Should Dosing of Rocuronium in Obese Patients Be Based on Ideal or Corrected Body Weight?

Purpose We report a case that involved immediate postoperative respiratory failure necessitating tracheal intubation, which was possibly related to recurarization after sugammadex reversal. Clinical findings A 54-yr-old woman weighing 115-kg was scheduled for laparoscopic repair of abdominal dehiscence under general anesthesia. Muscle relaxation was induced and maintained with rocuronium (170 mg iv total dose). At the end of the 170-min procedure, two twitches were visualized after supramaximal train-of-four (TOF) stimulation at the adductor pollicis muscle, and the patient's central core temperature was 35.6°C. Sugammadex 200 mg iv (1.74 mgÁkg -1 ) was administered. With the patient fully awake, a TOF ratio 0.9 was obtained five minutes later. The tracheal tube was then removed, and the patient was transferred to the postanesthesia care unit. Ten minutes later, the patient presented respiratory failure necessitating tracheal intubation and sedation with propofol. One TOF response only was visualized at the adductor pollicis muscle. Another dose of sugammadex 200 mg iv was administered. Forty-five minutes later, the patient was fully awake and her trachea was extubated after repeated measures of the TOF ratio (C 0.9) at the adductor pollicis muscle. The patient fully recovered without sequelae, further complication, or prolonged hospital stay. Conclusion Shortly after tracheal extubation, an obese patient experienced respiratory failure necessitating tracheal intubation and an additional dose of sugammadex. This occurred despite initial reversal of neuromuscular blockade with an appropriate dose of sugammadex 2 mgÁkg -1 iv given at two responses to TOF stimulation. RésuméObjectif Nous de´crivons un cas de de´tresse respiratoire survenu en postope´ratoire imme´diat ne´cessitant l'intubation de la trache´e, possiblement lie´a`une recurarisation apre`s une de´curarisation pharmacologique avec du sugammadex. É léments cliniques Une femme de 54 ans, pesant 115 kg, e´tait programme´e pour le traitement chirurgical d'une e´ventration de la paroi abdominale par laparoscopie sous anesthe´sie ge´ne´rale. La curarisation e´tait induite et entretenue par du rocuronium (dose totale 170 mg iv). A`la fin de l'intervention, durant 170 min, deux re´ponses e´taient visualise´es apre`s une stimulation supra-maximale par un train-de-quatre (Td4) a`l'adducteur du pouce, et la tempe´rature centrale e´tait de 35,6°C. Une dose de 200 mg iv de sugammadex (1,74 mgÁkg -1 ) a e´te´administre´e pour la de´curarisation pharmacologique. Un rapport de Td4 a`0,9 al 'adducteur du pouce e´tait obtenu cinq minutes plus tard permettant le retrait de la sonde d'intubation et le transfert en salle de re´veil, la patiente re´pondant aux ordres simples. Dix minutes plus tard, elle pre´sentait une de´tresse respiratoire ne´cessitant l'intubation de la trache´e et une se´dation au propofol. Une seule re´ponse e´tait visualise´e au Td4 a`l'adducteur du pouce. Une dose supple´mentaire de 200 mg iv de sugammadex a e´te´administre´e. Quarante-cinq

Section: Discussionmentioning

confidence: 99%

Recurarization after sugammadex reversal in an obese patient

Corre

Nejmeddine

Fatahine

et al. 2011

“…Data are available to provide some guidance on appropriate dosing for common perioperative medications (Table 3). 64,65,[67][68][69][70][71][72][73][74] In Table 4, there is an outline of the calculation methods for the various dosing weights.…”

Section: Intraoperative Carementioning

confidence: 99%

Perioperative management of the severely obese patient: a selective pathophysiological review

Cullen

Ferguson

2012

“…4 Meyhoff et al reported that the dose of rocuronium should be calculated according to ideal body weight to prevent the prolonged rocuroniuminduced neuromuscular block in morbidly obese patients. 9 The findings of the present study suggest that the higher the BMI, the longer the duration of rocuronium-induced neuromuscular block, even in non-obese patients. Thus, even if the patient is not categorized as ''obese'' according to the WHO classification, the higher the BMI of the patient, the more carefully rocuronium should be administered with neuromuscular monitoring to prevent prolonging neuromuscular block.…”

Section: Discussionmentioning

confidence: 47%

In non-obese patients, duration of action of rocuronium is directly correlated with body mass index

Fujimoto

Tanahira

Nishi

et al. 2013

Background Administration of neuromuscular blocking agents using a dose calculated on actual body weight carries a risk of prolonged duration of action in obese patients whose body mass index (BMI) is [ 30 kgÁm -2 . In the present study, we hypothesized that there could be a correlation between BMI and the duration of action of rocuronium administered according to actual body weight in non-obese patients, in particular, overweight (BMI 25-30 kgÁm -2 ) and underweight patients (BMI \ 18.5 kgÁm -2 ). Methods Sixteen female patients (BMI 15-30 kgÁm -2 , aged 45-60 yr) scheduled for elective surgery under total intravenous anesthesia were included in this study. Rocuronium 0.9 mgÁkg -1 was administered, and adductor pollicis train-of-four responses following ulnar nerve stimulation were monitored every minute with acceleromyography. The times from the injection of rocuronium until spontaneous recovery of first twitch to 5% (5% Duration) and 25% (25% Duration) of baseline were measured, and the correlation with BMI was analyzed.Results A significant correlation between 5% Duration and BMI (r 2 = 0.56; P \ 0.001) was found by linear regression analysis. A significant correlation was also found between 25% Duration and BMI (r 2 = 0.49; P = 0.003). Conclusion In adult female patients with a BMI in the range of 15-30 kgÁm -2 , the duration of action of rocuronium increases with BMI when the drug is administered on the basis of mg per actual kg body weight. RésuméContexte L'administration de curares a`une dose calcule´e en fonction du poids re´el comporte le risque d'une dure´e d'action prolonge´e chez les patients obe`ses dont l'indice de masse corporelle (IMC) est [ 30 kgÁm -2 . Dans cette e´tude, nous avons e´mis l'hypothe`se qu'il pourrait exister une corre´lation entre l'IMC et la dure´e d'action du rocuronium administre´selon le poids re´el chez les patients non obe`ses, en particulier chez les patients en surcharge ponde´rale (IMC 25-30 kgÁm -2 ) et en insuffisance ponde´rale (IMC \ 18,5 kgÁm -2 ). Méthode Seize patientes (IMC 15-30 kgÁm -2