Sugammadex: Good Drugs Do Not Replace Good Clinical Practice

To the Editor: Although we agree with both Miller (1) and Naguib (2) that sugammadex is an exciting new drug with complex binding properties that might serve as an example of a new elimination pathway for neuromuscular blocking agents and possibly other drugs, we disagree with the overall impact this drug will have on our clinical practice. First, although Naguib (2) argues that objective monitoring of neuromuscular blockade may no longer be needed, objective monitoring should still be routine for all patients (3). It helps to more precisely administer neuromuscular blocking agents during surgery and establishes an exact value of neuromuscular transmission at the end of surgery. Subjective monitoring methods will still be very unreliable, with or without sugammadex. In fact, we should actually make our objective monitoring methods not just routine but increase the detailed use of them (4). It seems that in the recent enthusiasm about the arrival of sugammadex, we could forget the progress made during the last 15 yr in terms of monitoring methods and our understanding of how different muscles behave. The abandoning of objective, quantitative monitoring methods would mean that a good drug replaces good clinical practice. Second, it would be very surprising if sugammadex would not only provide a completely new elimination mechanism but, in addition, be completely free of side effects. We agree with Dr. Miller's (1) assessment that many more patients are needed to show the real risk-benefit profile. Third, a first problem has already been described (5): the use of a sugammadex dose <2 mg/kg can lead to a rebound of rocuronium's effect with subsequent muscle relaxation. Fourth, we agree with Dr. Miller's (1) assessment of the short-comings of the current reversal drugs, with neostigmine being the most widely used drug. However, neostigmine and glycopyrrolate, when used in a proper dose, are associated with relatively minor side effects such as dry mouth. Finally, we question a new strategy of increasing the degree of neuromuscular blockade because of the availability of sugammadex. One of the many positive developments in the last 15 yr is the reduction of the use of neuromuscular blocking agents in our daily practice. This was possible by a better understanding of their use, the introduction of more short-acting neuromuscular blocking agents, the introduction of laryngeal mask airways without the need to facilitate insertion with neuromuscular blockade, the use of powerful, but short acting opioids and volatile anesthetics, such as remifentanil or sevoflurane and desflurane and the introduction of continuous regional and local anesthetic techniques. There is no best evidence showing that profound neuromuscular blockade improves outcome. In conclusion, we agree that sugammadex will be an important addition to clinical practice. In combination with rocuronium, it may allow for elimination of succinylcholine for rapid sequence inductions or situations of possible difficult intubations. It might also be helpful when surgery is extremely short or our timing, dose, or time of application of neuromuscular blocking agents was not adequate. However, it should in no way replace good clinical practice. Thomas M. Hemmerling, MD, DEAA Department of Anesthesiology McGill University Montreal, Canada [email protected] Goetz Geldner, MD, DEAA Department of Anesthesiology Klinikum Ludwigsburg Germany

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