Resistance to Neuromuscular Blockade by Rocuronium in Surgical Patients with Spastic Cerebral Palsy

Abstract

: Individuals with spastic cerebral palsy (CP) often exhibit altered sensitivities to neuromuscular blocking agents (NMBAs) used for surgical intubation. We assessed usage of the NMBA rocuronium in patients with spastic CP and evaluated potential modifiers of dosing including gross motor function classification system (GMFCS) level, birthweight, gestational age, and the use of anticonvulsant therapy. In a case-control study, surgical patients with spastic CP (n = 64) or with idiopathic or non-neuromuscular conditions (n = 73) were enrolled after informed consent/assent. Patient data, GMFCS level, anticonvulsant use, and rocuronium dosing for intubation and post-intubation neuromuscular blockade were obtained from medical records. Findings reveal participants with CP required more rocuronium per body weight for intubation than controls (1.00 ± 0.08 versus 0.64 ± 0.03 mg/kg; p < 0.0001). Dosing increased with GMFCS level (Spearman’s rho = 0.323; p = 0.005), and participants with moderate to severe disability (GMFCS III-V) had elevated rocuronium with (1.21 ± 0.13 mg/kg) or without (0.86 ± 0.09 mg/kg) concurrent anticonvulsant therapy. Children born full-term or with birthweight >2.5 kg in the CP cohort required more rocuronium than preterm and low birthweight counterparts. Individuals with CP exhibited highly varied and significant resistance to neuromuscular blockade with rocuronium that was related to GMFCS and gestational age and weight at birth.

Can Evoked Potential Changes during the Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery Predict Postoperative Improvement of Cerebral Perfusion and Functional Status?

“…Several previous studies have already used EP obtained just before dura opening as baseline values when testing for the reliability of MEP interpretation during IONM in open cranial surgery [ 35 , 36 ]. We used rocuronium for intubation, which has a duration of action of 30–60 min [ 37 ]. TBE of the MC and MB groups were 69 and 85 min, respectively.…”

What's New in Orthopaedic Management in Neuromuscular Disorders

“…Children with cerebral palsy require increased doses of the paralytic rocuronium. 11 In a prospective study, it is noted higher GMFCS level, higher birth weight, and fullterm gestational age need a larger amount of rocuronium for neuromuscular blockade. This is likely due to the disruption of the neuromuscular junctions.…”

“…This is likely due to the disruption of the neuromuscular junctions. 11 Regional anesthesia has gained popular acceptance for lower extremity surgery to decrease opioids in the perioperative period. Many children with cerebral palsy undergoing bilateral hip reconstructive surgery have baclofen pumps, which may be a contraindication for epidural anesthesia.…”

An Emerging Role for Epigenetics in Cerebral Palsy

“…Subjects with CP require different doses of neuromuscular blocking agents (NMBAs), which act at the NMJ, compared to subjects without CP. In particular, subjects with CP are more sensitive to the depolarizing agent succinylcholine and more resistant to the nondepolarizing agents vecuronium and rocuronium [50][51][52]. When the relative distribution of specific presynaptic, synaptic, and postsynaptic markers (presynaptic: SV2; synaptic: AChE, laminin β2; postsynaptic: nAChR) were quantified by fluorescence microscopy in spinalis muscle acquired from scoliotic subjects with or without CP, NMJs in the CP group were found to be disrupted, with all pairwise comparisons demonstrating significant differences except SV2 compared to nAChR [18].…”