Sugamma.....something or other

The only reason I had heard of this prior to the SAQs in April was because one of my previous bosses, who I did regular lists with as an SHO, was fascinated by it and would discuss it regularly - amazing to think that even a couple of years later those 'discussions' would be useful to me! So what's all the fuss about?

Sugammadex (AKA 'The Molecular Condom' as described by gaussling)

Company

- Organon

Codenames

- Org 25969

- Modified γ-cyclodextrin

Structure

- Lipophilic core and hydrophilic periphery enabling the molecule to engulf and bind lipophilic molecules while maintaining aqueous solubility (8 negatively-charged thio ether extensions are situated at the 6th carbon position of each ring, thus extending the cavity size allowing greater encapsulation of the rocuronium molecule).

Mechanism of action

- The first selective relaxant binding agent - it forms very tight water-soluble complexes at a 1:1 ratio with aminosteroidal neuromuscular blocking drugs e.g. rocuronium, preventing them from binding to the ACh molecule and exerting muscular relaxation.

Uses

- Reversal of profound neuromuscular blockade without the need to inhibit acetylcholinesterase i.e. eliminating the autonomic/CVS effects of the more traditional acetylcholinesterase inhibitors(neostigmine) and the concomitant antimuscarinics (glycopyrrolate) that must be also administered. (Phase 3 trials)

- Elimination of the incomplete reversal experienced with use of traditional acetylcholinesterase inhibitors.

- Also, the rapid onset (and now reversal by Sugammadex) of action of rocuronium could make it a safer alternative to suxamethonium in rapid sequence inductions.

Pharmacodynamics/Pharmacokinetics

- No effects on other receptor systems in body i.e. biologically inactive

- Does not bind to plasma protein
- No renal excretion

Is it Pimms o'Clock yet?

Exam Intelligence has a spanking sparkly new website up and running now - if you haven't already checked it out, it's definitely worth bookmarking for the breadth and sheer effort put in by Adam in providing valuable information to pass this exam.

My website skills are minimal but what I will continue to try and achieve is a regular update of both my revision progress (poor at present - anyone else feeling a bit lethargic in the hot weather?) and useful information, links etc.

Someone emailed me recently asking for advice about SAQs. RCOA have just produced their report on the April SAQ paper. This, in my opinion, is a great revision aid alone. It gives a unique insight into what the examiners expect from the SAQ answers.

Here are some thoughts:

-"Despite the questions being printed in the answer books, a small number of candidates failed to
answer all the questions." You will fail if you don't answer all the questions - that is expensive and time-consuming!!

-"Questions: 3 (air embolus), 4 (paediatric fluid balance) and 7 (neuromuscular blocking reversal) caused the most problems to candidates" Something to think about for next time maybe?

-"Question1 (paravertebral space) was generally well done but few candidates did a really good
anatomy section. The diagrams were especially poor – examiners assumed this was due to lack of knowledge." A diagram (even simple but well labelled) will get you a lot more marks and take less time than a block of prose.

-"Whilst the web sites related to the FRCA are mostly useful and enjoyable, there are occasional
moments when it is disappointing to see unhelpful advice being offered. This particularly relates to generic answers and, for example, it is rarely the case that a whole ‘pre, per and post op’ structure would facilitate a good answer on the SAQ paper.... It cannot be emphasised enough that the answer provided to the examiners is less than a page and is focused completely to the question." This is a fair point: as my experience of writing SAQs has grown, I have realised that there is no time for a complete generic answer. Whilst it can give you structure, usually in a viva, in the SAQs the answer has to be much more specific. In theory, you should be able to pass the question writing between one to two A4 sides of concise and relevant bullet points/labelled-diagrams. Paragraphs are unsightly, difficult to mark, and a waste of time that you do not have.