Different Reversal Agents in Pediatric Day-case Cancer Surgery

Study Overview
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Brief Summary
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The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockers in pediatric patients undergoing outpatient surgical procedures.

Detailed Description
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Postoperative residual curarization (PORC) a residual duration of action of muscle relaxants beyond the end of the operation in postoperative patients is a succession of the presence of blocked nicotinic receptors. Even in observationally asymptomatic patients, 60-70% of these receptors can be still blocked. PORC can cause delayed recovery, hypoxia, metabolic derangement and rarely death. Cholinesterase inhibitors are traditionally used for reversal of neuromuscular blockade (NMB). Among these agents neostigmine is the most potent and selective one. Cholinesterase inhibitors have multisystemic side effects. Since these agents are not selective to nicotinic receptors and also stimulate the muscarinic system, there can be quite a few serious adverse effects as follows: Bradycardia, QT lengthening, bronchoconstriction, hypersalivation and increased motility. To avoid these effects, concomitant anticholinergic agents, such as atropine or glycopyrolate, are administered to the patient. The incidence of PORC is still high with the prevalence of a train-of-four (TOF) ratio of less than 0.9 found in the postoperative recovery unit. Recent studies have been able to link even low levels of residual paralysis (TOF ratio <0.9) with significant impairment of pharyngeal muscle function, hypoxic ventilatory drive and decreased respiratory function in the immediate postoperative period. Despite the knowledge of such side effects, and despite the introduction of various new neuromuscular blocking agents (NMBA) such as rocuronium or mivacurium over the last 15 years, no significant reduction in the incidence of residual neuromuscular blockade has so far been observable. Today, sugammadex is an alternative to the decurarization procedure, which was traditionally executed with cholinesterase inhibitors. Sugammadex a γ-cyclodextrin with a high affinity to rocuronium and other aminosteroidal NMBA that allows the rapid and complete reversal of especially rocuronium-induced neuromuscular blockade, has raised hopes to overcome the problem of residual neuromuscular blockade. Sugammadex is proved to be a safe and superior agent in NMB reversal compared to neostigmine in adults. PORC and the muscarinic side effects are not anticipated when using sugammadex,. Also, due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, have the potential to displace succinylcholine as the gold standard muscle relaxant for rapid sequence induction. The rudimentary neuromuscular junction, the variability of fibrin fibers, the differences in drug distribution and body volume in children change their neuromuscular conduction. These factors can cause prolonged recovery and increased risk of PORC. However, there is few studies in the literature concerning sugammadex administration in pediatric patients.

Official Title
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Sugammadex Versus Neostigmine in Pediatric Day-case Cancer Surgery

Conditions
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Post-operative Residual Curarization

Intervention / Treatment
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* Drug: Sugammadex Injection [Bridion]
* Drug: Neostigmine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥2 years and < 18 years. American society of anesthesiologists (ASA) status 1-3. patients undergoing outpatient procedures Exclusion Criteria: Known drug hypersensitivity.- History of renal or hepatic failure. Diseases of the neuromuscular junction. history of malignant hyperthermia.

Ages Eligible for Study
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Minimum Age: 2 Years
Maximum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Group S<br>Sugammadex for reversal of steroidal neuromuscular blockers, intravenous injection ,2mg/kg | Drug: Sugammadex Injection [Bridion]<br>* Reversal of neuromuscular blockers<br>|
| Active Comparator: Group N<br>Reversal of neuromuscular blockers, iv injection, 0.05 mg/kg | Drug: Neostigmine<br>* Reversal of neuromuscular blockers<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recovery time | time from neostigmine or sugammadex administration until recovery of the TOF ratio to 0.9% | time from reversal administration until TOF ratio reaches0.9%, ranging from 1 to 2.5 minutes, measured withThe train-of-four (TOF) equipment working with the nerve-muscle acceleromyometry principle (TOF Draeger Medical Systems, Inc.16 Electronic Avenue, | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| extubation time | time from neuromuscular blocker administration to extubation | time from muscle relaxant administration until extubation,extubation will be performed based on clinical criteria extubation timeis estimated to range from 50 to 55 minutes |