Repeat dosing of rocuronium after reversal of neuromuscular block by sugammadex

Abstract

To the Editor, Sugammadex specifically antagonizes the steroidal neuromuscular blocking agent (NMBA), rocuronium, 1 and it also has affinity for other steroidal NMBAs. A period of 24 hr is currently recommended before re-administering rocuronium after sugammadex. A If neuromuscular block (NMB) is needed before this time interval ends, a nonsteroidal NMBA should be given; however, nonsteroidal NMBAs are not available clinically in Japan. We present herein a 35-yr-old male patient (weight 73 kg, height 173 cm) in whom NMB was achieved using rocuronium 19 min after administering sugammadex. The authors have obtained agreement from the patient for submission of this case report to a medical journal.The patient was scheduled for elective parotidectomy, and his preoperative blood chemistry was within normal limits. Anesthesia was induced with propofol, and endotracheal intubation was facilitated using rocuronium 40 mg. Maintenance of anesthesia was achieved with sevoflurane, remifentanil, and fentanyl. Repetitive train-of-four (TOF) stimulation was applied at the ulnar nerve using a TOF Watch (Organon Ltd, Dublin, Ireland) monitor. Rocuronium 10 mg was added every 30-40 min, for a total dose of 100 mg over 204 min. At the end of surgery, 60 min after rocuronium, sugammadex 200 mg (2.75 mgÁkg -1 ) was administered, and the patient's trachea was extubated.After that, bleeding from the drainage tube and progressive bulging of the surgical field were observed. The otolaryngologists requested immediate re-exploration for hemostasis. We prepared to monitor NMB at the adductor pollicis muscle using a TOF-WatchÒ SX with preload (the Hand Adapter, Organon, Oss, the Netherlands), and we obtained digitized data. Anesthesia was induced with propofol, remifentanil, and sevoflurane inhalation, and neuromuscular blockade was monitored throughout the second surgery. Peripheral skin temperature, measured at the thenar eminence of the palm, was maintained at 32.5-34.5°C, and body temperature was maintained at 36.2-37.2°C.Rocuronium 70 mg was administered 19 min after sugammadex, but the first twitch to TOF stimulation (T1) did not disappear 195 sec after this dose so an additional 30 mg was added (Figure). The first twitch disappeared 105 sec after the second dose, for an onset time of 300 sec. Anesthesia was maintained using sevoflurane, remifentanil, and fentanyl.A single response following post-tetanic stimulation (post-tetanic count) was observed 50 min after rocuronium, and T1 appeared at 64 min. At the end of the second surgery, sugammadex 150 mg was again administered when the train-of-four ratio was 16%. The train-of-four ratio reached 102% within 150 sec, and the patient's trachea was extubated ( Figure).Cammu et al. examined the onset and duration of re-administration of 1.2 mgÁkg -1 rocuronium after sugammadex 4.0 mgÁkg -1 under propofol anesthesia in healthy volunteers. 2 They found that sugammadex prolongs the onset time of rocuronium when the time interval from sugammadex administration was \25 min. Our patient was given ...

The use of rocuronium 20 minutes after sugammadex administration - a case report

“…The clinical duration (duration from the initial administration to spontaneous recovery to 25% of control twitch height) with 0.6 mg kg -1 rocuronium bromide is 30 to 40 min [9]. In the presented case the clinical duration was within the range of what was expected for the repeat dosing of rocuronium (about 30 min), as were the observations of Matsuki et al [7]. These authors reported the re-appearance of T1 64 min after re-administration of rocuronium 1 mg kg -1 being administered 19 min later after sugammadex.…”

“…However, the effect produced was less intense (86% T1 block) and had a slower onset time than would normally be expected, upon which another 10 mg of rocuronium were added. On the other hand, Matsuki et al reported a case where rocuronium 1 mg kg -1 administered 19 min later after sugammadex 2.75 mg kg -1 , in a patient under sevoflurane anesthesia, was unable to induce muscular relaxationand an additional 30 mg were required [7].…”

Shortened time to neuromuscular recovery with lower doses of rocuronium in elderly patients

“…There were some limitations to our study. Duration of action in Group Rocuronium 0.9 mg/kg may have been prolonged by the administration of sevoflurane in two patients [8]. Additionally, onset time may have been shortened in patients receiving ephedrine before TOF-0 was obtained as ephedrine increases cardiac output.…”

“…Additionally, some clinicians may be reluctant to administer sugammadex due to the challenges that may arise following a potential reoperation requiring administration of rocuronium within the first 24 hrs post-operatively [8]. Finally, sugammadex is not recommended in patients with significantly decreased kidney function (glomerular filtration rate below 30 ml/min, including dialysis) [17], and sugammadex has been correlated with a higher incidence of anaphylaxis than neostigmine [18].…”