rapid sequence induction e sugammadex...chambers, d., et al., sugammadex for reversal of...

Scuola di Specializzazione in Anestesia,

Rianimazione e Terapia Intensiva,

Università di Bologna

Rapid Sequence Induction

e

Sugammadex

Giannone S, Castagnoli A

Dir. Prof.ssa R.M. Melotti


• Scopo:

• Indicazioni:

Minimo intervallo di tempo tra

perdita di coscienza e intubazione

oro tracheale (sicurezza vie aeree)

Pz a rischio di aspirazione

(urgenze, ascite, parto cesareo)

Stept, W. and P. Safar, Rapid induction-intubation for prevention of

gastric-content aspiration. Anesthesia and analgesia, 1970. 49(4): p.

633-639

• Pre-ossigenazione

• Oppiaceo-ipnoinduttore-miorilassante

• NO ventilazione in maschera

• Pressione cricoidea

• Intubazione oro tracheale entro 60”


El-Orbany M and Connolly LA, Rapid Sequence Induction and

Intubation:Current Controversies. Anesthesia & Analgesia, 2010. 110.

• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

Rapid Sequence Induction:

Miorilassante ideale

SUCCINILCOLINA



• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

SUCCINILCOLINA



SUGAMMADEX

ROCURONIO

• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo



• Obiettivo: intubazione entro 60”

• Gold Standard “storico”: Succinilcolina 1 mg/kg

• Alternativa: Rocuronio 0,9-1,2 mg/kg

Rapido onset

Perry, J., J. Lee, and G. Wells, Are intubation conditions using

rocuronium equivalent to those using succinylcholine? Academic

emergency medicine : official journal of the Society for Academic

Emergency Medicine, 2002. 9(8): p. 813-836.

Punteggio Facilità della

Laringoscopia

Posizione Corde

Vocali

Risposta motoria

all’intubazione

1 Buona Aperte Nessuna

2 Accettabile Paramediana Movimento

diaframmatico

3 Difficile In movimento Tosse leggera

4 Impossibile Chiuse Tosse forte/sussulti

Totale Punti

3: condizioni di intubazione ottimali

4 - 6: accettabili

7 - 9: scadenti

10 - 12: inadeguate/impossibile

Scala di Goldberg per le Condizioni di Intubazione

Perry, J., et al., Rocuronium versus succinylcholine for rapid sequence

induction intubation. Cochrane database of systematic reviews , 2008

(n = 2690)


induction intubation. Cochrane database of systematic reviews , 2008

Rocuronium specific dose versus succinylcholine,

Outcome 1 Excellent versus other intubation conditions

Dose Rocuronio RR [IC 95%] n Peso

0.6-0.7mg/kg 0.81 [ 0.73, 0.90 ] 1782 62.7 %

0.9-1.0mg/kg 0.96 [ 0.89, 1.02 ] 923 32.2 %

1.2mg/kg 0.93 [ 0.75, 1.15 ] 86 5.1 %

totale 0.87 [ 0.81, 0.93 ] 2690 100%

“Overall, succinylcholine was superior to rocuronium …

We found no statistical difference in intubation conditions

when succinylcholine was compared to 1.2mg/kg

rocuronium; however, succinylcholine was clinically

superior as it has a shorter duration of action.”


induction intubation. Cochrane database of systematic reviews, 2008



• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

• Succinilcolina 1 mg/kg: 6-10 min

• Rocuronio 1,2 mg/kg: 37-72 min

Rapido offset

Perry, J., J. Lee, and G. Wells, Are intubation conditions using rocuronium

equivalent to those using sucinylcholine? Academic emergency medicine :

official journal of the Society for Academic Emergency Medicine, 2002.

9(8): p. 813-836.

• Procedure brevi ???

• Imprevista difficoltà di intubazione ?

Quando è necessario un rapido offset ?

• Procedure brevi ?

• Imprevista difficoltà di intubazione ?

Quando è necessario un rapido offset ?

Lee, C., et al., Reversal of profound neuromuscular block by Sugammadex administered three

minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine.

Anesthesiology, 2009. 110(5): p. 1020-1025.

“We would warn against a false sense of security developing from

the knowledge that sugammadex is available in the theatre

complex, should problems arise when using high dose rocuronium

for rapid sequence induction; the mean time to administer

sugammadex in our study was 6.7 min following which one could

predict that a further 2.2 min would be required to achieve a TOF

ratio of 0.920.”

Bisschops, M., C. Holleman, and J. Huitink, Can Sugammadex save a

patient in a simulated 'cannot intubate, cannot ventilate' situation?

Anaesthesia, 2010. 65(9): p. 936-977.

Benumof, J., R. Dagg, and R. Benumof, Critical hemoglobin desaturation will

occur before return to an unparalyzed state following 1 mg/kg intravenous

succinylcholine. Anesthesiology, 1997. 87(4): p. 979-1061

“While sugammadex can be relied upon to reverse

rocuronium-induced neuromuscular block, it should not be

relied upon to rescue all CICV events, especially where

airway instrumentation has led to airway swelling. The

availability of sugammadex does not obviate the need for

emergency tracheal access in the event of failed

oxygenation.”

Curtis, R., S. Lomax, and B. Patel, Use of sugammadex in a 'can't

intubate, can't ventilate' situation. Br J Anaesth, 2012.



• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

“ Neuromuscular block by

depolarisation of muscle cells is, in a

sense, like general anaesthesia by

depolarisation of cerebral neurons.

It is intuitively a bad idea.”

Lee, C., Goodbye suxamethonium!

Anaesthesia, 2009. 64 Suppl 1: p. 73-154.

Succinilcolina

• Effetti collaterali: mialgie, fascicolazioni, effetti

muscarinici, aumento della pressione

endocranica/endooculare, spasmo del massetere,

liberazione di K+ , anafilassi, ipertermia

maligna…

• Controindicazioni: Traumi, ustioni estese

presenti da > 12-24 hr, malattie neuromuscolari,

allettamento prolungato, lesioni bulbo oculare…

Lee, C., Goodbye suxamethonium!

Anaesthesia, 2009. 64 Suppl 1: p. 73-154.

Rocuronio

• Effetti collaterali: transitoria liberazione

di istamina, non emodinamicamente

significativa, anafilassi

• Controindicazioni: Allergia accertata

nei confronti del farmaco.

Engbaek, J. and J. Viby-Mogensen, Can rocuronium replace

succinylcholine in a rapid-sequence induction of anaesthesia?

Acta anaesthesiologica Scandinavica, 1999. 43(1): p. 1-4.

Sugammadex

• Effetti collaterali: ipotensione, dolore,nausea,

vomito, disgeusia, reazioni da ipersensibilità

• Controindicazioni: insufficienza renale grave

con ClCr < 30 ml/min (non raccomandato)

Yang, L.P. and S.J. Keam, Sugammadex: a review of its use in

anaesthetic practice. Drugs, 2009. 69(7): p. 919-42.



• Rapido onset

• Rapido offset

• Sicurezza

• Basso costo

Adulto 70 kg: Rapid Sequence Induction

Induzione:

• Succinilcolina 70 mg: 1,70 euro

• Rocuronio 70-80 mg: 14 euro

Antagonizzazione:

• Sugammadex dopo 3‟ (16mg/kg): 732 euro

• Sugammadex dopo 30‟ (4 mg/kg): 366 euro

Chambers, D., et al., Sugammadex for reversal of neuromuscular block

after rapid sequence intubation: a systematic review and economic

assessment. British Journal of Anaesthesia, 2010. 105(5): p. 568-643.

• Costo di 1 minuto in sala operatoria : 5,30 euro

• Costo di un minuto in recovery room: 0,39 euro

• Valore di 1 QALY (Quality Adjusted Life Year): 24.000 euro

• Perdita economica per decesso pz 20 anni: 22.9 QALY (552.000 euro)

• Perdita economica per decesso pz 60 anni : 12.33 QALY (296.000 euro)

Chambers, D., et al., Sugammadex for reversal of neuromuscular block

after rapid sequence intubation: a systematic review and economic

assessment. British Journal of Anaesthesia, 2010. 105(5): p. 568-643.

RSI in ostetricia

American Society of Anesthesiologists Task Force on Obstetric,

A., Practice guidelines for obstetric anesthesia: an updated

report by the American Society of Anesthesiologists Task Force

on Obstetric Anesthesia. Anesthesiology, 2007. 106(4): p. 843-6

“The consultants and ASA members agree that GA reduces

the time to skin incision when compared with either epidural

or spinal anesthesia; they also agree that GA increases

maternal complications. The consultants are equivocal and

the ASA members agree that GA increases fetal and neonatal

complications.”

RSI in ostetricia

Dahl, V. and U.J. Spreng, Anaesthesia for urgent (grade 1)

caesarean section. Curr Opin Anaesthesiol, 2009. 22(3): p. 352-6.

“The major disadvantage of general anaesthesia is the risk

of failure and the dramatic consequences of a potential

„cannot intubate, cannot ventilate‟ situation. The risk of failed

intubation is at least eight times higher in the obstetric

population… Tracheal intubation after rapid sequence

induction remains the approach to airway management

during general anaesthesia.”

RSI in ostetricia

“There is now a possibility that SCh might be rendered

obsolete by the combination of rocuronium and

sugammadex. High-dose rocuronium offers as swift an

onset of NMB than SCh, and a cleaner side-effect.

Sugammadex can cater for both routine reversal of

NMB at Caesarean section and, at higher doses, early

reversal of profound blockade in the event of „can‟t

intubate, can‟t ventilate‟ shortly after induction.”

Sharp LM, Levy DM, Rapid sequence induction in obstetrics

revisited. Current Opinion in Anaesthesiology, 2009. 22.

Conclusioni- 1

• Il Rocuronio a dosaggio 0.9-1,2 mg/kg permette di

ottenere condizione di intubazione ottimali in 60”, al

pari della Succinilcolina.

• Dopo una RSI con Rocuronio, il Sugammadex a 16

mg/kg permette una antagonizzazione del blocco

neuromuscolare più rapida della risoluzione

spontanea da Succinilcolina.

• Il Rocuronio può essere un‟alternativa alla

Succinilcolina anche in ambito ostetrico.

Conclusioni- 2

• Il Rocuronio presenta un profilo farmacologico superiore

rispetto alla Succinilcolina, per quanto riguarda gli effetti

collaterali e le controindicazioni.

• L‟elevato prezzo del Rocuronio/Sugammadex può essere

compensato dal risparmio di tempo in sala operatoria e

dalla riduzione dei costi legati alla morbidità/morbilità da

Succinilcolina.

Quando succinilcolina ?

• RSI a < 24 hr da somministrazione di Sugammadex

(es. revisione chirurgica)

• RSI in pz con allergia accertata nei confronti del

Rocuronio

• Procedure ultrabrevi ? (costo/beneficio)

Scuola di Specializzazione in Anestesia,

Rianimazione e Terapia Intensiva,

Università di Bologna


e Sugammadex

Giannone S, Castagnoli A

Dir. Prof.ssa R.M. Melotti

Sorensen, M.K., et al., Rapid sequence induction and intubation

with rocuronium-sugammadex compared with succinylcholine: a

randomized trial. Br J Anaesth, 2012.

rapid sequence induction e sugammadex...chambers, d., et al., sugammadex for reversal of...

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