Implementation of a Sugammadex Clinical Practice Guideline

Abstract

Background: Residual paralysis is the presence of muscle weakness postoperatively and leads to increased rates of respiratory complications. In a study of more than 200,000 cases where paralytics were administered, 64% of cardiac arrests were related to airway complications secondary to residual paralysis in the post anesthesia care unit. Of these cases, there was a mortality rate of 29%. A medium-sized hospital in Maryland reported postoperative complications associated with residual paralysis. It was identified that sugammadex was used 103 times over an 8-month period due to failed neostigmine reversal resulting in low tidal volumes and muscle weakness. Currently there is no guideline for the use of sugammadex at this institution. Sugammadex offers a definitive solution to the safety profile found lacking with neostigmine. If the use of neostigmine was replaced by sugammadex administration, these negative consequences would be abated—especially in high-risk populations. High risk populations include: can’t intubate, can’t ventilate situations, deep blockade, elderly, morbidly obese, pulmonary disease and neuromuscular disease. The focus of this doctorate project was to develop a Clinical Practice Guideline for the use of sugammadex in the prevention of residual paralysis for high risk patients. Intervention: A residual paralysis problem was identified. The solution was to develop a guideline for the use of sugammadex. A literature review was conducted for supporting evidence for the guideline. The project proposal was then submitted for a Non-Human Subjects Research determination. The guideline was revised and assessed using the gold standard guideline evaluation tool. The final guideline was presented to the anesthesia department. Practitioner Feedback Questionnaires were distributed to those in attendance. All data collected from the evaluation phase was then synthesized, analyzed, and evaluated. The final manuscript was submitted for review. Results: The results of the Appraisal of Guidelines for Research and Evaluation II Tool were 100% across the six domains and for overall assessment. Each appraiser had a total score of 161/161 and an overall of 322/322. The project leaders received 100% return rate of the Practitioner Feedback Questionnaires (n=22). In reviewing the data, majority of anesthesia providers felt the guideline should be approved for practice (95.5%), they would use it in their own practice (100%) and they would apply the recommendations to their patients (100%). This analysis demonstrated buy-in and acceptance of the guideline by the department. Conclusion: Study results indicate sugammadex compared to neostigmine is safe and effective in the reversal of muscle relaxants and reduces adverse events—especially in high-risk populations. The ability of sugammadex to rapidly reverse blockade can play a critical role in high-risk patients. A guideline of sugammadex use will help decrease postoperative complications at the local hospital. The guideline, the sugammadex algorithm and patient education handout will be incorporated into provider daily practice and placed in all operating rooms as a result.