Use of sugammadex in a ‘can’t intubate, can’t ventilate’ situation

Abstract

A 78-yr-old woman presented for a panendoscopy to investigate dysphonia and dysphagia. Intubation was anticipated to be difficult but possible, and mask ventilation was anticipated to be possible. After induction of anaesthesia and after three attempts at intubation, a 'can't intubate, can ventilate' situation deteriorated to a 'can't intubate, can't ventilate' (CICV) situation. Rocuronium-induced neuromuscular block was successfully reversed with sugammadex, as evidenced by the restoration of diaphragmatic movement, the ability of the patient to move her limbs, and the presence of a train-of-four nerve stimulation with no fade; however, ventilation was still not possible. A cricothyroid puncture using a Ravussin needle was performed successfully to provide emergency oxygenation. A tracheostomy was performed to allow the panendoscopy. CICV situations are rare anaesthetic emergencies. While sugammadex can be relied upon to reverse rocuronium-induced neuromuscular block, it should not be relied upon to rescue all CICV events, especially where airway instrumentation has led to airway swelling. The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation. The presence of head and neck pathology should lead to the consideration of securing the airway awake.

Sugammadex in anticipated difficult airways3

“…Of critical importance is full paralysis of the patient, allowing adequate time for expiration and manipulation of the airway to provide an expiratory pathway. We concur with the conclusion of Mendonca's accompanying editorial that sugammadex should not form part of the airway rescue plan in anticipated difficult airways [4]. In the group of patients described, definitive front-of-neck access allowing inspiration and expiration must be immediately available and always form part of the airway strategy.…”

“…Secondly, if the airway had deteriorated after sugammadex administration such that emergency front-of-neck access had become necessary, re-establishment of neuromuscular blockade (as currently advised [3]) using rocuronium would not have been possible. Sugammadex cannot be relied upon as a 'panacea' in these settings [4]; Mendonca is correct to describe its use as 'potentially dangerous' in an accompanying editorial [5] …”

“…Could they clarify which was used? 4 We were pleased to see both a case report and accompanying editorial on sugammadex [1,2]. Paton et al should be congratulated on making several important points related to the use of sugammadex in the 'cannot ventilate' scenario.…”

Safely Airway Management in Larinks and Tracheobronchial Injuries

“…Trakeal bütünlüğü bozulmuş, penedran travmalı hastalarda çoğu zaman cerrahi işleme gerek olmayıp, var olan travmatik trakeal ostomiden sokulan bir endotrakeal tüp güvenli hava yolunu sağlar. Son yıllarda, hava yolu rehberlerinde krikotiroidotomi ön planda tutulmasına rağmen, iki cerrahi prosedür arasında, krikotiroidotomiden çok trakeotomi yapma eğilimi mevcuttur (36) . Dört bin üç yüz on iki hastanın retrospektif analizinde, yalnızca 34 hastada (%0,008) acil cerrahi hava yolu yöntemi kullanıldığı-nı belirlemiş, bu 34 hastanın 24'ünde ise trakeotomi yapıldığını, kalan 10 hastada krikotiroidotomi uygulandığını raporlamışlardır.…”

S1 guidelines on airway management

“…sugammadex after rocuronium), as the actual time point of the return to spontaneous respiration cannot be predicted [82,83].…”