Prolonged neuromuscular blockade and insufficient reversal after sugammadex administration in cesarean section under general anesthesia: a case report

Postoperative residual neuromuscular block in a woman with severe preeclampsia treated with magnesium sulfate and nicardipine: A case report and literature review

Calcium channel blockers and magnesium sulfate are frequently used together, particularly in women with underlying chronic hypertension and pre-eclampsia. A review of the literature showed prolonged neuromuscular blockade after treatment with magnesium sulfate. Since magnesium and calcium have opposite effects on the neuromuscular junctions, muscle weakness may become a postoperative manifestation of magnesium sulfate and calcium antagonist treatment in the obstetric population; however, limited information is available regarding this postulation. Here, we report a case wherein rocuronium activity was markedly prolonged due to pretreatment with magnesium sulfate and nicardipine after general anesthesia during an emergency cesarean delivery.

Unexpected delayed reversal of rocuronium-induced neuromuscular blockade by sugammadex: A case report and review of literature

BACKGROUND

Rocuronium, a nondepolarizing muscle relaxant, is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery. Sugammadex, the selective reversal agent of rocuronium, fully reverses the neuromuscular blockade (NMB) at the end of surgery. Most reports show that sugammadex rapidly achieves a ratio of train-of-four (TOF), a quantitative method of neuromuscular monitoring, of 0.9 which ensures adequate recovery for safe extubation. However, very rare patients with neuromuscular diseases may respond poorly to sugammadex.

CASE SUMMARY

A 69-year-old female presented with abdominal fullness and nausea, and was diagnosed with gastroparesis. She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium (0.7 mg/kg). At the end of surgery, sugammadex 3.6 mg/kg was administered when TOF showed 2 counts. Afterward, the TOF ratio recovered to 0.65 in 30 min. She was awake but could not fully open her eyelids. The tidal volume during spontaneous breathing was low. After additional doses of sugammadex (up to 7.3 mg/kg) in the following 3 h, the TOF ratio was 0.9, and the endotracheal tube was smoothly removed. After excluding possible mechanisms underlying the prolonged recovery course, we speculated our patient may have had an undiagnosed neuromuscular disease, hinted by her involuntary movement of the tongue and mouth. Furthermore, her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.

CONCLUSION

In our case, both prolonged rocuronium-induced NMB and poor response to sugammadex were noted. To optimize the dose of rocuronium, perioperative TOF combined with other neuromuscular monitoring is suggested.

Utility of neuromuscular blockade reversal in the evaluation of acute neurosurgical patients: A retrospective case-series

OBJECTIVE

Sugammadex reversal of neuromuscular blocking agents (NMBAs) is usually performed postoperatively. A scarcity of literature exists exploring sugammadex use for timely neurological examination of neurosurgical patients. NMBAs, like rocuronium, are used in the Emergency Department during intubation and their unpredictable duration of action often impedes timely and accurate assessment of patient neurological status. We aim to explore the role of sugammadex in evaluating patients in need of acute neurosurgical care.

METHODS

Retrospective assessment of patients presenting with traumatic brain injury or intracranial hemorrhage was conducted at our level 1 trauma center. Patients of interest were those for whom sugammadex reversal of rocuronium neuromuscular blockade, from intubating doses, was pursued to ensure timely neurologic assessment. Nine patients were identified for whom GCS pre-/post-sugammadex, rocuronium dosing, elapsed time between rocuronium administration and reversal, and clinical course data were retrieved.

RESULTS

Arrival GCS was 5.2 ± 3.2, with intubation accomplished within 10 ± 2.5 min of presentation. Rocuronium dosing was consistent between patients, average single dose of 1.2 ± 0.3 mg/kg. Lingering neuromuscular blockade ranged from 28 to 132 min (87.3 ± 34.3 min). All patients exhibited a GCS of 3 T upon initial neurosurgical evaluation, prior to reversal. Post-reversal GCS rose to 6.0 T ± 2.2. Sugammadex facilitated more accurate clinical decision making in 8 of 9 patients, including prevention of unnecessary invasive procedures. Two of 9 patients were eventually discharged home or to a rehabilitation facility.

CONCLUSIONS

Rocuronium neuromuscular blockade can linger beyond pharmacokinetic predictions, thus delaying timely and precise neurologic assessment. Our data suggests sugammadex may be a useful addition to the clinician's armamentarium for acute neurologic assessment in the neurosurgical population. Sugammadex may impact clinical decision-making in certain patients and allow for more informed decision-making by families and physicians alike. Prospective studies are needed to definitively assess the impact of sugammadex on outcomes in acute neurosurgical settings.