A temporary decrease in twitch response following reversal of rocuronium-induced neuromuscular block with a small dose of sugammadex in a pediatric patient

Abstract

We report a temporary decrease in twitch response following reversal of rocuronium-induced neuromuscular block with a small dose of sugammadex in our dose-finding study in pediatric patients. A 19-month-old female infant (9.6 kg, 80 cm) was scheduled for elective cheiloplasty surgery. Anesthesia was induced with nitrous oxide 50 % and sevoflurane 5 % and maintained with air, oxygen, sevoflurane 3 %, and fentanyl (total, 3 μg/kg). Neuromuscular monitoring was performed at the adductor pollicis muscle after induction of anesthesia but before the administration of rocuronium. Total dose of rocuronium during the surgery was 0.9 mg/kg. Neuromuscular block was reversed with 0.5 mg/kg sugammadex when one response was observed with post-tetanic count stimulation. Twitch responses after sugammadex administration showed a temporary decrease after its initial recovery. Maximum decreases in twitch responses were observed 17 min after initial dose of sugammadex. Twitch responses recovered to their control values after additional doses of 3.5 mg/kg sugammadex (4 mg/kg in total). Time from sugammadex administration to maximum decreases in twitch responses is earlier than has been reported in adults (20–70 min). It is demonstrated that following neuromuscular block reversal with insufficient dose of sugammadex, there is a possibility of the recurrence of residual paralysis within less than 20 min in pediatric patients.

Preparing for the unexpected: special considerations and complications after sugammadex administration

“…Two of 10 patients who received 1 mg/kg of sugammadex at a depth of block of 1–2 PTCs met this definition in a Phase 2 trial [ 8 , 10 ]. Three patients in the same trial and one pediatric patient in a case report [ 11 ] did not completely meet the criteria for recurrent block, however, a temporary decrease in twitch response following sugammadex reversal was observed. In these reports, all patients had received less than the 4 mg/kg recommended dose of sugammadex (0.5 or 1 mg/kg) at a depth of block of 1–2 PTCs [ 8 , 10 , 11 ].…”

“…Three patients in the same trial and one pediatric patient in a case report [ 11 ] did not completely meet the criteria for recurrent block, however, a temporary decrease in twitch response following sugammadex reversal was observed. In these reports, all patients had received less than the 4 mg/kg recommended dose of sugammadex (0.5 or 1 mg/kg) at a depth of block of 1–2 PTCs [ 8 , 10 , 11 ]. The mean time from sugammadex administration to recovery of TOFR >0.9 (prior to recurrence) was 6.9 (range 3.6–11.5) minutes [ 8 ].…”

Sugammadex: Applications in Pediatric Critical Care

“…Albeit rare, anecdotal reports have demonstrated the potential for this phenomenon even with sugammadex. [94][95][96][97] One final issue that should be addressed with sugammadex is the concern that it may interfere with hormonal contraceptive agents. In vitro binding studies have demonstrated the binding of progesterone thereby decreasing the free plasma concentration.…”

A Short Update on Sugammadex with a Special Focus on Economic Assessment of its Use in North America

“…When neostigmine is used to reverse deep NMB, a mean of 50.4 min is necessary to reach a TOF ratio of 0.9 [9]. Doses of sugammadex below 1 mg.kg-1 have been shown to be initially effective to reverse rocuronium-induced deep NMB, but lead to the gradual reappearance of the NMB in both adults [15] and children [16]. In contrast, sugammadex doses ranging from 1 to 2 mg.kg-1 have shown to reverse rocuronium-induced deep NMB with significant time variability (TOF ratio ≥ 0.9 is obtained from 1.8 to 15.2 min) [17].…”