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Due to the great advantages, it is not possible to imagine current practice in anesthesia without the adminstration of muscle relaxants. For a long time the administration of succinylcholine for rapid sequence induction (RSI) was considered to be the state of the art for patients at risk for aspiration. The favorable characteristics are, however, accompanied by many, sometimes severe side effects. Due to the development of non-depolarizing muscle relaxants, in particular rocuronium in combination with sugammadex, there is the possibility to achieve a profile of action similar to succinylcholine with low side effects. After the introduction of sugammadex onto the market, further substances were conceived, which enable a complete encapsulation of muscle relaxants. Calabadion is a very promising new substance for the antagonization of muscle relaxants, which can antagonize the action of steroid as well as benzylisoquinoline types. In the USA new muscle relaxants are currently being tested, which have a rapid onset and the effect can be reversed by L‑cysteine. One of the most promising substances is gantacurium, which is currently being tested in the USA in phase III trials. It remains to be seen whether these muscle relaxants, which are not yet on the market and drugs for reversal of neuromuscular blockade have the potential to become a real alternative to the combination of rocuronium and sugammadex.

Unlabelled: The required characteristics of neuromuscular blockers for rapid sequence induction (RSI) are clearly defined: nearly immediate effectiveness and short duration of effect. These demands are not only necessary for ideal conditions of quick endotracheal intubation without mask-bag intermediate ventilation but are also essential to enable a quick return to sufficient spontaneous breathing in case of a cannot intubate cannot ventilate situation. Until recently only succinylcholine had these characteristics; however, a considerable number of dangerous side effects and contraindications had to be accepted. In 1996, rocuronium was introduced, which was capable of immediately establishing good intubation conditions similar to succinylcholine. However, the median duration of effect is 45-60 min and it therefore contains a risk if the patient cannot be ventilated and oxygenated. Therefore, rocuronium is considered a good alternative but not a complete substitute for succinylcholine. The introduction of sugammadex in 2008 for quick reversal of rocuronium changed matters. Comparative studies from the past 4 years dealing with rocuronium/sugammadex versus uccinylcholine in RSI showed that rocuronium and sugammadex combined enabled a significantly faster return to sufficient spontaneous ventilation in emergency situations and also proved that the use of rocuronium significantly reduced the degree of desaturation during the interval between injection and ventilation postintubation., Conclusion: rocuronium used in hospital is a very good substitute for succinylcholine as a neuromuscular blocker during RSI as long as sugammadex is at hand for reversal. It remains to be considered that in a situation with severe problems of the airway and breathing, which are the main preclinical indications for intubation, a forward strategy for ventilation of the patient is the only acceptable way in most cases and the return to spontaneous breathing is not an alternative. Therefore, the value of sugammadex and also of succinylcholine is limited for these situations. Additionally, economic factors such as storage conditions for rocuronium and the cost of sugammadex must also be considered.

Background: Aspiration is a feared complication of anesthesia and is accompanied by increased morbidity and mortality. Rapid sequence induction (RSI) describes the preferred procedure to perform endotracheal placement of the tubus in emergency cases of patients with an increased risk of aspiration of gastric contents. For more than 50 years RSI has consisted of the application of suxamethonium for neuromuscular blockade because of its fast onset and ultra short duration. Due to the serious side effects of suxamethonium attempts were made to find better alternative neuromuscular blocking drugs, e.g. rocuronium, to perform RSI., Materials and Methods: In this small clinical series RSI was performed for general anesthesia of ten pregnant women for Caesarean sections using 1.0 mg/kgBW rocuronium for induction and maintaining deep relaxation until the end of surgery. For rapid reversal of the neuromuscular blockade to a train-of-four (TOF) ratio of 0.9, the µ-cyclodextrin sugammadex was administered at the end of surgery. Major and minor side effects, such as cardiac dysrhythmia, anaphylactic reactions, hoarseness and postoperative nausea and vomiting were documented., Conclusions: The combination of rocuronium and sugammadex for RSI combines rapid onset and rapid reversal of neuromuscular blockades with avoidance of serious side effects and very comfortable conditions for intubation in all cases. Minor side effects such as hoarseness, throat discomfort (in up to 30%) and myalgia (10%) for up to 48 h were documented.

Sugammadex can reverse rocuronium-induced muscular relaxation by encapsulation of steroidal muscle relaxants without muscarinergic side effects. Clinical studies show effective dose-dependent reversal of neuromuscular blockades after rocuronium and vecuronium. We report on a patient with deep neuromuscular block at the end of surgery following rapid sequence induction of anesthesia with high-dose rocuronium, who could rapidly be reversed without side effects after adequate i.v. sugammadex application., (© Georg Thieme Verlag Stuttgart · New York.)

Up to now only acetylcholine esterase inhibitors, such as neostigmine, were available as antagonists of residual neuromuscular blocks. Sugammadex is a modified gamma-cyclodextrin that binds rocuronium and chemically similar aminosteroidal muscle relaxants, such as vecuronium. The underlying mechanism of action is new and differs completely from that of acetylcholine esterase inhibitors. This review summarizes data published so far within the framework of the licensing procedure about the efficacy, safety and side-effects of sugammadex and presents potential new anesthesiological concepts using this compound.