Rocuronium-induced Neuromuscular Block Research Articles

Intravenous lidocaine has no impact on rocuronium‐induced neuromuscular block. Randomised study

Intravenous lidocaine is increasingly used in surgical patients. As it has neuromuscular blocking effects, we tested the impact of an intravenous lidocaine infusion on the time course of a rocuronium-induced neuromuscular block. Fifty-two adults undergoing surgery were randomly allocated to intravenous lidocaine 1.5 mg/kg followed by a continuous infusion of 2 mg/kg/h or physiological saline (control) throughout surgery. Anaesthesia was induced and maintained with a target-controlled propofol infusion and sufentanil. After loss of consciousness, rocuronium 0.6 mg/kg was given. Neuromuscular transmission was measured using train-of-four (TOF)-watch SX (Organon, Swords Co., Dublin, Ireland) acceleromyography. Onset time (to 95% depression of first twitch) was on average 113.9 s (standard deviation 35.3) with lidocaine and 119.5 s (44.9) with saline (P = 0.618). Total recovery time (TOF ratio 0.9) was on average 58.1 min (15.1) with lidocaine and 54.3 min (16.9) with saline (P = 0.394). Clinical duration (until first twitch has recovered to 25%) was on average 33.3 min (7.2) with lidocaine and 30.6 min (8.1) with saline (P = 0.21). Recovery index (time between 25% and 75% recovery of the first twitch) was on average 11.5 min (5.0) with lidocaine and 10.6 min (4.1) with saline (P = 0.458). Recovery time (between 25% recovery of the first twitch and TOF ratio 0.9) was on average 24.8 min (9.3) with lidocaine and 23.2 min (9.2) with saline (P = 0.541). A continuous intravenous infusion of lidocaine has no impact on the time course of the neuromuscular blockade induced by a standard intubation dose of rocuronium.

Sensitivity to Rocuronium-Induced Neuromuscular Block and Reversibility with Sugammadex in a Patient with Myotonic Dystrophy

We report a patient with myotonic dystrophy who showed prolonged rocuronium-induced neuromuscular blockade, although with a fast recovery with sugammadex. During general anesthesia with propofol and remifentanil, the times to spontaneous recovery of the first twitch (T1) of train of four to 10% of control values after an intubating dose of rocuronium 1 mg/kg and an additional dose of 0.2 mg/kg were 112 min and 62 min, respectively. Despite the high sensitivity to rocuronium, sugammadex 2 mg/kg administered at a T1 of 10% safely and effectively antagonized rocuronium-induced neuromuscular block in 90 s.

Reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients

Reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients

The use of sugammadex in obese patients

To the Editor, We read with great interest the paper by Le Corre et al. on recurarization after reversal of rocuronium-induced neuromuscular block (NMB) with sugammadex. The authors reported a case of respiratory failure in an obese patient requiring sedation and tracheal intubation in the postoperative period. This situation occurred despite initial reversal of NMB to a train-of-four (TOF) ratio [ 0.9 with sugammadex 1.74 mg kg. We congratulate the authors for successful management of this case, and we take this opportunity to underscore an important aspect of the perioperative management of NMB in obese patients. Upper airway obstruction (UAO) in obese patients, which may be caused by the residual effects of the neuromuscular blocking agents (NMBAs), may lead to upper airway collapse and respiratory impairment in the postoperative period. To avoid these complications, a recovery to a TOF ratio C 0.9 at the adductor pollicis muscle is generally recommended. However, there is evidence that upper airway dysfunction and partial UAO may occur in some individuals even with recovery of the TOF ratio to C 0.9. The pharyngeal muscles are particularly susceptible to the residual effects of NMBAs. The impairment of the integrity of the upper airway may put obese individuals at risk for upper airway collapse and increase the risk for postoperative respiratory complications. In our view, the recovery of a TOF ratio of 0.9 should be considered insufficient, particularly in obese patients who have a pharyngeal lumen reduced in size due to peripharyngeal fatty tissue deposition and are at increased risk of UAO. We recommend to wait until a TOF ratio of 1.0 has been attained before proceeding with tracheal extubation in obese patients and to consider this value the goal for an adequate recovery from NMB in this patient population. In our experience, sugammadex now represents the best pharmacological approach to reach the threshold of 1.0 quickly and to reduce the risk of postoperative UAO and its associated morbidity. To achieve this outcome, however, it is necessary to adjust the dose of sugammadex to the level of spontaneous recovery (i.e., 2 mg kg at reappearance of T1-T2) 3,4 and base sugammadex dosing on total body weight, despite some recent evidence of efficacy of doses calculated on ideal body weight. Using the correct use of sugammadex changes the intraoperative management of NMB, but it also reduces the risk of residual paralysis or recurarization in obese patients.

Reversibility of Rocuronium-Induced Profound Neuromuscular Block With Sugammadex in Younger and Older Patients

Background This study compared the reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients. Methods Fifteen younger (20–50 yr) and 15 older (≥70 yr) patients were sequentially enrolled in this study. After induction of anaesthesia and laryngeal mask insertion, contraction of the adductor pollicis muscle in response to ulnar nerve stimulation was quantified using acceleromyography during 1.0–1.5% end-tidal sevoflurane and remifentanil anaesthesia. All patients initially received rocuronium 1 mg kg−1, followed by 0.02 mg kg−1 when a post-tetanic count (PTC) of 1 or 2 was observed. After completion of surgery, at reappearance of 1–2 PTC, the time required for a single bolus dose of 4 mg kg−1 sugammadex to produce recovery to a train-of-four (TOF) ratio of 0.9 was recorded. Results There were no differences in the total dose of rocuronium administered between the younger [mean ( sd ): 93.4 (17.5) mg] and the older [97.5 (32.2) mg] groups. In all patients, adequate recovery of the TOF ratio to 0.9 was achieved after administration of sugammadex, although it was significantly slower in the older [3.6 (0.7) min, P Conclusions Sugammadex can adequately restore neuromuscular function in older patients, although a longer time is required to recover from profound rocuronium-induced neuromuscular block than in younger patients.

Reversal of Rocuronium-Induced Neuromuscular Block with Sugammadex and Resulting Histopathological Effects in Rat Kidneys

Background: This study investigated the effect of injection of rocuronium or sugammadex alone and rocuronium + sugammadex on urea, creatinine, electrolyte levels, and histopathological findings in rats. Methods: Thirty-six Sprague-Dawley male rats were divided to receive intravenously 16 or 96 mg/kg sugammadex, 1 mg/kg rocuronium, 1 mg/kg rocuronium + 16 mg/kg sugammadex, or 1 mg/kg rocuronium + 96 mg/kg sugammadex. The control group received an equal volume of physiological serum. Rats receiving rocuronium were ventilated until resumption of spontaneous ventilation and followed for 72 h. Blood samples were withdrawn from the tail vein to measure urea, creatinine, and electrolyte values; then both kidneys were excised, and the tissues were used for histopathological examination. Results: Rats receiving rocuronium and high doses of sugammadex (96 mg/kg) showed increased glomerular vacuolation, tubular dilatation, vascular vacuolation and hypertrophy, lymphocyte infiltration, and tubular cell sloughing compared to the control group (p = 0.002). Biochemical markers of renal function were not significantly altered after treatment with high doses of sugammadex. Conclusion: The elimination half-life of the rocuronium–sugammadex complex was found to be greater than that of free rocuronium or sugammadex, which led to marginal histopathological changes in the kidney without affecting any renal functions.

Sugammadex Reversal of Rocuronium-induced Neuromuscular Block in Cesarean Section Patients

Sugammadex Reversal of Rocuronium-induced Neuromuscular Block in Cesarean Section Patients

Pralidoxime inhibits paraoxon-induced depression of rocuronium-neuromuscular block in a time-dependent fashion

ObjectiveThe composite effects of organophosphorus (OP)–cholinesterase (ChE) inhibitors and oximes on the actions of nondepolarizing neuromuscular blockers in acute OP-ChE inhibitor intoxication have not been evaluated in detail. We investigated the effects of paraoxon (Pox) (an OP-ChE inhibitor) and pralidoxime (PAM) (an oxime) on the nondepolarizing neuromuscular blocking action of rocuronium. MethodsIsometric twitch tensions of rat left phrenic nerve-hemidiaphragm preparations elicited by indirect (phrenic nerve) supramaximal stimulation at 0.1 Hz were evaluated. Analysis of variance with post hoc testing was used for statistical comparison, and P < .05 was accepted as significant. ResultsRocuronium reduced the indirectly elicited twitch tensions in normal (50% inhibitory concentration [IC50], 9.84 [9.64-10.04] μM, mean [95% confidence interval]) and all pretreated diaphragms (P < .01, n = 6) in a concentration-dependent fashion. Paraoxon caused a rightward shift in the rocuronium concentration–twitch tension curve (IC50, 15.48 [15.24-15.72] μM). The rightward shift was completely inhibited by previous copretreatment (IC50, 9.98 [9.77-10.20] μM) and partially inhibited by simultaneous copretreatment (IC50, 11.68 [11.45-11.91] μM) with PAM but was not inhibited by subsequent copretreatment (IC50, 13.69 [13.39-13.99] μM) with PAM (P < .01, n = 6). Atropine did not influence the rightward shift (P < .01, n = 6). DiscussionParaoxon depressed rocuronium-induced neuromuscular block by inhibiting ChEs, and the action of Pox was inhibited by PAM. Pralidoxime acts more intensely when applied earlier. The time-dependent effect of PAM indicates that the preceding presence of PAM in proximity to ChEs before Pox is necessary for definite suppression of the Pox-induced ChE inhibition.

Intraoperative reversal of neuromuscular block with sugammadex or neostigmine during extreme lateral interbody fusion, a novel technique for spine surgery

Extreme lateral interbody fusion (XLIF) is a method for stabilization of the lumbar spine. Intraoperatively, the surgeon identifies the lumbar nerve roots with a stimulator to prevent their injury. The objective of this study was to determine the extent to which shallow rocuronium-induced neuromuscular block must be intraoperatively reversed for reliable identification of nerve roots. General anesthesia (midazolam-propofol-sufentanil-oxygen/air/sevoflurane-rocuronium) was administered to all patients. Train-of-four (TOF) stimulation of the ulnar nerve at 15-s intervals and electromyographic response of the adductor pollicis muscle were used. During operation, the surgeon stimulated the lumbar nerve roots (5-10mA) to identify their course. At the appearance of two twitches to the TOF stimuli, sugammadex (2mg/kg) or neostigmine (0.04mg/kg) was administered. When the response to nerve root stimulation appeared, the TOF ratio was recorded. When the response to nerve root stimulation with 10mA became detectable, the median (range) TOF ratios were 0.67 (0.50-0.81) and 0.65 (0.42-0.71) after sugammadex and neostigmine, respectively. Similarly, TOF ratios at the first detectable response to stimulation with 5mA were 0.88 (0.67-0.93) and 0.83 (0.61-0.93). After sugammadex and neostigmine, the respective intervals until TOF ratio ≥0.90 were 2.0 (0.8-3.3) and 15.9 (7.3-28.8)min. Intraoperative reversal of shallow rocuronium-induced block with either sugammadex or neostigmine is an efficient method. For reliable detection of lumbar nerve roots with a stimulating current of 10mA, the block should be reversed to a TOF ratio of at least 0.70. For a current intensity of 5mA, the TOF ratio should reach 0.90.

Drug‐specific cyclodextrins with emphasis on sugammadex, the neuromuscular blocker rocuronium and perioperative anaphylaxis: implications for drug allergy

Cyclodextrins, oligosaccharides linked in a circular arrangement around a central cavity, are used extensively in the pharmaceutical industry to improve drug delivery. Their usefulness depends on their capacity to form a drug inclusion, or host-guest, complex within the cavity. In an attempt to improve the delivery of the widely used neuromuscular blocking drug (NMBD) rocuronium, a rocuronium inclusion complex was formed with a chemically modified γ-cyclodextrin. The high binding affinity and specificity of the modified carrier (named sugammadex) for rocuronium (and other aminosteroid NMBDs) led to its use in anaesthesia as an innovative and useful agent for rapid reversal of rocuronium-induced neuromuscular block by sequestering the drug as an inclusion complex. This, in turn, led to the suggestion that sugammadex might be useful to remove the NMBD from the circulation of patients experiencing rocuronium-induced anaphylaxis, a suggestion subsequently supported in case reports where traditional treatment had failed. Successful resuscitations suggested that sugammadex might be a valuable new treatment for such intractable cases but, given the inappropriateness of clinical trials, confirmation or refutation will have to await the slow accumulation of results of individual case reports. Important questions related to antibody accessibility of drug allergenic structures on the rocuronium-sugammadex inclusion complex, and the competition between sugammadex and IgE antibodies (both free and cell bound) for rocuronium, also remain and can be investigated in vitro. The sugammadex findings indicate that the use of carrier molecules such as the cyclodextrins to improve drug delivery will sometimes give rise to changed immunologic and allergenic behaviour of some drugs and this will have to be taken into account in preclinical drug safety assessments of drug-carrier complexes. The possibility of encapsulating and removing other allergenic drugs, e.g., penicillins and cephalosporins, in cases of difficult-to-reverse anaphylaxis to these drugs is discussed.

Re-establishment of neuromuscular block by rocuronium after sugammadex administration

To the Editor, Patients occasionally may require reoperation in the immediate postoperative period. We present a case where rocuronium-induced neuromuscular block (NMB) was achieved more than 2 h after sugammadex had been given. Written consent for publication of the manuscript was granted by the patient. A 65-year-old man (American Society of Anesthesiologists physical status III, weight 95 kg, body mass index 29.3 kg m) with a history of hypertension, dyslipidemia, and symptoms suggesting carotid vascular disease was scheduled for left carotid endarterectomy. Laboratory values were within normal limits. Two hours after the procedure while the patient was in the postanesthesia care unit, he developed an expanding neck hematoma without airway compromise and was brought back to the operating room for hematoma evacuation. Following preoxygenation, anesthesia was induced slowly with fentanyl 100 lg, etomidate 15 mg, and rocuronium 50 mg (0.53 mg kg). Once the patient was unconscious, gentle manual ventilation was applied, and neuromuscular function was monitored with acceleromyography using train-of-four (TOF) stimulation of the ulnar nerve (TOF-Watch SX, Organon Ireland Ltd, a division of MSD, Swords, Co. Dublin, Ireland). Calibration was performed at the left adductor pollicis (AP) before rocuronium administration. Neuromuscular data were collected via the TOF-Watch SX monitoring program. The onset time from the injection of rocuronium until maximum NMB was 4 min 56 s; the maximum first twitch depression (T1 block) attained at the AP was 86%. An additional 10 mg of rocuronium was administered, achieving a maximum T1 block of 90%. Tracheal intubation was accomplished with ease 5 min after rocuronium administration, and anesthesia was maintained with propofol and remifentanil. Accelerometer calibration was lost because it was impossible to access the patient’s arm during surgery. At the end of the procedure 60 min later, the TOF-Watch monitor was set in the TOF mode with the initial calibration parameters. At that time, the TOF ratio was 0.12. Sugammadex 160 mg (1.7 mg kg) was injected, and within 1 min, the TOF ratio reached the value of 0.9. The patient’s trachea was then extubated. Subsequently, we learned from the previous anesthesia team that sugammadex 400 mg (4.2 mg kg) had been given to antagonize rocuronium-induced NMB, but this was not recorded in the patient’s chart. No neuromuscular monitoring had been used for the first procedure. The time interval between the previous dose of sugammadex and the second intubating dose of rocuronium was 143 min. It is recommended to wait 24 h following the initial reversal of NMB with sugammadex before re-administering rocuronium. This waiting time is based on a mean clearance of 95 ml min for sugammadex. In our case, sugammadex 4.2 mg kg was administered only 143 min before another dose of rocuronium was given. Unnecessarily large doses of sugammadex have a potential downside, as patients occasionally may require re-operation in the immediate postoperative period. It is important to use

Intravenous lidocaine has no impact on rocuronium-induced neuromuscular block but improves intubation conditions: Randomised study

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Local and Regional Anaesthesia

Reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients

This study compared the reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients. Fifteen younger (20-50 yr) and 15 older (≥70 yr) patients were sequentially enrolled in this study. After induction of anaesthesia and laryngeal mask insertion, contraction of the adductor pollicis muscle in response to ulnar nerve stimulation was quantified using acceleromyography during 1.0-1.5% end-tidal sevoflurane and remifentanil anaesthesia. All patients initially received rocuronium 1 mg kg(-1), followed by 0.02 mg kg(-1) when a post-tetanic count (PTC) of 1 or 2 was observed. After completion of surgery, at reappearance of 1-2 PTC, the time required for a single bolus dose of 4 mg kg(-1) sugammadex to produce recovery to a train-of-four (TOF) ratio of 0.9 was recorded. There were no differences in the total dose of rocuronium administered between the younger [mean (sd): 93.4 (17.5) mg] and the older [97.5 (32.2) mg] groups. In all patients, adequate recovery of the TOF ratio to 0.9 was achieved after administration of sugammadex, although it was significantly slower in the older [3.6 (0.7) min, P<0.0001] than in the younger group [1.3 (0.3) min]. There were no clinical events attributable to recurarization. Sugammadex can adequately restore neuromuscular function in older patients, although a longer time is required to recover from profound rocuronium-induced neuromuscular block than in younger patients.

Combination of sugammadex and neostigmine for reversal of a rocuronium-induced neuromuscular block

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Local and Regional Anaesthesia

Train-of-four ratio recovery often precedes twitch recovery when neuromuscular block is reversed by sugammadex

Sugammadex reverses rocuronium-induced neuromuscular block (NMB). In all published studies investigating sugammadex, the primary outcome parameter was a train-of-four (TOF) ratio of 0.9. The recovery time of T1 was not described. This retrospective investigation describes the recovery of T1 vs. TOF ratio after the reversal of NMB with sugammadex. Two studies were analyzed. In study A, a phase II dose-finding study, ASA I-II patients received an intravenous (IV) dose of rocuronium 1.2 mg/kg, followed by an IV dose of sugammadex (2.0, 4.0, 8.0, 12.0 or 16.0 mg/kg) or placebo (0.9% saline) after 5 min. In study B, a phase III trial comparing patients with renal failure and healthy controls, rocuronium 0.6 mg/kg was used to induce NMB; sugammadex 2.0 mg/kg was administered at reappearance of T2. Neuromuscular monitoring was performed by acceleromyography and TOF nerve stimulation. The primary efficacy variable was time from the administration of sugammadex to recovery of the TOF ratio to 0.9. Retrospectively, the time to recovery of T1 to 90% was calculated. After the reversal of rocuronium-induced NMB with an optimal dose of sugammadex [16 mg/kg (A) or 2 mg/kg (B)], the TOF ratio recovered to 0.9 significantly faster than T1 recovered to 90%. Clinical signs of residual paralysis were not observed. After the reversal of NMB by sugammadex, full recovery of the TOF ratio is possible when T1 is still depressed. The TOF ratio as the only measurement for the adequate reversal of NMB by sugammadex may not always be reliable. Further investigations for clinical implications are needed.

Onset of rocuronium-induced neuromuscular block evaluated subjectively and accerelomyographically at the masseter muscle

The main aim of this study was to compare the onset times of rocuronium evaluated subjectively and by acceleromyography at the masseter muscle (MM). Forty female patients were sequentially enrolled in this study. In the first 20 patients, neuromuscular block was evaluated subjectively. After induction of anesthesia with fentanyl and propofol, both the left masseter and ulnar nerves were stimulated in 2-Hz train-of-four (TOF) mode using peripheral nerve stimulators. Contractions of the MM were felt with an anesthesiologist's left hand holding an anesthesia facemask; those of the adductor pollicis (APM) were visually observed. All the patients received a bolus of rocuronium, 0.6 mg/kg. Onset times after rocuronium were defined as the duration until the contractions became impalpable at the MM or invisible at the APM. At the time contraction of the MM had not been felt, intubating conditions were assessed. In the next 20 patients, contractions of the MM and the APM were concurrently quantified using acceleromyography after induction of anesthesia and laryngeal mask insertion. Following 0.6 mg/kg rocuronium, onset of the action was recorded. Onset of the action of rocuronium at the MM evaluated subjectively [mean (SD), 70.3 (17.7) s] was similar to that monitored acceleromyographically [73.3 (27.6) s, P > 0.05], and significantly shorter than that at the APM acceleromyographically [111.0 (34.8) s, P = 0.016]. Intubating conditions of 20 patients were graded either excellent or good. Subjective evaluation of contractions of the MM by an anesthesiologist's hand may be reliable to determine faster timing for safe tracheal intubation.

Reversal of rocuronium-induced neuromuscular block by sugammadex is independent of renal perfusion in anesthetized cats

Sugammadex is a selective relaxant binding agent designed to encapsulate the aminosteroidal neuromuscular blocking agent rocuronium, thereby reversing its effect. Both sugammadex and the sugammadex-rocuronium complex are eliminated by the kidneys. This study investigated the effect of sugammadex on recovery of rocuronium-induced neuromuscular block in cats with clamped renal pedicles, as a model for acute renal failure. Twelve male cats were divided into two groups and anesthetized with medetomidine, ketamine, and alpha-chloralose. The cats were intubated and ventilated with a mixture of oxygen and air. Neuromuscular monitoring was performed by single twitch monitoring. Rocuronium 0.5mg/kg i.v. was administered. After spontaneous recovery from neuromuscular block, both renal pedicles were ligated. A second dose of rocuronium 0.5mg/kg i.v. was given. One minute after disappearance of the twitches, in Group 1 placebo (0.9% saline) and in Group 2 sugammadex 5.0mg/kg i.v. was administered. Onset time, duration of neuromuscular block, and time to recovery to 25, 50, 75, and 90% were determined. After renal pedicle ligation, sugammadex reversed rocuronium-induced neuromuscular block significantly faster than spontaneous recovery. Mean time (SEM) to 90% recovery of the twitch response was 4.7 (0.25)min (Group 2) versus 31.1 (5.0)min (Group 1) (p<0.0001). No signs of recurrence of neuromuscular block were observed for 90min after complete twitch restoration. Sugammadex caused no significant cardiovascular effects. Sugammadex rapidly and effectively reversed rocuronium-induced neuromuscular block in anesthetized cats, even when both renal pedicles were ligated and renal elimination of the drugs was no longer possible.

The antagonistic effect of neostigmine on rocuronium-, clindamycin-, or both-induced neuromuscular blocking in the rat phrenic nerve-hemidiaphragm

BackgroundNeostigmine augments clindamycin-induced neuromuscular block and antagonizes rocuronium-induced neuromuscular block; however, it remains unclear whether neostigmine enhances the neuromuscular blocking (NMB) that is caused by combinations of rocuronium and clindamycin. The intent of this study was to determine whether neostigmine potentiates the muscle relaxation that is induced by combinations of rocuronium and clindamycin and to estimate whether both clindamycin and rocuronium have synergistic actions on NMB.MethodsForty-one left phrenic nerve-hemidiaphragms (from male Sprague-Dawley rats, 150-250 g) were mounted in Krebs solution. Three consecutive single twitches (ST, 0.1 Hz) and one tetanic tension (50 Hz for 1.9 s) were obtained for each increase in concentration of rocuronium or clindamycin. The concentrations of rocuronium were cumulatively increased until an 80% to 90% reduction in ST was attained in the Krebs solutions pre-treated with 0 (n = 5), 0.1 (n = 1), 0.25 (n = 1), 0.5 (n = 4), or 1.0 (n = 1) mM clindamycin or with 0 (n = 4), 0.1 (n = 1), 0.5 (n = 5), 1.0 (n = 5), or 2.0 (n = 4) mM clindamycin in combination with 250 nM neostigmine, and so were the concentrations of clindamycin in the Krebs solutions pre-treated with 0 (n = 6) or 250 nM (n = 6) neostigmine.ResultsClindamycin increased the potency of rocuronium for ST and tetanic fade, irrespective of the presence of neostigmine. Neostigmine shifted the concentration-response curve of rocuronium to the right in the presence or absence of clindamycin. The interaction between rocuronium and clindamycin was synergistic when clindamycin concentrations were in excess of 0.5 mM, irrespective of the presence of neostigmine.ConclusionsNeostigmine may partially antagonize the neuromuscular block that is induced by a combination of clindamycin and rocuronium. Clinicians are advised to be aware that clindamycin synergistically increases the degree of rocuronium-induced neuromuscular block, even when neostigmine is present.

A case where rocuronium was unable to achieve neuromuscular block immediately after sugammadex administration

We present a case where immediate muscle relaxation was needed following sugammadex administration. A 72 year-old female underwent surgery for a cerebral artery aneurysm. Upon conclusion of the operation sugammadex (9.3 mg/kg) was administered and the patient was noted to have left hemiplegia. Rocuronium (1.2 mg/kg × 2 doses) was given in order to gain neuromuscular block approximately 25 minutes after sugammadex had been injected. Although TOF monitoring was not utilized in this case and assessing residual muscular block was difficult, spontaneous respirations continued and breathing had to be controlled with sevoflurane and remifentanil. Sugammadex is a potent reversal agent for rocuronium-induced neuromuscular block, however, certain situations require immediate neuromuscular blockade following sugammadex. In this case, rocuronium was unable to induce neuromuscular blockade immediately after sugammadex and that higher concentrations were necessary in addition to intravenous analgesics and inhaled anesthetics.

Sugammadex reversal of rocuronium-induced neuromuscular block in Caesarean section patients: a series of seven cases

Sugammadex reversal of rocuronium-induced neuromuscular block in Caesarean section patients: a series of seven cases