The Takeaway
Patients with Chronic Kidney Disease who were given rocuronium and reversed with sugammadex had a significantly higher risk for acute cardiovascular and pulmonary complications when compared to patients who were administered cisatracurium plus neostigmine
Study Design
- Retrospective observational study
- Propensity-matched study including 20,548 patients with CKD
Physiology Review
- Rocuronium → Metabolized by the liver, excreted in kidneys → Delayed clearance in CKD.
- Cisatracurium → Hofmann elimination (temperature & pH-dependent) → Safer in CKD.
Excerpts
patients who received rocuronium and sugammadex had an increased risk of respiratory failure, acute respiratory distress, hypertensive crisis, heart failure, pleural effusion, and 30-day mortality.
One potential mechanism by which rocuronium buildup could cause adverse effects is through proinflammatory effects. Rocuronium has been shown to increase levels of IgE and C-reactive protein, as well as result in mast cell proliferation and degranulation. Cisatracurium has been shown to induce anti-inflammatory effects
higher circulating levels of rocuronium compared to cisatracurium are needed to induce adequate neuromuscular blockade. For example, doses of rocuronium range from 0.6–1.2mg/kg on average to cause paralysis for 20 to 35 minutes, whereas for cisatracurium, the initial dose typically falls between 0.15 and 0.2 mg/kg to achieve paralysis for 55 to 65 minutes. This difference in dose could contribute to the higher incidence of complications seen with the rocuronium plus sugammadex group
While rocuronium on its own can be eliminated hepatically and through bile, once complexed with sugammadex, it must be eliminated by the kidneys. This leads to rocuronium being in the body for a longer period, and the safety concerns of this are unclear.
Abstract
Background: Neuromuscular blocking agents (NMBAs) play an integral role in modern anesthesia by facilitating endotracheal tube placement, assisting with mechanical ventilation, and creating optimal surgical conditions. However, NMBAs can have deleterious side effects. The purpose of this study was to retrospectively analyze acute complications of 2 pharmacodynamically similar but pharmacokinetically different NMBAs and their respective reversal agents.
Methods: The global research network database, TriNetX, was used to evaluate deidentified patient information from 63 health care organizations. Cohort A was defined as patients aged 18 to 80 years who had chronic kidney disease (CKD) and were administered rocuronium with sugammadex. Cohort B was defined as patients aged 18 to 80 years who had CKD and were administered cisatracurium with neostigmine. Cohorts were propensity matched for age at event, ethnicity, race, sex, and relevant confounding pathologies. All outcomes besides mortality were analyzed from the same day to 1 week after administration of the indexed drug. Mortality was analyzed from the same day to thirty days after administration of the indexed drug.
Results: A total of 95,740 patients with CKD-administered rocuronium with sugammadex were matched with 10,708 patients with CKD-administered cisatracurium with neostigmine. Patients administered rocuronium with sugammadex had a significantly higher associated risk of respiratory failure (risk ratios [RR], 1.98, confidence interval [CI], 1.71-2.29, P < .0001), acute respiratory distress (RR, 2.70, CI, 1.31-5.58, P = .0052), hypertensive crisis (RR, 1.85, CI, 1.37-2.49, P < .0001), heart failure (RR, 1.14, CI, 1.06-1.23, P = .0004), pleural effusion (RR, 1.30, CI, 1.14-1.49, P < .0001), and 30-day mortality (RR, 1.31, CI, 1.10-1.56, P = .0021).
Conclusions: From 2003 to 2023, patients who were administered rocuronium plus sugammadex were at a significantly higher risk for acute cardiovascular and pulmonary complications when compared to patients who were administered cisatracurium plus neostigmine.
Citation
Georgakis NA, DeShazo SJ, Gomez JI, Kinsky MP, Arango D. Risk of Acute Complications with Rocuronium versus Cisatracurium in Patients with Chronic Kidney Disease: A Propensity-Matched Study. Anesth Analg. 2024 Oct 4. doi: 10.1213/ANE.0000000000007188. Epub ahead of print. PMID: 39466651.
