الفهرس 
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Abstract
Muscle relaxation can be achieved by direct central nervous system depression with volatile inhalation anesthetics or by neural blockade either at the peripheral nerve or with drugs that act at the neuromuscular junction. Neuromuscular blocking drugs (NMBDs) are essential in anesthetic practice to facilitate endotracheal intubation and provide optimum surgical conditions for a variety of procedures.
Acetylcholine (Ach), the neurotransmitter at the neuromuscular junction, is released from presynaptic nerve endings on passage of a nerve impulse (an action potential) down the axon to the nerve terminal. The neurotransmitter is synthesized from choline and acetylco enzyme A by the enzyme choline acetyltransferase and stored in vesicles in the nerve terminal. The action potential depolarizes the nerve terminal to release the neurotransmitter; entry of Ca 2+ ions into the nerve terminal is a necessary part of this process, promoting further acetylcholine release. On the arrival of an action potential, the storage vesicles are transferred to the active zones on the edge of the axonal membrane, where they fuse with the terminal wall to release the acetylcholine.
Acetylcholinesterase inhibitors are frequently used to reverse the effects of nondepolarizing neuromuscular blockers. However, acetylcholinesterase inhibitors have several disadvantages, such as development of residual blockade and hemodynamic adverse effects.
These agents are used in clinical practice to inhibit the action of acetylcholinesterase at the neuromuscular junction, thus prolonging the half- life of acetylcholine and potentiating its effect, especially in the presence of residual amounts of non-depolarizing muscle relaxant at the end of surgery. The most commonly used anticholinesterase during anesthesia is neostigmine, but edrophonium and pyridostigmine are also available
The usual dose of Neostigmine is of 0.04-0.08 mg/kg, in combination with either atropine 0.015 mg/ kg or glycopyrrolate 0.01 mg/ kg. It takes at least 2 min to have an initial effect, and recovery from neuro-muscular block is maximally enhanced by 10 min. It is excreted largely unchanged through the kidney and has a half-life of about 45 min. It produces bradycardia, salivation, sweating, bronchospasm, increased intestinal motility and blurred vision due to potentiation of Ach effects at muscarinic receptors.
Sugmmadex was discovered by Anton Bom a pharmaceutical chemist and presented in the 7th International Neuromuscular Meeting in Belfast.
Sugammadex is a selective relaxant binding agent, Sugammadex is a potent, fast, and safe reversal agent for aminosteroid muscle relaxants and has the potential to change anesthesia practice. It has revolutionized the way anesthe¬siologists think about drug reversal and pharmaceutical dose−response control. It also has the potential to eliminate succinylcholine from anesthesia practice. However, the price of the drug and the missing evidence of cost efficacy has led to a limited use in clinical anesthesia so far.
Sugammadex, a modified 𝛾-cyclodextrin, has been introduced into clinical practice as a selective relaxant binding agent for antagonism of prolonged rocuronium-induced neuromuscular block during general anesthesia.
The present study was done on sixty patients, categorized into 4 groups, each consisting of 15 patients with three of these groups receiving a single intravenous dose of sugmmadex. The first group received a dose of 1mg/kg, the second received a dose of 2m/kg and lastly the third received a dose of 4mg/kg, meanwhile the 4th group received a dose of 0.04mg/kg of Neostigmine with 0.02mg/kg atropine.
The results of this study showed a statistically significant difference regarding the reversal time which was faster with sugammadex than with neostigmine following rocuronium-induced blockade.
TOF ratio > 0.9 were between the 4 groups with a mean recovery time of 18.25 min with neostigmine which is significantly longer than reversal with sugammadex of the doses 1.0 mg/kg (3.48 min), 2.0 mg/kg (2.49min) or 4.0 mg/kg (1.21 min).
Patients were also assessed for clinical signs of residual paralysis using signs of general weakness, and head-lift test (sustained head-lift for 5 seconds). The P value results, comparing the 4 groups together as well as the Post hoc analysis between the “N” group with the other “S” groups was >0.05 i.e., of no clinical significance.
Post-operative nausea and vomiting (PONV) are among the complications patients most fear and may delay discharge thus increasing hospital costs. Mechanisms behind PONV are multifactorial, but the incidence is distinctly affected by choice of anesthetic medications.
In the present study, no differences in drug-related adverse effects (nausea, vomiting, and laryngospasm) were observed between sugammadex different doses and neostigmine (P-value >0.05).
In the current study, the hemodynamic parameters included the heart rate and the MAP, on comparing the “N” group with the other 3 “S” groups at 30 minutes, there was only a highly statistical significance between the “N” group and “S3” group (P value = 0.001) but no statistical significance between the “N” group and the “S1” group which had a P value of 0.282 and “S2” group with a P value of 0.093.
Mean arterial pressure increased in neostigmine group 2min, 10 min after the medication. Sugammadex group had lower heart rate when compared to neostigmine group.
There were increases on hemodynamic parameters in both groups, this increase was more prominent in patients receiving neostigmine. Therefore, we suggest that sugammadex might be a safety option to reverse neuromuscular blockage in cardiac patients undergoing noncardiac surgery.
The present study showed that at 30 minutes after drug administration, there was a mild increase in PT and PTT in S2 group with moderate increase in S4 group that return to normal values again at 120 minutes.
It’s important to mention that an important limitation in this study was that patients on anticoagulants or with known coagulopathies were excluded while Coagulation parameters should be carefully monitored in these types of patients.