812: PROLONGED NEUROMUSCULAR BLOCKADE IN THE ICU FROM INADVERTENT SUBCUTANEOUS ROCURONIUM DEPOT

Abstract

Introduction: Neuromuscular blockade (NMB) is essential in endotracheal intubation. Peripheral IVs (PIV) commonly infiltrate causing prolonged medication effects. The pharmacokinetics of subcutaneous or depot NMB are poorly defined. We report a case of intubation complicated by PIV infiltration resulting in subcutaneous (SQ) depot of rocuronium with prolonged NMB. This case encourages the inclusion of residual NMB in the differential diagnosis for patients whose neurologic exam fails to recover. Description: A 68-year-old male with hypertension and cirrhosis was admitted with urosepsis, acute kidney injury (AKI), rhabdomyolysis, and was intubated for respiratory failure. During induction with rocuronium, ketamine, and midazolam, no drug effects were noted, due to PIV infiltration. Re-induction via a different PIV and intubation were performed, causing hypotension. Vasopressors administered via a second PIV had no effect and brief cardiac arrest occurred. Epinephrine administered via Interosseous access produced return of spontaneous circulation and resolution of hypotension. The next day, the patient remained a Glasgow Coma Scale (GCS) 3T without sedation or NMB. After exclusion of other causes, train of four (TOF) twitch and bispectral Index (BiS) monitors suggested residual NMB. An NMB reversal agent (sugammadex) was administered resulting in improvement of TOF, spontaneous movement, respiration, and GCS. Due to the unknown duration of depot rocuronium with renal and hepatic injury, he remained intubated for 72 hours, then successfully extubated. Discussion: The differential diagnosis in a comatose patient following intubation and cardiac arrest is broad. In this patient, most diagnoses were excluded prior to identifying prolonged NMB. Prolonged NMB should have been considered and investigated earlier. Neither BIS nor TOF are commonly used tools and earlier utilization may have led to prompter recognition of NMB as the etiology of his poor neurologic exam. There is a paucity of literature on the identification and management of depot NMB, limited to isolated case reports. The diagnosis of prolonged NMB should be considered in the differential of any post-procedure patient without improvement in GCS.