Rocuronium and sugammadex and rapid emerge in day-care surgery.

Sir,

With great interest we read the review on rapid emergence of day-care anaesthesia by Gangadhar and co-workers.[1] In their review the authors describe the controversies in patient selection with comorbidities, preoperative assessment, anaesthesia techniques and some important post-operative issues of discharge criteria in day-care patients. Furthermore, they briefly discuss the drawbacks of the use of neuromuscular blocking agents (NMBAs) and describe that in patients with neuromuscular disorders general anaesthesia with neuromuscular block (NMB) may have prolonged or unpredictable effects and that the use of total intravenous anaesthesia in day-care surgery avoids the risk of residual paralysis.

Neuromuscular management as a part of balanced anaesthesia should consist a choice of an adequate NMBA, objective neuromuscular monitoring, and reversal of NMB. NMBAs agents are key components in modern anaesthesia to facilitate endotracheal intubation and create optimal surgical conditions, day-care surgery is no exception to this.

Depolarizing and various non-depolarizing NMBAs are used in day-care surgery, but the ideal NMBA should have a rapid onset, minimal side-effects, and a rapid and reliable recovery to avoid postoperative residual curarization (PORC) which may lead to interference with day-care process. Rocuronium is well known to have a rapid onset, creates optimal intubation conditions, and has minimal undesirable side-effects. However, the use of NMBAs, including rocuronium, in general is associated with PORC as the physiological consequences of residual paralysis, such as upper-airway collapse, abnormal swallowing, and respiratory impairment, are leading to increased post-operative morbidity and mortality.[23] Reversal of NMB is therefore necessary to avoid PORC.

Sugammadex, the first selective relaxant binding agent, is able to reverse a rocuronium-induced NMB very rapidly and effectively at any level of NMB without signs of PORC or recurarization. The reversal with sugammadex is not only faster, more efficient, and reliable, but also without the well known undesirable side-effects frequently seen with cholinesterase inhibitors as sugammadex has no direct or indirect action on the components of cholinergic transmission. The combination of rocuronium-sugammadex has shown its efficacy and safety in healthy patients, also in more vulnerable patients, like patients with cardiac, pulmonary disease, and in patients with a neuromuscular disorder.[45]

Patients with neuromuscular disorders can be a challenge to anaesthesiologists and although there is difference in aetiology, these patients are more sensitive to non-depolarizing NMBAs which may lead to a prolonged NMB and PORC, and concomitant morbidity and mortality. The combination of rocuronium-sugammadex has been used successfully in patients with neuromuscular disorders like myasthenia gravis.[5] Rocuronium can be used for rapid onset of NMB to facilitate a rapid endotracheal intubation to protect the airway and sugammadex and can provide a rapid and safe reversal thereby reducing the risk of PORC.

One of these advances in anaesthesia is the introduction of sugammadex. The use of rocuronium provides optimal intubation conditions and surgical relaxation and reversal with sugammadex minimizes the risk of PORC and its related morbidity and mortality. Besides it has been demonstrated that intubation without the use of muscle relaxants leads to less optimal intubating conditions and higher risk of damage to the vocal cords and larynx.[6] Thus, the use of muscle relaxants is advisable in day-care anaesthesia. Therefore, when in day-care surgery endotracheal intubation and surgical relaxation is needed neuromuscular management should preferably constist of the use of the combination of rocuronium-sugammadex and careful objective monitoring of NMB. This results in a rapid recovery of NMB without the risk of the dangerous PORC and related morbidity and mortality.