypercapnia.
Aim The aim of this work was to evaluate sugammadex and its effect on the respiratory outcome in OSA patients undergoing laparoscopic bariatric surgery.
Patients and methods Patients were included in the study after obtaining informed written consent (IRB NO: 000007555-FWA NO: 00015712). Inclusion criteria were as follows: age between 18 and 55 years, obesity (BMI>40), known OSA case with mild-to-moderate apnea–hypopnea index (<30), and scheduled for laparoscopic bariatric surgery under general anesthesia with rocuronium. Neuromuscular function monitoring was continued until the end of surgical procedure and at least 10 min after the train of four (TOF) ratio of 0.9. Anesthesia was maintained with sevoflurane. At the end of surgery and emergence of anesthesia, sugammadex group patients received 2 mg/kg ideal body weight sugammadex according to their ideal body weight, and the neostigmine group received neostigmine 50 μg/kg plus atropine 10 μg/kg. The time from start of sugammadex or neostigmine administration to recovery of the TOF ratio to 0.9 was calculated. All patients were extubated at TOF ratio of 0.9. They were monitored in the recovery room for 120 min after extubation. Oxygen saturation, respiratory rate, heart rate, and blood pressure were routinely monitored. Patients were placed in 30° head-up position. The patients were also monitored for the appearance of any sign of reoccurrence of muscle weakness and respiratory distress.
Results The mean time for recovery to TOF of 0.9 was recorded from the time of administration of the drug. It was shorter in the sugammadex group than that in the neostigmine group. As regards the vital signs of both groups in the postoperative period, vitals were relatively stable in the sugammadex group, whereas there were significant tachypnea, hypoxia, and tachycardia in the other group. Respiratory distress signs were much more frequent in the neostigmine group than in the sugammadex group. This concludes that sugammadex may improve the postoperative respiratory outcome in OSA patients undergoing baraiatric surgery.
Conclusion Sugammadex may improve the postoperative respiratory outcome in OSA patients undergoing baraiatric surgery.
Keywords: bariatric surgery, obstructive sleep apnea, sugammadex
|How to cite this article:|
Elhadidi MS. Sugammadex and its effect on respiratory outcome in obstructive sleep apnea patients undergoing laproscopic bariatric surgery. Res Opin Anesth Intensive Care 2016;3:80-5
|How to cite this URL:|
Elhadidi MS. Sugammadex and its effect on respiratory outcome in obstructive sleep apnea patients undergoing laproscopic bariatric surgery. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2021 Jun 15];3:80-5. Available from: http://www.roaic.eg.net/text.asp?2016/3/2/80/189789
| Introduction|| |
Obesity has become a worldwide epidemic, and because obesity is a well-known risk factor for the development of obstructive sleep apnea (OSA), physicians will undoubtedly face the challenge of anesthetizing patients with OSA undergoing surgery .
OSA can be described as partial or complete obstruction of the upper airway during sleep. This obstruction leads to oxygen desaturation, hypercapnia, and cortical arousals trying to restore upper airway patency. Complications such as hypoxemia, cardiac arrhythmias, myocardial injury, unanticipated admission to the ICU, and sudden unexpected death have been documented .
In obese adults, about 40% of them suffer from OSA; among extremely obese adults (BMI≥40 kg/m2), the prevalence increased to 98%. In addition, many studies on extremely obese adults have shown that significant weight loss after bariatric surgery decreases the severity of OSA .
Bariatric surgery has been increasingly accepted as a weight loss solution for a selected group of extremely obese patients who are affected by such disorders and who have failed to lose weight with less invasive traditional approaches .
In fact, anesthesia increases the upper airway anatomic changes that cause pharyngeal collapse during normal sleep in patients with OSA .
Knowingly, anesthetics also remove or blunt arousal from sleep, which is an important defense mechanism that occurs during natural sleep to avoid airway obstruction. Anesthetic agents, such as propofol, opioids, benzodiazepines, and inhaled halogenated agents, decrease the tone of the pharyngeal musculature and/or blunt ventilation and decrease the ventilatory stimulation to carbon dioxide .
OSA patients are very sensitive to opiates and benzodiazepines because of their synergistic respiratory depressant effects. Furthermore, airway obstruction occurs out of proportion to the level of sedation and/or analgesia achieved .
Sugammadex is a modified γ-cyclodextrin, specifically designed for the reversal of neuromuscular blockade induced by the steroidal neuromuscular blocking agents such as rocuronium and vecuronium. Sugammadex encapsulates the unbound drug molecules and decreases their concentration at the neuromuscular junction, making a rapid reversal of neuromuscular block at every stage .
Sugammadex also reverses profound neuromuscular block and is very well tolerated. The recommended doses of sugammadex are in the range of 2 to 16 mg/kg, depending on the intensity of the block .
| Patients and methods|| |
Patients were included in the study after obtaining informed written consent. Inclusion criteria were as follows: age between 18 and 55 years, obesity (BMI>40), known OSA cases with mild-to-moderate apnea–hypopnea index (<30), and scheduled for laparoscopic bariatric surgery under general anesthesia with rocuronium for endotracheal intubation. Patients were excluded if they were expected to have a severe OSA with apnea–hypopnea index more than 30, known neuromuscular disease, significant hepatic or renal dysfunction, family history of malignant hyperthermia, known allergy to one of the drugs used in this protocol, or intake of any medication that may interact with muscle relaxants.
General anesthesia was induced identically in both groups using propofol 2.0 mg/kg ideal body weight (IBW). For intraoperative analgesia, fentanyl 1 μg/kg IBW was used. Anesthesia was maintained using sevoflurane in a mixture of oxygen and air. The ventilation parameters were adjusted to maintain a normocapnia.
Muscle relaxation was induced using rocuronium 0.9 mg/kg IBW for endotracheal intubation. When train of four (TOF) reached a score of 1, a booster dose of rocuronium 0.1 mg/kg IBW was given. The standard anesthesia monitoring consisted of ECG, noninvasive arterial pressure, pulse oximetry, gas monitoring, and monitoring of neuromuscular function.
At the end of surgery and when two responses were achieved on the TOF stimulation, one of the studied drugs was administered. Sugammadex 2 mg/kg IBW or neostigmine 0.05 mg/kg IBW together with atropine 0.02 mg/kg IBW was administered in the sugammadex or the neostigmine group, respectively.
All patients were extubated at a TOF ratio of 0.9. The time from the administration of the drug until the TOF reached a value of 0.9 was calculated.
Patients were monitored in the recovery room for 120 min after extubation. Oxygen saturation, respiratory rate, heart rate, and blood pressure were routinely monitored. Patients were placed in 30° head-up position.
The patients were also monitored for the appearance of any sign of muscle weakness and respiratory depression according to the classification described by Murphy et al. .
- Upper airway obstruction requiring an intervention (jaw thrust or oral or nasal airway).
- Mild-to-moderate hypoxia (SpO2 of 93–90%) on 3 l nasal cannula oxygen that did not improve after active intervention (increasing oxygen more than 3 l/min, application of high-flow face mask oxygen, verbal request to breathe deeply, or tactile stimulation).
- Severe hypoxia (SpO2<90%) on 3 l nasal cannula oxygen that did not improve after active intervention (increasing oxygen more than 3 l/min, application of high-flow face mask oxygen, verbal request to breathe deeply, or tactile stimulation).
- Signs of respiratory distress or impending ventilator failure (respiratory rate>20 breaths/min, accessory muscle use, and tracheal tug).
- Inability to breathe deeply when requested.
- Patient complaining of symptoms of respiratory or upper airway muscle weakness (difficulty in breathing, swallowing, or speaking)
- Patient requiring intubation in the postanesthesia care unit.
- Clinical evidence or suspicion of aspiration after tracheal extubation (gastric contents observed in the oropharynx and hypoxemia).
Respiratory distress was assessed using this classification every 20 min for 2 h before discharge from the postoperative recovery room.
| Results|| |
A total of 40 patients were included in this study and were comparable with respect to age and BMI. All patients were known OSA patients who were classified as having OSA of mild-to-moderate in severity.
The mean time for recovery was recorded from the time of administration of the drug to TOF of 0.9. It was about 16.60±2.39 s in the sugammadex group compared with 155.80±5.65 s in the neostigmine group [Table 1].
|Table 1 Comparison between the studied groups according to time from drug administration to TOF of 0.9|
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As regards the vital signs of both groups in the postoperative period, the oxygen saturation in the sugammadex group was significantly higher than that in the neostigmine group during the first 60 min postoperatively and remained nonsignificant in the next 60 min.
The respiratory rate was significantly higher in the neostigmine group than that in the sugammadex group during the first 40 min. However, in the remaining 80 min the difference was nonsignificant.
The heart rate of the neostigmine group was significantly higher than that in the sugammadex group throughout the 120 min of the postoperative period.
There was no significant difference as regards blood pressure during the 2 h in the postoperative period.
Upper airway obstruction requiring an intervention (jaw thrust or oral or nasal airway) was significantly higher in the neostigmine group compared with the sugammadex group during the first 80 min.
Mild-to-moderate hypoxia (SpO2 of 93–90%) on 3 l nasal cannula oxygen occurred in both groups during the first 80 min postoperatively and was nonsignificant in both groups.
Severe hypoxia (SpO2<90%) on 3 l nasal cannula oxygen occurred during the first 40 min and was significantly higher in the neostigmine group during the first 20 min [Figure 1].
|Figure 1 Comparison between the two studied groups according to the number of patients complaining of severe hypoxia. NEO, neostigmine; SUG, sugammadex.|
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Signs of respiratory distress or impending ventilator failure occurred during the first 20 min and was significantly higher in the neostigmine group immediately after being transferred to the recovery room [Figure 2].
|Figure 2 Comparison between the two studied groups according to the number of patients complaining of respiratory distress and failure. NEO, neostigmine; SUG, sugammadex.|
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Only two patients of the neostigmine group were unable to breathe deeply or swallow and speak; however, it was nonsignificant when compared with the sugammadex group.
Only one patient required reintubation in the neostigmine group and none in the sugammadex group.
None showed clinical evidence of aspiration in both groups.
| Discussion|| |
OSA patients are very challenging and problematic. This may be attributed to the multiple comorbid conditions and risks that are to be faced .
Anesthetizing an obese OSA patient for bariatric surgery is a growing concern in recent times. This is because reducing weight is thought to improve the respiratory condition of those patients .
Moreover, the morbidly obese patient is especially susceptible to critical respiratory events during the postoperative period, including airway obstruction, hypoventilation, hypercapnia, hypoxia, and acute respiratory failure in the postoperative period .
The presence of postoperative residual curarization is one of the factors increasing the risk for critical respiratory events. Postoperative residual curarization is also associated with increased risk for pulmonary complications such as lung inflammation caused by ineffective swallowing and coughing and inaccurate protective reflexes from the larynx and pharynx, resulting in the aspiration of secretions .
The challenge was to avoid the respiratory complications of these patients, if possible. This can be accomplished by improving the recovery so that they can maintain their own airway and ventilation without any external support.
Sugammadex envelops neuromuscular blocker in the blood, increases the concentration gradient of neuromuscular blocker between the blood and neuromuscular junction, and removes neuromuscular blocker from the receptors. The mechanism of sugammadex is direct and its onset of action is within few seconds .
In this study, we thought that using sugammadex may aid in a faster recovery of those patients and decrease the need for postoperative ventilatory support.
No other study was conducted on such type of patients, and so this study was designed to evaluate sugammadex and its effect on the respiratory outcome in the OSA patients undergoing laparoscopic bariatric surgery.
Many other studies evaluated the effect of sugammadex compared with neostigmine in the morbidly obese patients but those were not complaining of OSA ,.
Sanfilippo et al. , Gaszynski et al. , Woo et al. , and Carron et al.  proved that the administration of sugammadex provides fast-track recovery of the neuromuscular junction and prevents residual curarization in the morbid obese, whereas neostigmine does not.
In this study, the time from the start of sugammadex administration to the recovery to TOF ratio of 0.9 was faster and significantly shorter compared with neostigmine.
In agreement with this study, Van Gestel and Cammu  reported that patients who received sugammadex had a faster recovery than those who received neostigmine. Patients of the previous studies underwent a nonbariatric surgery. Geldner et al.  also reported the same results.
In this study, patients were monitored in the recovery room for 120 min after extubation. Vital signs were routinely monitored.
The patients were also monitored for occurrence of respiratory depression, hypoxia, obstruction, and reintubation and artificial ventilation according to the classification described by Murphy and colleagues.
On comparing sugammadex with neostigmine, it was proved that the incidence of postoperative respiratory complications reduced in the sugammadex group. Moreover, the hemodynamics of the sugammadex group was far much closer to the normal range than those of the neostigmine group, and this may be due to the decreased incidence of hypoxia and respiratory distress in the sugammadex group.
Paul et al. , in a retrospective observational study, included all patients who presented for gastric bypass surgery between 2008 and 2011 in Belgium and studied the introduction of sugammadex on the incidence of respiratory failure after bariatric surgery and proved that the incidence of postoperative respiratory failure dropped to 0. Moreover, they stated that sugammadex could facilitate faster and safer recovery, had shorter total anesthesia time, diminished postanesthesia care unit stay, better SpO2 level, faster ability to swallow, and got to bed independently.
Llaurado et al.  assessed the respiratory outcomes in laparoscopic bariatric surgery using both sugammadex and neostigmine; the study proved that pathological postoperative chest radiography changes were found in the neostigmine group.
| Conclusion|| |
From this study, we conclude that the use of sugammadex improved the postoperative recovery and reduced the respiratory complications and the need for extra ventilatory support in the mild-to-moderate OSA patients undergoing laparoscopic bariatric surgery.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Van Gestel L, Cammu G. Is the effect of sugammadex always rapid in onset? Acta Anaesthesiol Belg 2013;64:41–47.
Koeck ES, Barefoot LC, Hamrick M, Owens JA, Qureshi FG, Nadler EP. Predicting sleep apnea in morbidly obese adolescents undergoing bariatric surgery. Surg Endosc 2014;28:1146–1152.
Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest 2010;138:1489–1498.
Llauradó S, Sabaté A, Ferreres E, Camprubí I, Cabrera A. Postoperative respiratory outcomes in laparoscopic bariatric surgery: comparison of a prospective group of patients whose neuromuscular blockade was reverted with sugammadex and a historical one reverted with neostigmine. Rev Esp Anestesiol Reanim 2014;61:565–570.
Deutzer J. Potential complications of obstructive sleep apnea in patients undergoing gastric bypass surgery. Crit Care Nurs Q 2005;28:293–299.
Kalra M, Inge T, Garcia V, Daniels S, Lawson L, Curti R et al.
Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res 2005;13:1175–1179.
Caldwell JE, Miller RD. Clinical implications of sugammadex. Anaesthesia 2009;64(Suppl 1):66–72.
Carron M, Gasparetto M, Vindigni V, Foletto M. Laparoscopic surgery in a morbidly obese, high-risk cardiac patient: the benefits of deep neuromuscular block and sugammadex. Br J Anaesth 2014;113:186–187.
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008;107:130–137.
Lindauer B, Steurer MP, Müller MK, Dullenkopf A. Anesthetic management of patients undergoing bariatric surgery: two year experience in a single institution in Switzerland. BMC Anesthesiol 2014;14:125.
Iyer US, Koh KF, Chia NC, Macachor J, Cheng A. Perioperative risk factors in obese patients for bariatric surgery: a Singapore experience. Singapore Med J 2011;52:94–99.
Gaszynski T, Szewczyk T, Gaszynski W. Randomized comparison of sugammadex and neostigmine for reversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia. Br J Anaesth 2012;108:236–239.
Park JY. Benefits and risks of sugammadex. Korean J Anesthesiol 2015;68:1–2.
Sanfilippo M, Alessandri F, Wefki Abdelgawwad Shousha AA, Sabba A, Cutolo A. Sugammadex and ideal body weight in bariatric surgery. Anesthesiol Res Pract 2013;2013:389782.
Woo T, Kim KS, Shim YH, Kim MK, Yoon SM, Lim YJ et al.
Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients. Korean J Anesthesiol 2013;65:501–507.
Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fast-track bariatric surgery. Obes Surg 2013;23:1558–1563.
Geldner G, Niskanen M, Laurila P, Mizikov V, Hübler M, Beck G et al.
A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012;67:991–998.
Mulier JP, van Lancker P, Dillemans B. A retrospective analysis of the introduction of sugammadex on the incidence of respiratory failure after bariatric surgery. ESPCOP 2011;23:10–13.
[Figure 1], [Figure 2]