rocuronium and Respiratory-Insufficiency

Burn injury leads to resistance to the effects of non-depolarizing muscle relaxants. We tested the hypothesis that a larger bolus dose is as effective as priming for rapid onset of paralysis after burns.. Ninety adults, aged 18-59 yr with 40 (2)% [mean (SE)] burn and 30 (2) days after injury, received rocuronium as a priming dose followed by bolus (0.06+0.94 mg kg(-1)), or single bolus of either 1.0 or 1.5 mg kg(-1). Sixty-one non-burned, receiving 1.0 mg kg(-1) as a primed (0.06+0.94 mg kg(-1)) or full bolus dose, served as controls. Acceleromyography measured the onset times.. Priming when compared with 1.0 mg kg(-1) bolus in burned patients shortened the time to first appearance of twitch depression (30 vs 45 s, P<0.05) and time to maximum twitch inhibition (135 vs 210 s, P<0.05). The onset times between priming and higher bolus dose (1.5 mg kg(-1)) were not different (30 vs 30 s for first twitch depression and 135 vs 135 s for maximal depression, respectively). The onset times in controls, however, were significantly (P<0.05) faster than burns both for priming and for full bolus (15 and 15 s, respectively, for first twitch depression and 75 and 75 s for maximal depression). Priming caused respiratory distress in 10% of patients in both groups. Intubating conditions in burns were significantly better with 1.5 mg kg(-1) than with priming or full 1.0 mg kg(-1) bolus.. A dose of 1.5 mg kg(-1) not only produces an initial onset of paralysis as early as 30 s, which we speculate could be a reasonable onset time for relief of laryngospasm, but also has an onset as fast as priming with superior intubating conditions and no respiratory side-effects.

Topics: Adult; Aged; Androstanols; Burns; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Humans; Intubation, Intratracheal; Male; Middle Aged; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Prospective Studies; Respiratory Insufficiency; Rocuronium; Time Factors; Young Adult

We present a case of a pediatric patient who developed recurarization after a cardiac catheterization procedure. Intraoperative neuromuscular blockade was achieved with 2 doses of rocuronium, and the blockade was reversed with a bolus dose of sugammadex at the end of the procedure. While recovering in the pediatric cardiac intensive care unit, the patient developed respiratory failure and a decline in the train-of-four response. The patient fully recovered after receiving a second dose of sugammadex.

Topics: Delayed Emergence from Anesthesia; Female; Humans; Infant; Neuromuscular Blockade; Postoperative Period; Respiratory Insufficiency; Rocuronium; Sugammadex

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

We report the anesthetic management of a female neonate with congenital cyst adenoid malformation (CCAM) type III of the lung who underwent the lower right lobe resection 22 days after birth. General anesthesia was induced with propofol and rocuronium. The trachea was intubated with a 3.0 standard tube. Anesthesia was maintained with sevoflurane in an air/oxygen mixture and fentanyl. Intraoperative anesthetic course was uneventful except transient desaturation during lung compression. Immediately, the saturation was restored by interruption of lung compression. One lung ventilation was not necessary in this operation. Postoperative course was uneventful. Patient was discharged home on the 28th postoperative day.

Topics: Androstanols; Anesthesia, General; Cystic Adenomatoid Malformation of Lung, Congenital; Female; Humans; Infant, Newborn; Intubation, Intratracheal; Pain, Postoperative; Perioperative Care; Pneumonectomy; Propofol; Respiratory Insufficiency; Rocuronium

A 40-year-old man was scheduled for video assisted thoracoscopic surgery due to pneumothorax. He had been diagnosed with inclusion body myositis and received nocturnal non-invasive positive pressure ventilation. Anesthesia was induced with propofol, remifentanil, and rocuronium, and maintained with propofol, remifentanil and fentanyl. The dosage of rocuronium was 10 mg. Although we administered neostigmine at the end of the operation and TOF ratio was over 90%, he was transported to the ICU with tracheal intubation because of poor spontaneous respiration. On POD 1, the tracheal tube was extubated and NPPV was administered again. Minitrach was inserted on POD 2, and he left the ICU on POD 4. Generally, in patients with myopathy the dose of muscle relaxant should be decreased in proportion to their muscle atrophy. Rocuronium 10 mg was administered in this case and we thought it could be antagonized by neostigmine, but extubation on the day of operation was impossible. We think this is not because of the residual effect of muscle relaxant, but because of decreases in pulmonary function. In this case, we expected long-term mechanical ventilation might be necessary, but he showed a good postoperative course owing to minimally invasive surgery, NPPV, and suctioning of sputum via Minitrach.

Topics: Androstanols; Anesthesia, Intravenous; Chronic Disease; Humans; Male; Myositis, Inclusion Body; Neuromuscular Depolarizing Agents; Perioperative Care; Pneumonectomy; Pneumothorax; Positive-Pressure Respiration; Respiratory Insufficiency; Rocuronium; Sputum; Suction; Thoracoscopy; Treatment Outcome

A 47-year-old woman with amyotrophic lateral sclerosis was scheduled for total thyroidectomy with cervical node dissection. During anesthetic management by total intravenous anesthesia using remifentanil, propofol, and rocuronium, train-of-four (TOF) monitoring findings were not consistent with clinical signs. Sugammadex successfully reversed shallow respiration.

Topics: Amyotrophic Lateral Sclerosis; Androstanols; Anesthesia, Intravenous; Anesthetics, Intravenous; Female; gamma-Cyclodextrins; Humans; Intraoperative Complications; Lymph Node Excision; Middle Aged; Neuromuscular Nondepolarizing Agents; Piperidines; Propofol; Remifentanil; Respiratory Insufficiency; Rocuronium; Sugammadex; Thyroidectomy

Topics: Adult; Androstanols; Anesthesia, General; Female; gamma-Cyclodextrins; Humans; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Postoperative Period; Respiratory Insufficiency; Rocuronium; Sugammadex; Time Factors

We report a case that involved immediate postoperative respiratory failure necessitating tracheal intubation, which was possibly related to recurarization after sugammadex reversal.. A 54-yr-old woman weighing 115-kg was scheduled for laparoscopic repair of abdominal dehiscence under general anesthesia. Muscle relaxation was induced and maintained with rocuronium (170 mg iv total dose). At the end of the 170-min procedure, two twitches were visualized after supramaximal train-of-four (TOF) stimulation at the adductor pollicis muscle, and the patient's central core temperature was 35.6°C. Sugammadex 200 mg iv (1.74 mg·kg(-1)) was administered. With the patient fully awake, a TOF ratio 0.9 was obtained five minutes later. The tracheal tube was then removed, and the patient was transferred to the postanesthesia care unit. Ten minutes later, the patient presented respiratory failure necessitating tracheal intubation and sedation with propofol. One TOF response only was visualized at the adductor pollicis muscle. Another dose of sugammadex 200 mg iv was administered. Forty-five minutes later, the patient was fully awake and her trachea was extubated after repeated measures of the TOF ratio (≥ 0.9) at the adductor pollicis muscle. The patient fully recovered without sequelae, further complication, or prolonged hospital stay.. Shortly after tracheal extubation, an obese patient experienced respiratory failure necessitating tracheal intubation and an additional dose of sugammadex. This occurred despite initial reversal of neuromuscular blockade with an appropriate dose of sugammadex 2 mg·kg(-1) iv given at two responses to TOF stimulation.

Topics: Androstanols; Anesthesia, General; Female; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Laparoscopy; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity; Respiratory Insufficiency; Rocuronium; Sugammadex; Surgical Wound Dehiscence

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