The safety and efficacy of sugammadex for reversing neuromuscular blockade in younger children and infants

ABSTRACT

Introduction

Sugammadex, a novel selective antagonist of non-depolarizing neuromuscular blocking agents, has been shown to rapidly and effectively reverse moderate and deep paralysis in adults and pediatric patients over age 2, improving patient recovery and reducing the risk of postoperative complications.

Areas covered

Since the use of sugammadex in patients under age 2 is not widely studied, we aim to provide an overview on the drug’s application and potential use in infants and neonates. There is a limited but growing body of evidence for the safe, efficacious use of sugammadex in children under age 2. Relevant studies were identified from the most updated data including case reports, clinical trials, systematic reviews, and meta analyses.

Expert opinion

The results suggest that at a dose of 2 to 4 mg/kg of sugammadex can be safely used to rapidly and effectively reverse neuromuscular blockade in neonates and infants; it is non-inferior based on incidence of adverse events compared to neostigmine. Additionally, sugammadex doses between 8 and 16 mg/kg may be used as a rescue agent for infants during ‘can’t intubate, can’t ventilate’ crisis. Overall, sugammadex offers new value in the perioperative care of patients under age 2, with further studies warranted to better understand its application and full effect in the pediatric population.

KEYWORDS:

• Sugammadex
• neuromuscular blockade reversal
• postoperative recovery
• pediatric
• acetylcholinesterase antagonism

Article highlight

• Sugammadex has been shown to rapidly and effectively reverse moderate and deep paralysis in adults and pediatric patients over age 2 which improves patient recovery and reduces the risk of postoperative complications.

• However, since the use of sugammadex in patients under age 2 is not widely studied, this study provides an overview on the drug’s application and potential use in infants and neonates. There is a limited but growing body of evidence for the safe, efficacious use of sugammadex in children under age 2, including retrospective analyses, randomized trials, and case reports.

• The results suggest that at a 2 to 4 mg/kg dose of sugammadex can be safely used for rapidly and effectively reversing neuromuscular blockade in neonates and infants; this is non-inferior compared to neostigmine.

• Sugammadex doses between 8 and 16 mg/kg may be used as a rescue agent for infants during ‘can’t intubate, can’t ventilate’ crisis.

• Recent studies have suggested that quantitative rather than qualitative neuromuscular monitoring may further protect against pulmonary complications in the setting of neuromuscular blockade reversal. Quantitative neuromuscular monitoring should be further studied in the pediatric population.

• Overall, sugammadex offers new value in the perioperative care of patients under age 2, with further studies warranted to better understand its application and full effect in the pediatric population.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer received Industry-sponsored research (Merck Inc) with funds to their employer. The remaining reviewers have no other relevant financial relationships or otherwise to disclose.

Author contribution statement

Conceptualization, Z.J, E.A., and R.M.; formal analysis, A.W., A.T., and S.M.; investigation, A.W., A.T., and S.M.; writing – original draft preparation, A.W., A.T., S.M., E.A., and R.M.; writing – review and editing, A.W., E.A., and R.M.; supervision, Z.J., E.A., and R.M. All authors have read and agreed to the published version of the manuscript.

Additional information

Funding

This paper was not funded.