Failure of reversion of neuromuscular block with sugammadex in patient with myasthenia gravis: case report and brief review of literature

Fernandes, Hermann dos Santos; Ximenes, Jorge Luiz Saraiva; Nunes, Daniel Ibanhes; Vieira, Joaquim Edson

doi:10.1186/s12871-019-0829-0

Cited by 22 publications

(8 citation statements)

References 8 publications

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“…Although rare, there have been reports of unexpectedly large amounts of sugammadex needed to reverse rocuronium-induced paralysis. Fernandes et al reported a case of a patient with obesity (BMI: 37.2 kg•m − 2 ) and myasthenia gravis in whom a total of 800 mg (7.27 mg•kg − 1 ) of sugammadex and 2 mg of neostigmine was required to antagonize 25 mg of rocuronium [7]. Kiss et al reported another case of a patient with obesity (BMI: 32.0 kg•m − 2 ) and myasthenia Review article [3] For reversal of moderate block (TOF count, 1-3), a dose of 2 mg/kg is recommended; for reversal of deep block (PTC ≥ 1), a dose of 4 mg/kg is recommended.…”

Section: Discussionmentioning

confidence: 99%

Residual paralysis caused by 50 mg rocuronium after reversal with 4 mg/kg sugammadex: a case report

2021

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Background Rocuronium-induced neuromuscular blockade can be quickly and completely reversed by administration of an optimal dose of sugammadex. Sugammadex antagonizes rocuronium-induced neuromuscular blockade by encapsulating rocuronium. Herein, we report a case of residual neuromuscular paralysis in which the recommended dose of sugammadex (4 mg·kg− 1) failed to antagonize a rocuronium-induced blockade. Case presentation A 71-year-old man (body mass index: 26.7 kg·m− 2) underwent endoscopic submucosal dissection of early-stage gastric cancer. He had no known factors that may have affected the effects of rocuronium and sugammadex. He received rocuronium (50 mg; 0.7 mg·kg− 1) for anesthesia induction. No additional rocuronium was administered during the 71-min procedure. Ninety-four minutes after rocuronium administration, neuromuscular monitoring showed 20 twitches in response to post-tetanic count stimulation. The train-of-four (TOF) ratio was not measurable despite sugammadex (280 mg; 4 mg/kg) administration, although four weak twitches in response to TOF stimulation appeared in 3 min. The TOF ratio became detectable following administration of an additional dose of sugammadex (120 mg; 1.7 mg·kg− 1), and it recovered to 107% 8 min after the second dose. The patient opened his eyes; moved his neck, arms, and limbs; and regained consciousness. The trachea was extubated and the patient was transferred to the ward. Conclusions Neuromuscular monitoring should be used if a neuromuscular blockage agent is administered, even if the recommended dose of sugammadex is administered.

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Section: Discussionmentioning

confidence: 99%

Residual paralysis caused by 50 mg rocuronium after reversal with 4 mg/kg sugammadex: a case report

2021

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“…29 Furthermore, reversal of block by sugammadex does not always succeed in myasthenic patients. 30 Currently, biochemical BChE testing is only performed in patients who are undergoing surgery and have a personal or family history of prolonged postsuccinylcholine neuromuscular blockade. The high frequency of patients predicted to have moderate or severe BChE deficiency suggests that genetic testing may be feasible for all patients who are undergoing surgery.…”

Section: Discussionmentioning

confidence: 99%

<p>Genetic Testing for <em>BCHE</em> Variants Identifies Patients at Risk of Prolonged Neuromuscular Blockade in Response to Succinylcholine</p>

Zhu

Dawson

Huskey

et al. 2020

PGPM

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Background: Genetic variants in the BCHE (butyrylcholinesterase) gene are associated with reduced BChE enzyme activity and prolonged post-succinylcholine neuromuscular blockade, which can lead to postanesthetic apnea and respiratory depression. Testing for BChE deficiency is usually performed by biochemical methods and is generally only offered to patients who have a personal or family history of prolonged post-succinylcholine neuromuscular blockade. Purpose: Using a clinical test, we investigated the frequencies of BCHE genotypes that are associated with increased risk for prolonged post-succinylcholine neuromuscular blockade. Materials and Methods: Five BCHE variants, including the A (atypical, rs1799807), K (Kalow, rs1803274), F 1 (fluoride-1, rs28933389), F 2 (fluoride-2, rs28933390), and S 1 (silent-1, rs398124632), were genotyped in a large (n = 13,301), multi-ethnic cohort in the United States. Subjects were recipients of pharmacogenetic testing ordered by their physicians as part of routine care. Results: The minor allele frequencies of A, K, F 1 , F 2 , and S 1 were 1.60%, 19.93%, 0.08%, 0.47%, and 0.04%, respectively, in this cohort. Based on a review of biochemical and clinical data of these variants, we grouped BCHE genotypes into four phenotypic categories to stratify the risk for prolonged post-succinylcholine neuromuscular blockade. Approximately 0.06% of patients were predicted to have severe BChE deficiency, 8% were predicted to have moderate BChE deficiency, and 29% were predicted to have mild BChE deficiency. Compared to other ethnic groups, Caucasians were predicted to have the highest frequency of BChE deficiency. Conclusion: While severe BChE deficiency is rare in the United States, approximately 8% of Americans are at moderate risk of prolonged post-succinylcholine neuromuscular blockade, suggesting that a sizable percentage of patients may benefit from preoperative genetic testing of BCHE.

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“…For example, both the chapter on medication management and ischemic heart disease identify cardiac medications that need to be withheld or continued during the perioperative period. Medications to treat myasthenia gravis (pyridostigmine and azathioprine) are omitted in the robust table (chapter 4, page 34), and importance of avoiding general anesthesia and neostigmine reversal in these patients is paramount to safe emergence by using newer agents, perhaps sugammadex (which is not mentioned in the text at all) [3][4][5]. At times, use of medication names, either brand or generic, is not consistent.…”

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confidence: 99%

Book Review: Cohn, S.L. (Ed.). Decision Making in Perioperative Medicine: Clinical Pearls. (New York: McGraw-Hill), 2021. ISBN: 978-1-260-46810-6

Parrish

2021

Healthcare

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Failure of reversion of neuromuscular block with sugammadex in patient with myasthenia gravis: case report and brief review of literature

Cited by 22 publications

References 8 publications

Residual paralysis caused by 50 mg rocuronium after reversal with 4 mg/kg sugammadex: a case report

Residual paralysis caused by 50 mg rocuronium after reversal with 4 mg/kg sugammadex: a case report

<p>Genetic Testing for <em>BCHE</em> Variants Identifies Patients at Risk of Prolonged Neuromuscular Blockade in Response to Succinylcholine</p>

Book Review: Cohn, S.L. (Ed.). Decision Making in Perioperative Medicine: Clinical Pearls. (New York: McGraw-Hill), 2021. ISBN: 978-1-260-46810-6

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