Postoperative rocuronium reparalysis

Abstract

Recurarization appears to occur frequently and we would like to provide two further reports.Patient #1 sustained a gunshot to her neck causing an intimal flap injury to the carotid artery. During stent placement under conscious sedation an intracranial AV fistula was discovered during arteriography. Subsequently, invasive radiological ablation under general anaesthesia after awake fibreoptic intubation, proceeded uneventfully. After standard neuromuscular reversal and tracheal extubation, the patient was transported awake, sitting up, and talking in the SICU. Fifteen minutes after extubation, she was unable to open her eyes and noted difficulty breathing. Bag mask ventilation was begun. Fibreoptic intubation under controlled ventilation via an LMA proceeded uneventfully. The ulnar nerve response revealed one weak twitch to TOF stimulation. Twenty minutes later, the patient was again able to open her eyes, lift her head and cough. The trachea was extubated uneventfully Patient #2 presented for breast biopsy under general anaesthesia. Anaesthesia was induced with propofol and fentanyl, followed by an intubation dose ofrocuronium (0.6 mg-kg q) and anaesthesia was maintained with nitrous oxide-oxygen-sevoflurane. Vancomycin (1 g) was given preoperatively. Post surgery, normal TOF, sustained tetanus and head lift (> 5sec) was evident after standard reversal. After awake extubation, the patient was transported to PACU. Within 20 min, she became progressively dyspneic and weak as evidenced by depressed ulnar twitch responses. Calcium chloride (1.5 mg.kg -1) followed by 10 mg pyridostigmine and 0.2 mg glycopyrrolate was given with no immediate improvement. Subsequently, the trachea was reintubated after 5 mg midazolam and the lungs were ventilated until spontaneous neuromuscular recovery. Extubation proceeded uneventfully.In summ~y, we describe two cases of rocuronium reparalysis in which neuromuscular recovery was demonstrated prior to PACU arrival. Vancomycininduced neuromuscular potentiation should be given serious consideration when used with rocuronium.

A survey of peripheral nerve stimulator (PNS) use

“…It was interesting to find no increase in PNS use for the newer agents. This may reflect their predictability, although there are reports of recurarization with rocuronium [4].…”