Successful Management of Subcutaneous Infiltration of an Intubating dose of Rocuronium in a Morbidly Obese Patient: A Case Report

Abstract

Introduction: Induction of anesthesia relies on multiple factors including appropriate monitoring, administration, and dosing of induction agents. In morbidly obese patients, placement and maintenance of intravenous lines may be difficult and accidental subcutaneous infiltration of medications may be challenging to identify. The treatment of accidental subcutaneous administration of neuromuscular blocking agents may be complex as the absorption and subsequent elimination is altered and not well known, and the inadvertent prolonged dosing could lead to catastrophic complications. Case Report: We present a case report of the successful management of the accidental subcutaneous administration of rocuronium in a morbidly obese, 65-year-old Caucasian female with multiple comorbidities undergoing an elective endovascular procedure. The perioperative management of the patient is discussed, and a review of the literature is provided. Conclusion: Relatively little information is available regarding the absorption of medications outside of the typical route of administration. The accidental subcutaneous infiltration of neuromuscular blockers could lead to airway compromise or prolonged blockade due to the unknown onset, peak effect, and duration of action. Open discussion among the many treatment team members after identification of accidental misadministration of medications is critical and clinical acumen is paramount to ensure optimal patient outcomes. Since intravenous line infiltration and subsequent subcutaneous extravasation are not a rare intraoperative event, more research into the effects of neuromuscular blocking agents is needed to aid clinical outcomes. Keywords: Anesthesia, critical care, drug administration routes, extravasation, neuromuscular blocker.

Extravascular injection of neuromuscular blocking drugs

“…7,8,10 Table 2 shows the characteristics of the subcutaneous injection of NMBDs. Rocuronium was used in nine cases, [4][5][6][7][8]11 vecuronium in two cases 9,10 and pancuronium in one case. 12 No case reports were retrieved describing the extravasation of atracurium, cisatracurium, mivacuror succinylcholine.…”

“…11 None of the cases reported a high injection pressure during initial injection. The subcutaneous injections occurred at the level of the upper (n ¼ 8), [4][5][6][7]9,11 the lower (n ¼ 2) extremity 8,12 and the neck (n ¼ 1). 10 One case did not specify the site of injection.…”

“…After the suspicion of extravasation, seven patients received an additional dose of intravenous NMBD (five patients rocuronium and two patients vecuronium) to facilitate intubation and achieve adequate surgical relaxation before the start of the surgery. 5,[7][8][9]11 All intravenous top-up doses of NMBDs were administered through a newly placed intravenous line. In four cases, the additional intravenous top-up dose of NMBD was given prior to measurement of the TOF count.…”

“…In four cases, the additional intravenous top-up dose of NMBD was given prior to measurement of the TOF count. 5,9,11 Apart from the doses mentioned in Table 2, no additional doses of NMBDs were given during the procedure. Eur J Anaesthesiol 2024; 41:367-373…”

“…One of these patients received an intravenous injection of vecuronium after an initial extravasation of rocuronium and was thus not included in our calculation of median and average doses. 5 All cases noticed a delay in onset of neuromuscular blockade, based on TOF measurement and clinical findings such as persistent spontaneous respiration. Three of the cases reported a time of onset of the neuromuscular block with a median delay of 20 min.…”