The use of rocuronium 20 minutes after sugammadex administration – a case report

Sugammadex has proven to be highly effective for the reversal of moderate or deep neuro¬muscular blockade induced by rocuronium or vecuronium. We present a case where optimal conditions for tracheal intubation were attained using rocuronium (0.5 mg kg-1) 20 minutes (min) after sugammadex had been given. A 59-yr-old female patient, ASA II was scheduled for elective total thyroidectomy. Anesthesia included propofol, fentanyl and rocuronium with sugammadex for neuromuscular blockade reversal, and sevoflurane/air for maintenance. 20 minutes after reversal of neuromuscular blockade with sugammadex the patient returned to operating room for evacuation of cervical hematoma and second general anesthesia was induced with the usage of rocuronium (0.5 mg kg-1) and propofol 2 mg kg-1. Good intubation conditions were obtained after approximately 2 minutes and tracheal intubation was performed uneventfully without any observed desaturation below 96%. Patient returned to post anesthesia care unit after the second procedure, well and fully recovered, and had hospital discharge after 3 days. Our case shows that a short time of twenty minutes between use of sugammadex and rocuronium (0.5 mg kg-1) did not affect intubation conditions, with normal induction doses of propofol. Correspondence to: Humberto S Machado, Department of Anesthesiology, Centro Hospitalar do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal, Tel: +351 935848475; E-mail: [email protected] Received: August 05, 2015; Accepted: August 28, 2015; Published: September 02, 2015 Introduction Sugammadex, a modified γ-cyclodextrin, has proven to be highly effective for the reversal of moderate or deep neuro muscular blockade induced by rocuronium or vecuronium [1]. Sugammadex has revolutionized post-operative care due to its capability to reverse neuromuscular blockade (NMB) safely, rapidly and efficiently. Although uncommon, patients may require anesthesia and tracheal intubation in the immediate postoperative period, soon after successful reversal of rocuronium-induced NMB by sugammadex. One of the options in such situations would be to re-administer rocuronium. We present a case where optimal conditions for tracheal intubation were attained using rocuronium (0.5 mg kg-1) 20 minutes (min) after sugammadex had been given. The patient granted written consent for publication of the manuscript. Materials and methods A 59-yr-old female patient, American Society of Anesthesiologists Physical Status II (hypothyroidism), weight 60 kg, height 160 cm and body mass index 23.4 kg m-2 was scheduled for elective total thyroidectomy. The only drug usually taken was sodium levothyroxine. Laboratory values where within normal limits. Intraoperative monitors included electrocardiogram, non-invasive blood pressure, pulse oxymetry and end-tidal CO2. Temperature was not monitored. Following preoxygenation, general anesthesia was induced with fentanyl 150 μg, propofol 150 mg and rocuronium 50 mg (0.83 mg kg-1) to facilitate tracheal intubation. Anesthesia was maintained with sevoflurane and fentanyl. Neuromuscular function was monitored with NMT MechanoSensor monitor using repetitive train-of-four (TOF) stimulation of the ulnar nerve (NMT Mechanosensor®, Datex Ohmeda Division, Finland). Surgery was uneventful and lasted 79 min. Postoperative analgesia was started during the procedure with tramadol 100 mg and paracetamol 1 g. Postoperative nausea and vomiting prophylaxis was provided with dexamethasone 4 mg and droperidol 0.625 mg. The antibiotic prophylaxis was made with cefazolin 2 g. At the end of the procedure and about 80 min after rocuronium was administered there were two twitches to TOF stimulation. The NMB was antagonized with sugammadex 150 mg (2.5 mg kg-1) and the patient’s trachea was extubated when the TOF reached the value of 1. Almost immediately after the patient being admitted in the post anesthesia care unit (PACU), she developed an expanding neck hematoma without airway compromise and was brought back to the operating room for hematoma evacuation. A second round of general anesthesia was performed 20 min after the previous dose of sugammadex with fentanyl 100 μg, propofol 100 mg and rocuronium 30 mg (0.5 mg kg-1), and the same monitors were applied. Endotracheal intubation was performed approximately 2 minutes and 30 seconds (sec) after rocuronium. Despite the fact that a TOF of 0.6 was still registered, optimal conditions for intubation were encountered and intubation was performed without difficulty. Rocuronium time of administration to maximum effect (onset time) was about 7 min. The second surgery procedure took 34 minutes to be completed. About 40 min after the second dose of rocuronium, TOF was 0.1 and sugammadex 200 mg (3.3 mg kg-1) was again administered. Extubation was carried out after consciousness and regular, spontaneous respirations resumed. Real C (2015) The use of rocuronium 20 minutes after sugammadex administration – a case report Volume 1(4): 118-120 Glob Anesth Perioper Med, 2015 doi: 10.15761/GAPM.1000129 The patient’s remaining hospital course was uneventful and the patient was discharged.