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Sugammadex versus Neostigmine in Thyroidectomy

Sugammadex versus Neostigmine in Thyroidectomy

Today, many operations require changes in the level of intraoperative neuromuscular blockade. Historically, the drug neostigmine has been used to reverse the neuromuscular blockade, even if it was risky and the speed of reversal was unsatisfactory. There are also several related problems caused by neostigmine including increased gland secretion and decreased heart rate. Sugammadex is a special neuromuscular reversal drug that has a lot of promising properties. It is known to have a rapid onset and can be highly efficient for operations, especially in thyroidectomy. During this surgery, doctors use the EMG Endotracheal Tube to locate the laryngeal nerve and avoid any damage. 

Sugammadex is the first-ever selective agent for binding and reversing neuromuscular blockade. It is made from a modified γ-cyclodextrin designed to reverse the effects of rocuronium selectively by encapsulating the aminosteroid within its lipophilic core. Sugammadex can also reverse the effects of vecuronium, although to a lesser extent. It currently has no relevant effect on the duration of action of benzylisoquinoline neuromuscular blockers. Sugammadex also forms a stable complex in plasma which results in a rapid reduction in the site concentration at the neuromuscular junction. This is similar to neostigmine which can prolong the action of acetylcholine at the neuromuscular junction. 

Preoperative bleeding can be the most fatal complication in patients undergoing thyroidectomy which is why it’s a very serious concern for surgeons and anesthetists. Bleeding after operation in thyroidectomy can cause dyspnea by obstruction of the airway. Applying sugammadex after anesthesia reverses muscle relaxant rapidly which ensures the effect of the EMG Endotracheal Tube. A previous study reported that sugammadex might be associated with moderate hypercoagulation in the whole blood of healthy subjects.

Despite this, a single change in its coagulation profile can bring danger for the patient citing this as a primary concern for surgeons and anesthetists. To further understand the effects of summagadex in patients with thyroidectomy, researchers compared both drugs sugammadex and neostigmine in the operative setting. The study aims to study sugammadex or neostigmine and find out their effects on coagulation profiles in patients undergoing thyroidectomy. 

Methods 

A total of 80 random thyroidectomy patients were put in the sugammadex group or neostigmine group. The medical personnel injected anesthesia using rocuronium, sufentanil, and propofol. The sugammadex group received sugammadex 2.0mg/kg after trachea intubation, similarly, the neostigmine group received neostigmine 40 µg/kg, for reversal of rocuronium-induced neuromuscular blockade. The intraoperative coagulation profiles were observed after the rocuronium injection, 10 minutes after reversal, and another 30 minutes after reversal by testing activated partial thromboplastin time, prothrombin time, fibrinogen, thrombin time, and TEG-Haemonetics. They recorded an amount of bleeding during the perioperative period.

The study was conducted in accordance with the Declaration of Helsinki was approved by the ethics Committee of the First Affiliated Hospital of Sun Yat-sen University. It was registered in the China clinical trial registry (number: ChiCTR2000030083). Each patient signed a consent.

Inclusion criteria 

  • Patients with American Society of Anesthesiologists physical status ASA Ⅰ to ASA Ⅱ
  • Age 18–65 years
  • Scheduled for thyroidectomy

Exclusion criteria 

  • Patients with cardiac disease
  • Hepatic failure
  • Distant metastasis of a malignant tumor
  • Allergy to the test drugs

 

A total of eighty patients were included in the study. There was no significant difference in age, sex, body weight, or other general characteristics between the two groups. For anesthesia induction, patients were administered propofol by target-controlled infusion of 4.0 µg/mL, sufentanil 0.5µg/kg iv, and rocuronium 0.6 mg/kg iv. After tracheal intubation, anesthesia was maintained with propofol target-controlled infusion of 2.0 ng/mL and remifentanil target-controlled infusion as 5.0 ng/mL. The time at which we administered rocuronium for the neuromuscular blockade was defined as T0.

Patients in Group S received sugammadex 2.0mg/ kg for reversal of rocuronium-induced neuromuscular blockade. The time 10 minutes and 30 minutes after the reversal were defined as T1 and T2. Group N received neostigmine 40ug/kg for the reversal. Heart rate, blood pressure, and oxygen saturation (pulse oximeter) were monitored. If the heart rate declined to less than 50 beats per minute, a dose of 0.3 mg atropine was administered. The researchers collected 3 mL of peripheral venous blood samples from each patient at T0 and at 10 min (T1) and 30 min (T2) after the reversal. The researchers used QLabs Electrometer for four coagulation items including prothrombin time (PT), activated partial thromboplastin time (aPTT), Thrombin time (TT), and fibrinogen (FIB) and TEGHaemonetics, the kinetics time (K time), α angle, and maximum amplitude (MA). 

20µg CaCl2 and the test reagent were mixed with the blood samples in the TEG-Haemonetics cup. After 30 minutes we received the TEG items values. The amount of blood loss of surgery was recorded. The episodes of bradycardia were recorded. The tracheal tube was extubated when the patient woke up after the surgery.

Statistical Analysis

Statistical analysis was performed with SPSS 19.0 for Windows (IBM Corporation, Armonk, NY, USA). Continuous variables were presented as mean ± standard deviation (SD), and categorical variables were presented as frequency. Serial changes in coagulation profiles were analyzed with a repeated-measures analysis of variance. Pairwise differences in coagulation profiles were analyzed with LASt-test. P-values <0.05 were considered to be statistically significant.

Results 

Data shows that there is no significant difference in the thromboelastogram, aPTT, PT, FIB, or TT measurements at each time point in Group N. The reaction time (R time) and kinetics time (K time) of Group S in T1 were significantly longer than the corresponding times at T0 and T2, and the R times were significantly longer than those in Group N at the same time points (P<0.05). Additionally, in Group S, the aPTT was prolonged in T1 and returned to normal in T2. It also showed that a dose of 2.0 mg/kg sugammadex might prolong the aPTT index and the R time, and K time in the thromboelastography TEG test temporarily. While a dose of neostigmine used to reverse neuromuscular blocks did not affect the coagulation profile.

Conclusion 

Sugammadex provided transient efficacy in prolonging the coagulation parameters while neostigmine did not change the coagulation profile. The researchers also found that maintaining a neuromuscular blockade is a crucial part of anesthesia as it provides a clear surgical field and ensures proper intubation or facilitation of other surgical operations. 

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