rocuronium and Myasthenia-Gravis

Myasthenia gravis (MG) is a challenge for anesthesia management. This report shows that the use of rocuronium-sugammadex is not free from flaws and highlights the importance of cholinesterase inhibitors management and neuromuscular block monitoring in the perioperative period of myasthenic patients.. Myasthenic female patient submitted to general balanced anesthesia using 25 mg of rocuronium. Under train-of-four (TOF) monitoring, repeated doses of sugammadex was used in a total of 800 mg without recovery of neuromuscular blockade, but TOF ratio (TOFR) was stabilized at 60%. Neostigmine administration led to the improvement of TOFR.. Although the use of rocuronium-sugammadex seems safe, we should consider their unpredictability in myasthenic patients. This report supports the monitoring of neuromuscular blockade as mandatory in every patient, especially the myasthenic ones.

Topics: Adult; Cholinesterase Inhibitors; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neostigmine; Neuromuscular Blockade; Neuromuscular Monitoring; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy.. Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg. Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg. Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy.. Clinical Trial Registry of China ( http://www.chictr.org.cn ) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Topics: Adult; Anesthetics; Dose-Response Relationship, Drug; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Intubation, Intratracheal; Magnesium Sulfate; Male; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Thymectomy; Young Adult

The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium-sugammadex in myasthenic patients undergoing thoracoscopic thymectomy.. After ethical approval, 10 myasthenic patients undergoing videothoracoscopic-assisted thymectomy were enrolled in the study. Neuromuscular block was achieved with 0.3 mg/kg rocuronium and additional doses were given according to train-of-four (TOF) monitoring or movement of the diaphragm. Sugammadex 2 mg/kg was given after surgery. Recovery time (time to obtain a TOF value > 0.9) was recorded for all subjects.. All patients were extubated in the operating room after administration of sugammadex. Mean rocuronium dose was 48 mg and the average operation time was 62 min. Recovery time after sugammadex administration was 111 s (min 35; max 240).. A rapid recovery of neuromuscular function was found in myasthenic patients receiving rocuronium when sugammadex was used for reversal. This combination could be a rational alternative for myasthenic patients for whom neuromuscular blockade is mandatory during surgery.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Cholinesterase Inhibitors; Elective Surgical Procedures; Female; gamma-Cyclodextrins; Humans; Male; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Monitoring; Neuromuscular Nondepolarizing Agents; Pyridostigmine Bromide; Rocuronium; Severity of Illness Index; Sugammadex; Thoracic Surgery, Video-Assisted; Thymectomy; Thymoma; Thymus Neoplasms

Myasthenia gravis is an autoimmune disease marked by high titers of immunoglobulin G antibodies, which accelerate destruction of cholinergic receptors and interfere with neuromuscular transmission. This study aimed to determine whether neuromuscular function under a rocuronium block is different from function under a vecuronium block patients with myasthenia gravis and to describe extubation conditions in the operating room or the intensive care unit.. Randomized, single-blind clinical trial enrolling patients with myasthenia gravis type IIa and IIb according to the classification of Osserman. The patients were randomized to groups receiving a vecuronium or rocuronium block. We recorded arterial oxygen saturation, capnogram, heart rate, noninvasive blood pressure, electrocardiogram, and neuromuscular function by accelerometry. During surgery 25% of the total dose of the neuromuscular blocking agent was administered. Maintenance was with a continuous infusion of propofol and fentanyl. All patients were extubated according to clinical criteria, confirmed by train-of-four ratio (T4/T1).. The mean (SD) time elapsed before recovery of 25% of neuromuscular function was 53.1 (1.9) min in the rocuronium group and 56.2 (0.8) min in the vecuronium group (P = .01). Time elapsed before recovery of 90% of function was 71.3 (2.7) min in the rocuronium group and 96.3 (1.2) min in the vecuronium group (P = .001). Twenty-eight of the 30 patients in the rocuronium group (93.3%) were extubated with recovery of 89.1% (0.5%) of twitch response and a T4/T1 ratio of 0.83. The difference between groups was statistically significant (P = .01). In no case was it necessary to administer a maintenance dose or reverse the block.. The rocuronium block had a better profile than the vecuronium block in this study. With this blocking agent we were able to circumvent respiratory depression, with its immediate consequences, and thus meet the main clinical criterion when anesthetizing patients with myasthenia gravis.

Topics: Adult; Androstanols; Female; Humans; Male; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Single-Blind Method; Thymectomy; Vecuronium Bromide

Patients with myasthenia gravis are more sensitive than healthy patients to nondepolarizing neuromuscular blocking drugs. We performed a pharmacokinetic/pharmacodynamic modeling study of rocuronium in eight myasthenic patients and eight matched control patients. Patients were anesthetized with propofol and sufentanil and a mixture of nitrous oxide/oxygen. Mechanomyographical monitoring of the adductor pollicis was applied. Rocuronium was infused at a rate of 25 micro g. kg(-1). min(-1) in myasthenic patients and 116.7 micro g. kg(-1). min(-1) in control patients and was terminated at 70% neuromuscular block. Arterial blood samples were drawn during onset and offset of the block and for 4 h after the administration of rocuronium. Plasma concentrations were determined by high-performance liquid chromatography. Pharmacokinetic/pharmacodynamic modeling was performed by using the Sheiner model and the unbound receptor model (URM), which takes into account the number of unbound acetylcholine receptors. The effective concentration at 50% effect and the steepness of the concentration-effect relationship were significantly decreased in myasthenic patients. Both the URM and the Sheiner model provided an adequate fit in myasthenic patients. The acetylcholine receptor concentration was significantly decreased in myasthenic patients. The URM explains the observed differences in time course and potency, whereas the Sheiner model does not.. We performed a pharmacokinetic/pharmacodynamic modeling study in myasthenic patients and control patients. The unbound receptor model, which takes into account the number of unbound acetylcholine receptors in the biophase, was introduced and compared with the model proposed by Sheiner.

Topics: Adolescent; Adult; Androstanols; Bayes Theorem; Cholinesterase Inhibitors; Electric Stimulation; Electromyography; Female; Humans; Male; Middle Aged; Models, Biological; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Pyridostigmine Bromide; Receptors, Cholinergic; Rocuronium

BACKGROUND Incomplete recovery from residual neuromuscular block agent (NMBA) after anesthesia is a serious adverse event in the post-anesthesia care unit. Acetylcholinesterase neostigmine is usually used to reverse residual neuromuscular blockade and facilitate spontaneous breathing and endotracheal extubation. CASE REPORT A 40-year-old woman received general anesthesia for strabismus correction surgery. At the end of surgery, repeated doses of neostigmine up to 85 µg/kg failed to reverse the residual neuromuscular blockade (train-of-four [TOF] ratio below 21%). Sugammadex (200 mg) provided immediate reversal, with the TOF ratio up to 100%. The patient regained spontaneous breathing, and the endotracheal tube was removed. After surgery, myasthenia gravis was diagnosed. CONCLUSIONS When unexpected prolonged neuromuscular blockade presents, the TOF ratio should be used to detect its depth and guide a reasonable dose of reversal agents. Anticholinesterase has a ceiling effect; once acetylcholinesterase activity is fully inhibited, administration of additional anticholinesterase can result in no further recovery. Furthermore, excessive acetylcholine can cause muscle weakness. In contrast, sugammadex is a selective reversal agent for steroidal NMBA, which works by encapsulation via tight water-soluble complexes with amino steroids (eg, rocuronium) rather than increasing acetylcholine at the neuromuscular junction. In this case, the recovery from moderate neuromuscular blockade by sugammadex was more effective and rapid than that by neostigmine. When refractory and prolonged residual neuromuscular blockade presents after repeated doses of anticholinesterase, sugammadex should be considered as an effective reversal agent. Particularly in cases of myasthenia gravis, sugammadex is superior to neostigmine for reversing rocuronium-induced NMBA in patients undergoing surgery.

Topics: Acetylcholine; Acetylcholinesterase; Adult; Androstanols; Cholinesterase Inhibitors; Delayed Emergence from Anesthesia; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neostigmine; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it.. To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex.. A retrospective cohort study.. Nationwide acute in-patient care database.. A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals.. The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy.. There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035.. Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Topics: Humans; Japan; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Retrospective Studies; Rocuronium; Sugammadex; Thymectomy; Treatment Outcome

In myasthenia gravis (MG) patients, postoperative myasthenic crisis, and residual neuromuscular blocking agent (NMBA) can cause respiratory failure that requires mechanical ventilation. However, it remains unclear whether the use of sugammadex for NMBA reversal reduces postoperative myasthenic crisis in MG patients undergoing surgery. We analyzed the association between use of sugammadex and postoperative myasthenic crisis in patients with MG using a national inpatient database.. Adult patients with MG who received thymectomy under general anesthesia were identified in the Japanese Diagnosis Procedure Combination database from July 1, 2010 to March 31, 2016. Patients who received sugammadex (sugammadex group) were compared with those who did not receive sugammadex (control group). The primary outcome was postoperative myasthenic crisis, and the secondary outcomes were postoperative pneumonia, tracheostomy, 28-day mortality, total hospitalization costs, and length of stay after surgery. Propensity scores were estimated by logistic regression based on the following variables: age; sex; body mass index (BMI); smoking index; history of cancer; Charlson comorbidity index (CCI); type of thymectomy; time from hospital admission to surgery; use of plasma exchange, immunosuppressants, corticosteroids, anticholinesterase, and oral benzodiazepine before surgery; type of hospital; and treatment year. The outcomes were compared using stabilized inverse probability of treatment weighting (IPTW) analyses to obtain good between-group balance.. Of 795 patients identified, 506 patients received sugammadex and 289 patients did not. After stabilized IPTW, the sugammadex group was associated with a decrease in postoperative myasthenic crisis (22/507 [4.3%] vs 25/288 [8.7%]; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.91), but not associated with a decrease in postoperative pneumonia (5/507 [1.0%] vs 7/288 [2.4%]; OR, 0.44; 95% CI, 0.17-1.14) or tracheostomy (7/507 [1.4%] vs 10/288 [3.5%]; OR, 0.38; 95% CI, 0.12-1.22) compared with the control group. The sugammadex group had significantly lower median (interquartile range) total hospitalization costs ($13,186 [$11,250-$16,988] vs $14,119 [$11,713-$20,207]; P < .001) and median length of stay after surgery (10 [8-15] vs 11 [8-18] days; P < .001), compared with the control group.. In this retrospective observational study, sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs in adult patients with MG who received thymectomy. Given the present findings, sugammadex should be routinely administered for MG patients undergoing thymectomy.

Topics: Adult; Aged; Cohort Studies; Databases, Factual; Female; Humans; Japan; Male; Middle Aged; Myasthenia Gravis; Neuromuscular Blocking Agents; Postoperative Complications; Propensity Score; Retrospective Studies; Rocuronium; Sugammadex; Thymectomy; Treatment Outcome

The objective of this systematic review is to identify the effectiveness of sugammadex versus neostigmine on the reversal of rocuronium-induced neuromuscular blockade in surgical patients with myasthenia gravis undergoing general anesthesia.

Topics: Anesthesia, General; Cholinesterase Inhibitors; Delayed Emergence from Anesthesia; Humans; Incidence; Myasthenia Gravis; Neostigmine; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex; Systematic Reviews as Topic; Time Factors; Vecuronium Bromide

Myaesthenia Gravis is an autoimmune disorder that results in increased sensitivity to neuromuscular blockers. Anaesthesia and surgery in patients with Myaesthenia Gravis is associated with an increased incidence of complications, including post operative ventilation. We report the successful use of intra-operative train of four ratio monitoring and Sugammadex to reverse rocuronium induced neuromuscular blockade in an elderly octagenarian with Myaesthenia Gravis undergoing an emergency laporotomy.. An 87year old man with Myaesthenia Gravis underwent an emergency laporotomy for a perforated sigmoid diverticulum. Induction of anaesthesia was performed with 100μg of fentanyl, 120mg propofol and 25mg rocuronium. Intraoperative boluses of 5mg rocuronium were guided by train of four ratio of 50%. At the end of the procedure 4mg/kg of Sugammadex was given to reverse neuromuscular blockade as observed by return of four twitches on the train of four. He was then successfully extubated and did not require any post operative ventilation.. We report the successful use of intra-operative neuromuscular monitoring and Sugammadex to reverse rocuronium induced neuromuscular blockade in an elderly octagenarian with Myaesthenia Gravis undergoing emergency laporotomy.

Topics: Aged, 80 and over; Androstanols; Anesthesia, General; Colectomy; Colon, Sigmoid; Diverticulum, Colon; Emergency Treatment; gamma-Cyclodextrins; Humans; Intestinal Perforation; Male; Monitoring, Intraoperative; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Blocking Agents; Neuromuscular Nondepolarizing Agents; Propofol; Rectum; Rocuronium; Sugammadex

Train-of-four ratio (TOFR) is often used to evaluate muscle relaxation caused by neuromuscular-blocking agents (NMBAs). However, it is unknown whether TOFR reliably correlates with the first twitch tension (T1) in patients with myasthenia gravis (MG). By using rat models of experimental autoimmune MG (EAMG), the authors verified the hypothesis that the severity of MG influences the relationship between TOFR and T1.. EAMG rats were divided into sham, moderate MG, and severe MG groups. Isometric twitch tension of the hemidiaphragm was elicited by phrenic nerve stimulation with and without use of the NMBA rocuronium to measure TOFR and T1, and run-down of endplate potentials was estimated in the three groups. Changes around the neuromuscular junction in EAMG rats were investigated by observation of electron micrographs.. With similar attenuation of T1, TOFR was significantly (n = 6) different among the three groups in the presence of 50% inhibitory concentrations of rocuronium (IC50). Run-down in the sham group was significantly (n = 8) greater with exposure to IC50, whereas that in the severe MG group was statistically insignificant. Width of the primary synaptic cleft in the severe MG group was significantly (n = 80) greater than that in the other groups.. Severity of MG influences the relationship between TOFR and T1, together with changes in run-down of endplate potentials and those around the neuromuscular junction in rats. TOFR may, therefore, not be an accurate indicator of recovery from NMBAs in MG patients.

Topics: Androstanols; Animals; Diaphragm; Disease Models, Animal; Excitatory Postsynaptic Potentials; Female; Myasthenia Gravis; Neuromuscular Junction; Neuromuscular Monitoring; Neuromuscular Nondepolarizing Agents; Rats; Rats, Inbred Lew; Rocuronium; Severity of Illness Index; Synaptic Transmission

Topics: Aged; Androstanols; Anesthesia; Aortic Valve; Cardiopulmonary Bypass; gamma-Cyclodextrins; Humans; Male; Myasthenia Gravis; Rocuronium; Sugammadex

Several previous studies using univariate analysis have suggested that the pre-anaesthetic train-of-four (TOF) ratio, concentration of anti-acetylcholine receptor (AChR) antibodies and the presence of preoperative generalised muscular involvement are determinants of an increased response to neuromuscular blocking agents (NMBAs) in patients with myasthenia gravis. However, the determinants of the response of patients with myasthenia gravis to rocuronium, which is expected to be used more frequently since the advent of sugammadex, have not been studied.. To clarify whether previously suggested determinants of the response to other intermediate-acting NMBAs would also affect the response to rocuronium and to reveal the determinants of the increased response to rocuronium in individual patients with myasthenia gravis using multivariate analysis.. Case control study.. Kumamoto University Hospital, November 2010 to September 2013.. Thirty-eight patients with myasthenia gravis having surgery using a total intravenous anaesthetic technique were investigated. After induction of general anaesthesia, the 95% effective dose (ED95) of rocuronium was calculated using cumulative dose-finding methods. Neuromuscular function was monitored by acceleromyographic assessment of TOF responses of the adductor pollicis muscle to ulnar nerve stimulation. Patients were then divided into the increased response (ED95 <0.15 mg kg, n = 13) and non-increased response groups (ED95 ≥0.15 mg kg, n = 25).. Demographic data, TOF ratio before rocuronium injection (baseline TOF ratio), concentration of anti-AChR antibodies, Osserman classification and treatment for myasthenia gravis in the two groups were compared.. Stepwise logistic regression identified baseline TOF ratio and age of onset of myasthenia gravis as determinants of the increased response to rocuronium in patients with myasthenia gravis [odds ratios (95% confidence interval) of 0.87 (0.77 to 0.98; P = 0.02) and 0.92 (0.86 to 0.99; P = 0.03), respectively].. Multivariate analysis identified baseline TOF ratio and age of disease onset as determinants of the increased response to rocuronium in patients with myasthenia gravis.. Registered with UMIN Clinical Trials Registry, identifier: UMIN000006766.

Topics: Accelerometry; Adult; Aged; Androstanols; Anesthesia, General; Case-Control Studies; Female; Hospitals, University; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myasthenia Gravis; Neuromuscular Monitoring; Neuromuscular Nondepolarizing Agents; Rocuronium; Young Adult

The anesthetic management of patients affected by myasthenia gravis is usually challenging in elective surgery and even more so in emergency procedures. The difficulties involved are several-fold, ranging from the choice of an appropriate muscle relaxant (i.e. one that enables safe and rapid airway management) to neuromuscular monitoring and normal muscular recovery. Additionally, optimizing patient conditions - either pharmacologically or with plasmapheresis - before intervention is well beyond the realm of possibility. We discuss the anesthetic management of two myasthenic patients undergoing emergency surgery (for sigmoid perforation and upper gastrointestinal bleeding respectively). In both cases, we opted for rapid-sequence induction with high-dose rocuronium to prevent inhalation of gastric contents. We also report on the implication of neuromuscular monitoring. We found that the rocuronium-sugammadex combination was a useful and effective option in the emergency setting.

Topics: Aged; Androstanols; Female; gamma-Cyclodextrins; Humans; Male; Middle Aged; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Monitoring; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Topics: Adult; Androstanols; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex; Thymectomy

We report a patient with myasthenia gravis whose rocuronium induced neuromuscular block was reversed with sugammadex. A 26-year-old man, 175 cm and 76 kg, with myasthenia gravis, was scheduled for extended thymectomy under general anesthesia. An epidural catheter was inserted at the T5-6 interspace before induction of general anesthesia. Anesthesia was induced with propofol and remifentanil. Rocuronium was given in divided doses to obtain > 95% neuromuscular block to intubate the trachea. The ED50 and ED95 of rocuronium for this patient were 0.18 mg x kg(-1) and 0.39 mg x kg(-1), respectively. The values were similar to the ED50 and ED95 of rocuronium for normal patients. General anesthesia was maintained with propofol and remifentanil. Additional doses of rocuronium were given intermittently. Sugammadex, 2 mg x kg(-1), was given at the end of the surgery. The train-of-four ratio reached 93% 105 sec later. His postoperative course was uneventful.

Topics: Adult; Androstanols; gamma-Cyclodextrins; Humans; Male; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex; Thymectomy

We report on two patients with ocular myasthenia gravis who received rocuronium, followed later by sugammadex to reverse neuromuscular blockade. Recovery was monitored simultaneously at the adductor pollicis muscle (APM) and the corrugator supercilii muscle (CSM).. Two patients with ocular myasthenia gravis (case 1: 74 yr-old female, 54 kg; case 2: 71 yr-old male, 72 kg) were scheduled for surgery under general anesthesia. Neuromuscular blockade was induced with rocuronium 0.3 mg·kg(-1) after placing two separate monitors at the APM and the CSM, respectively. Additional doses of rocuronium 0.1-0.2 mg·kg(-1) were given to maintain neuromuscular blockade at fewer than two twitches at the APM during surgery. Train-of-four response at the CSM did not show recovery of the twitch after its initial disappearance. At the end of surgery, sugammadex was administered. Twitch height at the APM recovered to the control value in 12 min (case 1) and 13 min (case 2) after sugammadex administration; however, twitch height at the CSM took 26 min (case 1) and 14 min (case 2) to recover to the control value.. After rocuronium-induced paralysis in both patients with ocular myasthenia, spontaneous recovery and sugammadex-assisted recovery were slower at the CSM than at the APM. In patients without the disorder, CSM recovery is faster than APM recovery. Thus, in ocular myasthenia gravis, neuromuscular recovery at the APM may not reflect recovery of all muscles.

Topics: Aged; Androstanols; Female; gamma-Cyclodextrins; Humans; Male; Monitoring, Physiologic; Muscle, Skeletal; Myasthenia Gravis; Neuromuscular Blockade; Recovery of Function; Rocuronium; Sugammadex

Topics: Adult; Androstanols; Cesarean Section; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Pregnancy; Pregnancy Complications; Rocuronium; Sugammadex

Topics: Aged; Androstanols; Anesthesia, General; Cholinesterase Inhibitors; Female; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Pyridostigmine Bromide; Rocuronium; Sugammadex; Thymectomy; Thyroidectomy

Neuromuscular blocking drugs (NMBDs) can predispose patients with myasthenia gravis to postoperative paralysis and respiratory complications. We had a 12-year-old female patient undergoing thoracoscopic thymectomy. She had suffered from MGFA class IIa (mild systemic) myasthenia gravis for 4 months. Anesthesia was induced with 3 mg x kg(-1) of thiopental and 0.2 mg x kg(-1) of rocuronium, which was given incrementally to achieve 100% blockade. Anesthesia was maintained with oxygen, air, 2% sevoflurane and 0.2 microg x kg(-1) x min(-1) of remifentanil. 0.05 mg x kg(-1) of rocuronium was added when the TOF ratio recovered to 20%. Towards the end of the surgery, remifentanil was withdrawn and 4 microg x kg(-1) of fentanyl was given. Intercostal nerve block with 0.2% ropivacaine was performed to relieve postoperative pain. TOF ratio was 32% at the end, when we gave 2 mg x kg(-1) of sugammadex to get 100% reversal of neuromuscular blockade in 120 seconds. There was no residual paralysis and respiratory complications postoperatively.

Topics: Androstanols; Anesthesia, General; Child; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Perioperative Care; Rocuronium; Severity of Illness Index; Sugammadex; Thoracoscopy; Thymectomy

As myasthenia gravis affects neuromuscular transmission, these patients show various responses to neuromuscular blocking drugs. We report a successful use of the sugammadex in a myasthenic patient to reverse rocuronium-induced neuromuscular block. A 69-year-old woman was scheduled for laparoscopic cholecystectomy and total of rocuronium 20 mg was administered. After spontaneous recovery of T1, we administered sugammadex 200mg intravenously, reversing neuromuscular blockade to a train-of-four ratio (T4/T1) of 100% within 30 sec. Sugammadex can be used to reverse rocuronium-induced neuromuscular blockade in patients with myasthenia gravis, thereby avoiding the need for reversal with acetylcholinesterase inhibitors.

Topics: Aged; Androstanols; Cholecystectomy, Laparoscopic; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Topics: Androstanols; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Male; Middle Aged; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Myasthenia gravis, affecting neuromuscular transmission, leads to a large variability in sensitivity to depolarising and non-depolarising neuromuscular blocking drugs. We report the successful use of the modified mu-cyclodextrin sugammadex in a myasthenic patient to reverse a rocuronium-induced deep level of neuromuscular block. After spontaneous neuromuscular recovery of T2 (second twitch of the train-of-four series), we administered 2 mg.kg(-1) of sugammadex intravenously, reversing neuromuscular blockade to a train-of-four ratio (T4/T1) > 90% within 210 s. Sugammadex, in combination with objective neuromuscular monitoring, can be used to reverse rocuronium-induced neuromuscular blockade in patients with myasthenia gravis, thereby avoiding the need for reversal with acetylcholinesterase inhibitors.

Topics: Aged; Androstanols; Anesthesia Recovery Period; gamma-Cyclodextrins; Humans; Male; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Postoperative Care; Rocuronium; Sugammadex

Topics: Adult; Androstanols; Cholecystectomy, Laparoscopic; Female; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

A neuromuscular blocking drug (NMBD) induced neuromuscular blockade (NMB) in patients with myasthenia gravis usually dissipates either spontaneously or by administration of neostigmine. We administered sugammadex to a patient with myasthenia gravis to reverse a rocuronium-induced profound NMB. NMBDs predispose such patients to severe postoperative residual paralysis and respiratory complications. Sugammadex binds steroidal NMBDs and, therefore reverses a rocuronium or vecuronium-induced NMB, without interfering with cholinergic transmission. A rapid and complete recovery from profound NMB was achieved and no adverse events were observed. This case suggests that sugammadex is a safe and effective antagonist of a rocuronium induced NMB blockade in patients with myasthenia gravis.

Topics: Aged; Androstanols; Anesthesia Recovery Period; Breast Neoplasms; Disease Susceptibility; Female; gamma-Cyclodextrins; Humans; Mastectomy; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Paralysis; Postoperative Complications; Preanesthetic Medication; Rocuronium; Sentinel Lymph Node Biopsy; Sugammadex

Topics: Androstanols; gamma-Cyclodextrins; Humans; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Postoperative Care; Rocuronium; Sugammadex

Thymectomy continues to be the treatment of choice for certain patients with myasthenia gravis. As surgical techniques have developed, anesthesiologists have considered the need to adapt anesthetic techniques to improve care of patients undergoing this procedure. We describe the anesthetic management of 2 patients undergoing thymectomy performed with a bilateral thoracoscopic approach. Because it is best to avoid the use of opiates during and after surgery, we performed a bilateral paravertebral thoracic block, inserting the catheters into the paravertebral space on each side to infuse local anesthetics on either side as needed as the operation progressed. Surgery was completed without adverse events and tubes were removed from the tracheas of both patients at the end of the procedures. Bilateral continuous infusion of local anesthetics provided satisfactory analgesia on the following days.

Topics: Adult; Analgesia; Androstanols; Anesthesia, Inhalation; Anesthetics, Local; Combined Modality Therapy; Contraindications; Dose-Response Relationship, Drug; Female; Humans; Methyl Ethers; Myasthenia Gravis; Nerve Block; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Pyridostigmine Bromide; Rocuronium; Sevoflurane; Thoracic Surgery, Video-Assisted; Thymectomy; Thymoma; Thymus Neoplasms

A decrement in evoked muscle force with repetitive nerve stimulation (fade) suggests impaired neuromuscular transmission. We tested the hypothesis that fade of pulmonary function, ie, a decrease in values of FVC with the second spirometric maneuver compared to the first maneuver, occurs during impaired neuromuscular transmission.. Prospective study.. Six healthy male volunteers.. A series of three consecutive spirometric maneuvers was performed every 5 min in six awake healthy volunteers before, during, and after partial paralysis evoked by rocuronium (0.01 mg/kg IV plus 2 to 8 microg/kg/min).. We measured FVC, FEV(1), forced inspiratory volume in 1 s (FIV(1)), peak expiratory flow (PEF), and peak inspiratory flow (PIF) by spirometry, and force of adductor pollicis muscle by mechanomyography (train-of-four [TOF] stimulation). A statistically significant fade (reduction of the second maneuver from the first maneuver) of FVC, FEV(1), FIV(1), PEF, and PIF was observed during neuromuscular blockade. With peak relaxation (TOF ratio, 0.5) fade amounted to medians of 10% (interquartile range [IQR], 9 to 23%), 7% (IQR, 2 to 16%), 31 (IQR, 19 to 47%), 9% (IQR, 3 to 24%), and 30% (IQR, 5 to 43%), respectively. A fade of >or= 10% was always associated with a clinically relevant (>or= 10%) FVC reduction from baseline (ie, FVC before rocuronium administration). However, FVC reduction from baseline was still present in 23% of measurements without a relevant FVC fade.. A clinically relevant fall (fade) in FVC from the first to the second value during or after neuromuscular blockade suggests impaired pulmonary function and may be due to muscle paralysis. For this reason, the first (best) FVC value may overestimate pulmonary function and expose the patient to an unidentified risk.

Topics: Adult; Androstanols; Humans; Male; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Prospective Studies; Respiratory Mechanics; Rocuronium; Spirometry; Vital Capacity

Topics: Androstanols; Anesthesia Recovery Period; Half-Life; Humans; Intraoperative Care; Male; Middle Aged; Myasthenia Gravis; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Postoperative Care; Rocuronium; Thymectomy; Thymus Neoplasms

Topics: Adult; Androstanols; Female; Humans; Male; Middle Aged; Myasthenia Gravis; Neuromuscular Nondepolarizing Agents; Rocuronium; Thymectomy

Topics: Adult; Androstanols; Female; Humans; Myasthenia Gravis; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium