Wang HC, Lu CW, Lin TY, Chang YY. Unexpected delayed reversal of rocuronium-induced neuromuscular blockade by sugammadex: A case report and review of literature. World J Clin Cases 2022; 10(35): 13138-13145 [PMID: 36569003 DOI: 10.12998/wjcc.v10.i35.13138]
Corresponding Author of This Article
Ya-Ying Chang, PhD, Professor, Department of Anesthesiology, Far-Eastern Memorial Hospital, No. 21 Sec. 2 Nanya S. Road, Banqiao District, New Taipei City 220, Taiwan. gingerdoll@gmail.com
Research Domain of This Article
Anesthesiology
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Hao-Chen Wang, Cheng-Wei Lu, Tzu-Yu Lin, Ya-Ying Chang, Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
Cheng-Wei Lu, Tzu-Yu Lin, Department of Mechanical Engineering, Yuan Ze University, Chung-Li 320, Taiwan
Ya-Ying Chang, International Program in Engineering for Bachelor, Yuan Ze University, Chung-Li 320, Taiwan
Author contributions: Wang HC and Lu CW contributed to manuscript writing and editing, and data collection; Wang HC and Lin TY performed the general anesthesia; Chang YY contributed to conceptualization and supervision; All authors have read and approved the final manuscript.
Supported byFar-Eastern Memorial Hospital, No. FEMH-2022-C-057.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ya-Ying Chang, PhD, Professor, Department of Anesthesiology, Far-Eastern Memorial Hospital, No. 21 Sec. 2 Nanya S. Road, Banqiao District, New Taipei City 220, Taiwan. gingerdoll@gmail.com
Received: November 3, 2022 Peer-review started: November 3, 2022 First decision: November 14, 2022 Revised: November 16, 2022 Accepted: November 18, 2022 Article in press: November 18, 2022 Published online: December 16, 2022
Abstract
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.
Core Tip: Sugammadex reverses rocuronium-induced neuromuscular blocking effect, providing full and rapid recovery from general anesthesia. However, in rare cases, patients with neuromuscular diseases may response poorly to sugammadex. In our patient, suspected neuromuscular disease, renal insufficiency, and a history of delayed recovery from general anesthesia may indicate a delayed recovery course. An optimal dose of rocuronium adjusted by train-of-four neuromuscular monitoring throughout the surgery helps reduce the risk of prolonged recovery from general anesthesia.
