rocuronium and Myotonic-Dystrophy

A 37-year-old female patient with myotonic dystrophy was scheduled for laparoscopic cholecystectomy for gall stone under general anesthesia with continuous propofol infusion. Rocuronium was administered with careful monitoring using TOF- Watch®, measuring train-of-four count (Tc), TOF ratio (Tr), and posttetanic count The total amount of rocuronium was 70 mg ; 0.6 mg .kg⁻1 for anesthetic induction and 0.3 mg .kg⁻1 when Tc exceeded 1. When the operation was completed, Tc was 4, Tr was uncountable and she showed reaction to calling her name. Then sugammadex 2 mg .kg⁻1, rapidly antagonized the neuromuscular block, such that the Tr recovered to 100% but tidal volume was 250 ml in 3 minutes. Additional dorsage of sugammadex, 2 mg .kg⁻1, was required for tidal volume to recover to 530 ml. After 20 minutes of first administration of sugammadex, we extubated the tracheal tube without respiratory depression. To avoid respiratory depression, we did not use postoperative opioids. Intraoperative transversus abdominis plane block and postoperative thoracic epidural block with ropivacaine were successful for postoperative pain relief.

Topics: Adult; Androstanols; Anesthesia, Epidural; Anesthesia, General; Cholecystectomy, Laparoscopic; Female; gamma-Cyclodextrins; Humans; Myotonic Dystrophy; Nerve Block; Neuromuscular Blockade; Propofol; Respiratory Insufficiency; Rocuronium; Sugammadex

Topics: Adult; Androstanols; Anesthesia, General; Cesarean Section; Contraindications; Female; gamma-Cyclodextrins; Humans; Infant, Newborn; Myotonic Dystrophy; Neostigmine; Neuromuscular Nondepolarizing Agents; Pregnancy; Pregnancy Outcome; Rocuronium; Sugammadex

Myotonic dystrophy type 1 (MD1) is the commonest muscular dystrophy found in adults; however, it may present in the neonatal period with hypotonia, talipes, poor feeding, and respiratory failure. Inheritance is autosomal dominant with a defect in the DMPK gene found on the long arm of chromosome 19 with variable expansion of the cytosine-thymine-guanine (CTG) triplet repeat. A 14-month-old boy with congenital MD type 1 was scheduled for percutaneous endoscopic gastrostomy (PEG) insertion, orchidopexy, and division of tongue-tie. Following induction of anesthesia, acceleromyography was used to monitor neuromuscular function. This revealed a very rapid onset of profound neuromuscular block which lasted significantly longer than would be expected in a child without MD1. Sugammadex reversed the block rapidly. The anesthetic management of children with MD1 has been well described but not the acceleromyographic monitored use of rocuronium and its subsequent reversal with the new cyclodextrin sugammadex.

Topics: Androstanols; Anesthesia; Electrocardiography; gamma-Cyclodextrins; Gastrostomy; Humans; Infant; Male; Monitoring, Intraoperative; Myography; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Orchiopexy; Rocuronium; Sugammadex; Tongue

Neuromuscular disorders like myotonic dystrophy (dystrophia myotonica or Steinert's disease) and spinal muscular atrophy are associated with perioperative complications related to muscle weakness. These patients have an increased sensitivity to non-depolarising neuromuscular blocking agents, which can lead to postoperative residual curarization (PORC) and its associated respiratory complications. Adequate reversal of neuromuscular blockade is essential to prevent this. Sugammadex is the first selective relaxant binding agent and it reverses rocuronium- and vecuronium-induced neuromuscular block. Two cases are reported in which the patients received sugammadex to reverse a rocuronium-induced neuromuscular block. Reversal of the rocuronium-induced neuromuscular block (NMB) in both cases was fast, effective and without recurarization, and no safety concerns were observed.

Topics: Adult; Androstanols; Female; gamma-Cyclodextrins; Humans; Middle Aged; Muscular Atrophy, Spinal; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

We report in this clinical case the successful use of a combination of rocuronium and sugammadex in a patient with Steinert myotonic dystrophy to perform a rapid sequence induction of anaesthesia. The patient had both contraindication to succinylcholine and a risk of prolonged neuromuscular blockade with non-depolarizing neuromuscular blocking agents. The use of high dose rocuronium (1mg/kg) allowed a quick and easy orotracheal intubation but induced a prolonged neuromuscular block, reversed with success by sugammadex (8 mg/kg).

Topics: Adult; Androstanols; Anesthesia; Drug Therapy, Combination; gamma-Cyclodextrins; Humans; Male; Myotonic Dystrophy; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex; Time Factors

Topics: Androstanols; Female; gamma-Cyclodextrins; Humans; Laparoscopy; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Ovarian Cysts; Rocuronium; Sugammadex; Young Adult

Topics: Adult; Androstanols; Female; gamma-Cyclodextrins; Humans; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

Patients with Myotonic Dystrophy show an unpredictable response to several anesthetic drugs including opioids, neuromuscular blocking agents and especially reversal agents like neostigmine. We describe the case of a 40 year old patient with myotonic dystrophy who underwent laparoscopic cholecystectomy and ovarian cyst removal under general anesthesia. The authors suggest the use of the new reversal agent suggamadex, for reversing neuromuscular blockade caused by rocuronium, in patients suffering from neuromuscular disease and especially from Myotonic Dystrophy, because it rapidly and completely reverses any residual neuromuscular blockade, but also underline the increased susceptibility of these patients to opioids.

Topics: Adult; Analgesics, Opioid; Androstanols; Anesthesia Recovery Period; Anesthesia, General; Cholecystectomy, Laparoscopic; Female; gamma-Cyclodextrins; Humans; Meperidine; Myotonic Dystrophy; Naloxone; Narcotic Antagonists; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Ovarian Cysts; Pain, Postoperative; Respiratory Insufficiency; Rocuronium; Sugammadex

We measured acceleromyography and mechanomyography simultaneously with monitoring of rocuronium-induced neuromuscular block in four patients with myotonic dystrophy type 1. Furthermore, we compared neuromuscular block measures from these patients with those from normal controls from previous studies. In myotonic dystrophy type 1 patients, the dose-response curve obtained with acceleromyography was steeper and right-shifted compared with that obtained using mechanomyography. However, the effective doses to produce 95% neuromuscular block determined with both acceleromyography and mechanomyography were similar to each other and to values found in normal patients. In the three myotonic dystrophy type 1 patients with mild to moderate disease, times to recovery from block were similar to those observed in normal controls. In both patients and normal controls, neuromuscular block recovered faster with acceleromyography. However, in one patient with severe muscle wasting, recovery of neuromuscular block was prolonged. We conclude that mechanomyography and acceleromyography cannot be used interchangeably to monitor neuromuscular block in myotonic dystrophy type 1 patients.

Topics: Adult; Androstanols; Dose-Response Relationship, Drug; Female; Humans; Middle Aged; Monitoring, Intraoperative; Myography; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium

Topics: Androstanols; gamma-Cyclodextrins; Humans; Laparoscopy; Male; Middle Aged; Myotonic Dystrophy; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex

In general anesthesia for a patient with dystrophia myotonica (DM), respiratory depression and muscle weakness by opioid, as well as prolongation of the effect of muscle relaxant are seen postoperatively. Therefore it is desirable to choose agents with short duration of action and to dose these medicines to the minimum. We report a case of a 45-year-old woman with DM who underwent laparotomy for uterine cancer under general anesthesia combined with epidural anesthesia. Epidural catheter was placed from T 11-12, and anesthesia was inducted with propofol and remifentanil (RF). We administered rocuronium bromide (RB) 5 mg while watching TOF ratio with a muscle relaxation monitor (TOF-Watch). T1 became 0 after giving a dose of 10 mg, and intubation was performed. We maintained anesthesia by propofol and RF combined with epidural anesthesia. TOF ratio was restored to around 80% 90 minutes after RB administration, but we did not give supplemental doses because the operation went well smoothly. Recovery was smooth and fast. The respiratory depression and the muscle spasm were not noticed. RB and RE both with short duration of action, are useful in anesthesia management in DM cases.

Topics: Androstanols; Anesthesia, Epidural; Anesthesia, Intravenous; Anesthetics, Intravenous; Female; Humans; Middle Aged; Myotonic Dystrophy; Neuromuscular Nondepolarizing Agents; Piperidines; Propofol; Remifentanil; Rocuronium; Uterine Neoplasms