Rocuronium und Sugammadex in der Notfallmedizin

Zusammenfassung

Die Anforderungen an ein Muskelrelaxans für die „rapid sequence induction“ (RSI) liegen in einer möglichst kurzen Anschlagszeit und möglichst kurzen Wirkdauer. Diese Eigenschaften bot bis vor wenigen Jahren ausschließlich Succinylcholin. Das 1996 eingeführte Muskelrelaxans Rocuronium kann zwar in einem ähnlich kurzen Zeitintervall annähernd gleich gute Intubationsbedingungen schaffen wie Succinylcholin, birgt jedoch mit einer mittleren Wirkdauer von 45–60 min ein Risiko, falls der Patient nicht beatmet werden kann. Um die relaxierende Wirkung schnell aufzuheben, kann Sugammadex zur Reversierung bereitgehalten werden. Damit eignet sich Rocuronium innerklinisch sehr gut als Alternative für Succinylcholin bei der RSI. Auch in der präklinischen Notfallmedizin könnte diese Kombination eine gute Alternative zu Succinylcholin darstellen; Vor- und Nachteile werden im vorliegenden Beitrag diskutiert.

Abstract

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.