Hypotension and Bradycardia with Sugammadex Administration

Abstract

Abstract

Introduction: In 2015 the Food and Drug Administration (FDA) approved sugammadex (Bridion) for use as a reversal agent for nondepolarizing muscle relaxants.¹ The drug works by binding free molecules of the muscle relaxant, specifically rocuronium and vecuronium, resulting in a rapid offset of neuromuscular blockade.² When compared to the use of Neostigmine and Glycopyrrolate for reversal, sugammadex has shown to be faster and able to provide reversal for deeper blockades.² However, this new drug is not without risks. Several case reports have been published describing profound hypotension and bradycardia after administration of sugammadex, with some cases progressing to asystole and death.^1,3,4,5,6,7 This case report describes a patient who experienced a significant drop in cardiac output after being reversed with sugammadex.

Case Description: The patient being reviewed is a 63-year-old caucasian female who underwent general anesthesia for a laparoscopic cholecystectomy. Her medical history was significant current cigarette use, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), anxiety, depression and chronic pain. Her labs the day of surgery were within normal limits. The patient took her 100 mg of Atenolol at 0430 the morning of the surgery to remain current on her beta-blocker therapy. The patient’s initial blood pressure in the preoperative holding area was 103/75 mmHg with a heart rate of 69 beats per minute (bpm). Throughout her operative course, her blood pressure was treated to remain within 20% of this baseline. Her heart rate remained between 63-76 bpm throughout the procedure. The patient received 30 mg of rocuronium at the beginning of the procedure for relaxation. At the end of the case, 200mg of sugammadex (2.6 mg/kg) was given to reverse a train of four of 2/4 with significant fade. After the administration of sugammadex her heart rate dropped as low as 44 bpm and her blood pressure decreased as low as 48/33 mmHg. The patient was treated with 0.2 mg of glycopyrrolate and 20 mg of ephedrine. The patient responded are heart rate returned to 77 bpm and blood pressure increased to 109/77 mmHg.

Discussion and conclusions: There are several factors that could have contributed to this patient’s decline in cardiac output. The rapid decrease in heart rate and blood pressure is similar to other case reports of sugammadex reactions, however other factors in this case cannot be ruled out as potential causes for the event. It is important to investigate potential drug reactions as sugammadex is gaining popularity for the reversal of nondepolarizing muscular blockade. Understanding the risks of this drug is important when deciding whether or not to administer it to certain patient populations.

References

1. Mirza, K., et al. (2020). "Sugammadex-Associated Hypotension, Bradycardia, Asystole, and Death." Case Reports in Anesthesiology 2020: 8767195.

       2. Cada DJ, Levien TL, Baker DE. Sugammadex. Hosp Pharm. 2016;51(7):585-596. doi:10.1310/hpj5107-585

       3. Fierro C, Medoro A, Mignogna D, Porcile C, Ciampi S, Foderà E, Flocco R, Russo C, Martucci G. Severe Hypotension, Bradycardia and Asystole after Sugammadex Administration in an Elderly Patient. Medicina. 2021;        57(1):79. https://doi.org/10.3390/medicina57010079

       4. M. Hunter, M. Naguib,Sugammadex-induced bradycardia and asystole: how great is the risk?,British Journal of Anaesthesia,Volume 121, Issue 1,2018,Pages 8-12,ISSN 0007-0912,https://doi.org/10.1016/j.bja.2018.03.003.

       5. Bilgi, A. Demirhan, A. Akkaya, U.Y. Tekelioglu, H. Kocoglu. Sugammadex associated persistent bradycardia. Int J Med Sci Public Health, 3 (2015), pp. 372-374

       6. Saito, I., Osaka, Y. & Shimada, M. Transient third-degree AV block following sugammadex. J Anesth29, 641 (2015). https://doi.org/10.1007/s00540-015-1980-5

       7. Choi Y, Park J, Kim S, Jung K. Sugammadex associated profound bradycardia and sustained hypotension in patient with the slow recovery of neuromuscular blockade - A case report -. Anesth Pain Med. 2019;14(3):299-304. doi:10.17085/apm.2019.14.3.299

 8. https://fis.fda.gov/sense/app/d10be6bb-494e-4cd2-82e4-0135608ddc13/sheet/45beeb74-30ab-46be-8267-5756582633b4/state/analysis