NM-236
When train-of-four and reversal fail. Recurarization and suggamadex rescue in a pediatric patient undergoing allogenic renal transplantation
1Brackett S, 2Diallo M
1The George Washington University Hospital, Washington, DC, United states; 2Children's National Health System, Washington, DC, United states
INTRODUCTION
Rocuronium has an increased duration of action in patients with severe renal disease, particularly at repeat or higher doses. Patients with renal impairment are at an increased risk of residual postoperative paralysis or recurarization. The incidence of recurarization is 4-50%, which can be mitigated by the use of acetylcholinesterase inhibitors. However, despite reversal of neuromuscular blockade, recurarization can persist. A novel γ-cyclodextrin, suggamadex, has been shown to be effective in reversing residual blockade. We present a case of rocuronium recurarization despite appropriate reversal with neostigmine, and suggamadex rescue of residual paralysis in a pediatric patient undergoing renal transplantation.
CASE PRESENTATION
An 18 year old 74 kg female with obesity, hypertension, and end-stage renal disease was scheduled for allogenic renal transplantation. General anesthesia was induced with propofol, fentanyl, rocuronium, and maintained with desflurane. Two large bore IVs and an arterial line were placed post-induction. Her HD catheter was used for central access. A total of 140 mg of rocuronium was administered throughout the case.
Qualitative TOF was assessed 120 minutes following the last rocuronium dose, which revealed 2/4 twitches. Reversal was administered with 5 mg neostigmine and 0.6 mg of glycopyrrolate. At this time, the patient was on pressure support, triggering breaths with adequate tidal volumes. Ten minutes after the administration of neostigmine, TOF was rechecked and revealed 4/4 twitches. The patient was transitioned to spontaneous ventilation and desflurane was discontinued. She continued to take adequate tidal volumes while breathing spontaneously and was following commands. She was extubated 35 minutes after reversal agents were given.
However, before transitioning off of the OR table, the patient had poor respiratory effort and desaturated. She was assisted with manual bag mask ventilation. She appeared weak with poor muscle strength. TOF revealed 4/4 twitches. Suggamadex 500 mg was administered one hour after the initial neostigmine dose. Within thirty seconds, her respiratory effort and muscle strength improved. She no longer required manual assistance of her respirations and she was transferred to the PICU in stable condition.
DISCUSSION
Prolonged neuromuscular blockade in patients with renal failure has been reported with recurarization up to 3 hours post-operatively. Despite TOF 4/4 after reversal, unexpected rocuronium reparalysis can occur. By using a strategic approach to neuromuscular blockade in patients with renal failure, recurarization rates can be attenuated. In patients with renal failure, non-steroidal neuromuscular blocking drugs should be carefully titrated based on TOF assessment, and lower doses should be considered. In addition, benzylisoquinolines may be a better choice.
Acetylcholinesterase inhibitors have a ceiling effect, and thus their efficacy is limited when the block is too intense. Therefore, it is recommended that 4/4 twitches should be recovered before administering neostigmine. In such cases where there is an increased potential for recurarization, suggamadex is a novel agent that is effective in reversing prolonged rocuronium blockade.
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