Anesthesia
Conditions
Brief summary
The primary purpose of this study is to compare the incidence of residual neuromuscular blockade at the time of tracheal extubation after reversal of rocuronium bromide-induced neuromuscular blockade by 4 mg/kg sugammadex with that of 50 µg/kg neostigmine. Residual neuromuscular blockade is defined as the fourth twitch to first twitch (T4/T1) ratio of \< 0.90.
Detailed description
Undetected residual neuromuscular blockade is common in the post-anesthesia care unit (PACU). In fact, 16%-42% of patients receiving intermediate-acting muscle relaxants in the operating room have T4/T1 ratios \<0.7-0.8 in the PACU. Respiratory and pharyngeal muscle function can be adversely affected during minimal neuromuscular blockade. Studies in awake volunteers and surgical patients have demonstrated that T4/T1 ratios of 0.7 - 0.9 are associated with impaired airway protective reflexes, upper airway obstruction, a decreased hypoxic ventilatory response, and post-operative hypoxemia. The incidence and severity of residual neuromuscular blockade at the time of tracheal extubation will be evaluated to determine how these influence the length of stay in the operating room and PACU.
Interventions
DRUGSugammadex
Participants received 4 mg/kg sugammadex at 1-2 Post Tetanic Counts (PTCs) or better after the last dose of rocuronium bromide.
DRUGNeostigmine
Participants received 50 µg/kg neostigmine combined with 10 µg/kg glycopyrrolate after the last dose of rocuronium bromide as per standard of care.
DRUGRocuronium
Participants received a single intubation bolus dose of 0.6 mg/kg rocuronium bromide, followed if necessary to maintain neuromuscular blockade by one or more single bolus dose(s) of 0.15 mg/kg rocuronium bromide.
Sponsors
Merck Sharp & Dohme LLC
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
* male or females who are \>= 18 and \<= 65 years of age * classified by the American Society of Anesthesiologists (ASA) as Class 1 or 2 or 3; * Body Mass Index (BMI) of \<35 kg/m\^2; * is scheduled to undergo an elective open abdominal surgical procedure under general anesthesia requiring neuromuscular relaxation using rocuronium bromide (maintenance of neuromuscular blockade if required) for endotracheal intubation and requiring neuromuscular blockade reversal; * is scheduled to undergo a surgical procedure in a position that does not interfere with the use of TOF-Watch® SX; * is scheduled to undergo an elective open abdominal procedure expected to last \<=4 hours (from start of skin incision to end of last stitch of the skin); * have given written informed consent.
Exclusion criteria
* participants for whom a difficult intubation is expected because of anatomical malformations; * is known or suspected to have neuromuscular disorders that may impair neuromuscular blockade; * is known or suspected to have significant renal dysfunction (e.g., creatinine clearance \< 30 mL/min) ; * is known or suspected to have significant hepatic dysfunction; * is known or suspected to have a (family) history of malignant hyperthermia; * is known or suspected to have an allergy to opioids, muscle relaxants or other medications used during general anesthesia; * participants for whom the use of neostigmine and/or glycopyrrolate may be contraindicated; * participants for whom a pre-established need for postoperative intensive care admission is expected; * pregnant or breast-feeding females; * have participated in a previous sugammadex clinical trial;
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Residual Neuromuscular Blockade Evidenced by T4/T1 Ratio at the Time of Tracheal Extubation | Up to the first 24 hours after tracheal extubation | Neuromuscular function was monitored by applying repetitive Train-Of-Four (TOF) electrical stimulations to the ulnar nerve every 15 seconds, and assessing twitch response at the adductor pollicis muscle with a TOF-Watch® SX. The magnitudes (heights) of the first and fourth twitches (T1 and T4) were used to calculate the T4/T1 ratio, where a higher T4/T1 ratio indicates a greater recovery from neuromuscular blockade, with a value of 1.0 indicating complete recovery. After anesthesia, when neuromuscular function was expected to be fully recovered, tracheal extubation was performed, at which time the T4/T1 ratio was measured, with any missing recovery times imputed. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With Post-operative Complications | Up to 7 days after surgery | Post-operative complications include any of the following: procedural pain, nausea, vomiting, incision-site pain, constipation, headache, pyrexia, dizziness and pruritus. |
| Number of Participants With Evidence of Possible Interaction of Sugammadex With Endogenous Compounds or Exogenous Compounds Other Than Rocuronium Bromide | Up to 7 days after surgery | Evidence of adverse events due to a possible interaction of sugammadex with exogenous compounds or endogenous compounds other than rocuronium was recorded. |
| Time From Start of Administration of Investigational Medicinal Product (IMP) to Recovery of the T4/T1 Ratio to 0.9 | Up to 1 hour after treatment | Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.9, with imputed data included. |
| Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.8 | Up to 1 hour after treatment | Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.8, with imputed data included. |
| Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.7 | Up to 1 hour after treatment | Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.7, with imputed data included. |
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Sugammadex 4 mg/kg sugammadex | 51 |
| Neostigmine 50 µg/kg neostigmine | 49 |
| Total | 100 |
Baseline characteristics
| Characteristic | Sugammadex | Neostigmine | Total |
|---|---|---|---|
| Age, Continuous | 49 years STANDARD_DEVIATION 11 | 52 years STANDARD_DEVIATION 9 | 51 years STANDARD_DEVIATION 10 |
| Sex: Female, Male Female | 29 Participants | 31 Participants | 60 Participants |
| Sex: Female, Male Male | 22 Participants | 18 Participants | 40 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 51 / 51 | 49 / 49 |
| serious Total, serious adverse events | 4 / 51 | 6 / 49 |
Outcome results
Primary
Residual Neuromuscular Blockade Evidenced by T4/T1 Ratio at the Time of Tracheal Extubation
Neuromuscular function was monitored by applying repetitive Train-Of-Four (TOF) electrical stimulations to the ulnar nerve every 15 seconds, and assessing twitch response at the adductor pollicis muscle with a TOF-Watch® SX. The magnitudes (heights) of the first and fourth twitches (T1 and T4) were used to calculate the T4/T1 ratio, where a higher T4/T1 ratio indicates a greater recovery from neuromuscular blockade, with a value of 1.0 indicating complete recovery. After anesthesia, when neuromuscular function was expected to be fully recovered, tracheal extubation was performed, at which time the T4/T1 ratio was measured, with any missing recovery times imputed.
Time frame: Up to the first 24 hours after tracheal extubation
Population: Intent to treat (ITT) group consisting of all randomized participants who were treated with sugammadex or neostigmine and had at least one efficacy measurement. Three participants treated with neostigmine did not have at least one efficacy measurement, and hence were excluded from the analysis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Sugammadex | Residual Neuromuscular Blockade Evidenced by T4/T1 Ratio at the Time of Tracheal Extubation | 1.02 T4/T1 Ratio | Standard Deviation 0.15 |
| Neostigmine | Residual Neuromuscular Blockade Evidenced by T4/T1 Ratio at the Time of Tracheal Extubation | 0.78 T4/T1 Ratio | Standard Deviation 0.24 |
Secondary
Number of Participants With Evidence of Possible Interaction of Sugammadex With Endogenous Compounds or Exogenous Compounds Other Than Rocuronium Bromide
Evidence of adverse events due to a possible interaction of sugammadex with exogenous compounds or endogenous compounds other than rocuronium was recorded.
Time frame: Up to 7 days after surgery
Population: All subjects treated (AST) group consisting of randomized participants who were treated with sugammadex or neostigmine
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Sugammadex | Number of Participants With Evidence of Possible Interaction of Sugammadex With Endogenous Compounds or Exogenous Compounds Other Than Rocuronium Bromide | 0 participants |
| Neostigmine | Number of Participants With Evidence of Possible Interaction of Sugammadex With Endogenous Compounds or Exogenous Compounds Other Than Rocuronium Bromide | 0 participants |
Secondary
Number of Participants With Post-operative Complications
Post-operative complications include any of the following: procedural pain, nausea, vomiting, incision-site pain, constipation, headache, pyrexia, dizziness and pruritus.
Time frame: Up to 7 days after surgery
Population: All subjects treated (AST) group consisting of randomized participants who were treated with sugammadex or neostigmine
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Sugammadex | Number of Participants With Post-operative Complications | 51 participants |
| Neostigmine | Number of Participants With Post-operative Complications | 49 participants |
Secondary
Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.7
Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.7, with imputed data included.
Time frame: Up to 1 hour after treatment
Population: ITT group consisting of all randomized participants who were treated with sugammadex or neostigmine and had at least one efficacy measurement. Three participants treated with neostigmine did not have at least one efficacy measurement, and hence were excluded from the analysis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Sugammadex | Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.7 | 1.60 Minutes | Standard Deviation 0.72 |
| Neostigmine | Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.7 | 4.98 Minutes | Standard Deviation 4.98 |
Secondary
Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.8
Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.8, with imputed data included.
Time frame: Up to 1 hour after treatment
Population: ITT group consisting of all randomized participants who were treated with sugammadex or neostigmine and had at least one efficacy measurement. Three participants treated with neostigmine did not have at least one efficacy measurement, and hence were excluded from the analysis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Sugammadex | Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.8 | 1.87 Minutes | Standard Deviation 0.82 |
| Neostigmine | Time From Start of Administration of IMP to Recovery of the T4/T1 Ratio to 0.8 | 6.18 Minutes | Standard Deviation 5.73 |
Secondary
Time From Start of Administration of Investigational Medicinal Product (IMP) to Recovery of the T4/T1 Ratio to 0.9
Neuromuscular function was monitored by applying repetitive TOF electrical stimulations to the ulnar nerve every 15 seconds, and assessing T1 and T4 twitch response at the adductor pollicis muscle with a TOF-Watch® SX. Nerve stimulation was continued until the T4/T1 ratio, which indicates the extent of recovery from neuromuscular blockade, achieved a ratio of 0.9, with imputed data included.
Time frame: Up to 1 hour after treatment
Population: ITT group consisting of all randomized participants who were treated with sugammadex or neostigmine and had at least one efficacy measurement. Three participants treated with neostigmine did not have at least one efficacy measurement, and hence were excluded from the analysis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Sugammadex | Time From Start of Administration of Investigational Medicinal Product (IMP) to Recovery of the T4/T1 Ratio to 0.9 | 2.53 Minutes | Standard Deviation 1.18 |
| Neostigmine | Time From Start of Administration of Investigational Medicinal Product (IMP) to Recovery of the T4/T1 Ratio to 0.9 | 7.95 Minutes | Standard Deviation 6.92 |