Recurarization after sugammadex following a prolonged rocuronium infusion for induced hypothermia
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Recurarization after sugammadex following a prolonged rocuronium infusion for induced hypothermia Tetsuya Murata, MD • Toshi Kubodera, MD • Masakazu Ohbayashi, MD • Kichiro Murase, MD, PhD • Yushi U. Adachi, MD, PhD • Naoyuki Matsuda, MD, PhD
Received: 14 January 2013 / Accepted: 15 February 2013 / Published online: 5 March 2013 Ó Canadian Anesthesiologists’ Society 2013
To the Editor, Sugammadex encapsulates the steroidal neuromuscular blocking agents, rocuronium and vecuronium, and rapidly reverses their effect. Although recurarization is possible after administration of sugammadex,1 only a few cases have been documented clinically.2 We report here a patient showing signs of neuromuscular block in spite of repeated administration of sugammadex. Consent for publication of this report was obtained from the patient’s family. A 56-yr-old male patient with chronic renal failure was scheduled for a pancreatoduodenectomy. On the morning of the planned surgery, he underwent a cardiac arrest while still on the ward of our university hospital. After recovery of spontaneous circulation, tracheal intubation was performed, and emergency contrast-enhanced computed tomography revealed a pulmonary air embolism. He was admitted to the intensive care unit where therapeutic mild hypothermia was induced (day 1) and continuous hemodiafiltration therapy was initiated. T. Murata, MD Department of Anesthesia, Daiyukai General Hospital, Nagoya City, Aichi, Japan T. Kubodera, MD Department of Emergency Medicine, Ohgaki Municipal Hospital, Ohgaki City, Gifu, Japan M. Ohbayashi, MD K. Murase, MD, PhD N. Matsuda, MD, PhD Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya City, Aichi, Japan Y. U. Adachi, MD, PhD (&) Department of Emergency Medicine, Nagoya University Hospital, Nagoya City, Aichi, Japan e-mail: [email protected]
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To prevent shivering as one of the complications of hypothermia, rocuronium was infused continuously at a rate of 25 mghr-1. The patient received 1,376 mg over 46.5 hr (day 3). Two days later (day 5), his body temperature had recovered, hemodynamic variables were stable, and consciousness had improved. Accordingly, weaning from mechanical ventilation was attempted for tracheal extubation; however, his tidal volume was small under pressure support mode (8 cm H2O). An accelomyographic monitor (TOF-WatchÒ, NihonKoden, Tokyo, Japan) applied to the adductor pollicis muscle showed a train-of-four (TOF) count of four with a TOF ratio of 0.2. Consequently, sugammadex 400 mg was administered. Immediately after the injection, the patient’s responses to noxious stimuli and verbal commands showed improvement; however, 12 hr later, tidal volume in the pressure support mode (8 cm H2O) had decreased, and the patient’s response to stimuli was weak. A second injection of sugammadex (400 mg) was administered, and this clearly increased tidal volume and the response to noxious stimuli. On the next day (day 6), after confirmation of adequate ventil
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