Sugammadex for the Reversal of Neuromuscular Blockade in Surgical Patients: A Review of Clinical Effectiveness and Cost-Effectiveness

In many procedures requiring intubation neuromuscular blocking agents are administered during anesthesia to facilitate the intubation of the trachea and to optimize the surgical field.¹ For short procedures (e.g., less than 30 minutes), a short acting neuromuscular blocking agent, such as succinylcholine, is required for rapid sequence induction and intubation.¹ Succinylcholine, a depolarizing neuromuscular blocking agent, produces a reliable neuromuscular block (NMB), has the fastest onset and the shortest duration of all neuromuscular blocking agents, and the recovery of the NMB typically occurs by spontaneous recovery.¹ Alternatives to succinylcholine may include using a longer acting neuromuscular blocking agent in conjunction with a reversal agent to produce a short-term NMB. Rocuronium is a non-depolarizing neuromuscular blocking agent with fast onset, which can be used at higher doses for rapid sequence induction and intubation.¹ Sugammadex is a selective relaxant binding agent indicated for the reversal of moderate to deep NMB,² with a high affinity for rocuronium.^1,3 A manufacturer shortage of succinylcholine occurred in Canada in May 2019, and at the time this report was written, the drug shortage was anticipated to last until mid-August 2019.⁴ In these circumstances, the use of rocuronium with sugammadex may be an alternative to succinylcholine when there is a need for short acting NMB. Neuromuscular blocking agents and reversal agents are associated with various adverse effects, including residual NMB, myalgias, muscle fasciculations, headache, nausea, and vomiting,^1,3 and it is unclear how the clinical benefits and harms of using rocuronium with sugammadex compare with using succinylcholine alone. In addition, the cost of sugammadex is significantly higher than other common reversal agents (e.g., neostigmine), and it is unknown if sugammadex is cost effective for routine clinical use.⁵ The purpose of this report is to synthesize and critically appraise the available evidence on the clinical effectiveness of rocuronium with sugammadex compared to succinylcholine in patients undergoing surgery who require rapid sequence induction. Additionally, the cost-effectiveness of sugammadex in patients undergoing surgery will be reviewed. This information may be used to inform decision making relating to health policy of the use of sugammadex.