Use of sugammadex after neostigmine incomplete reversal of rocuronium-induced neuromuscular blockade.
OBJECTIVE
Neuromuscular blockers (NMB) have been used for more than half of a century in anesthesia and have always been a challenge for anesthesiologists. Until recently, the reversal of nondepolarizing neuromuscular blockers had only one option: the use of anticholinesterase agents. However, in some situations, such as deep neuromuscular blockade after high doses of relaxant, the use of anticholinesterase agents does not allow adequate reversal of neuromuscular blockade. Recently, sugammadex, a gamma-cyclodextrin, proved to be highly effective for reversal of NMB induced by steroidal agents.


METHODS
A female patient who underwent an emergency exploratory laparotomy after rapid sequence intubation with rocuronium 1.2mg.kg(-1). At the end of surgery, the patient received neostigmine reversal of NMB. However, neuromuscular junction monitoring did not show the expected recovery, presenting residual paralysis. Sugammadex 2mg.kg(-1) was used and the patient had complete reversal of NMB in just 2 minutes time.


CONCLUSIONS
Adequate recovery of residual neuromuscular blockade is required for full control of the pharynx and respiratory functions in order to prevent complications. Adequate recovery can only be obtained by neuromuscular junction monitoring with TOF ratio greater than 0.9. Often, the reversal of NMB with anticholinesterase drugs may not be completely reversed. However, in the absence of objective monitoring this diagnosis is not possible. The case illustrates the diagnosis of residual NMB even after reversal with anticholinesterase agents, resolved with the administration of sugammadex, a safe alternative to reverse the NMB induced by steroidal non-depolarizing agents.
São Paulo Serviços Médicos de Anestesiologia (SMA), Brazil.
Cássio Campelo
CC
de Menezes
Lilian Akemi Moore
LA
Peceguini
Enis Donizetti
ED
Silva
Claudia Marquez
CM
Simões
D000368:Aged; D000732:Androstanols / Q000627:therapeutic use*; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use; D005260:Female; D006801:Humans; D009388:Neostigmine / Q000627:therapeutic use; D019148:Neuromuscular Blockade; D003473:Neuromuscular Nondepolarizing Agents / Q000627:therapeutic use*; D000077123:Rocuronium; D000077122:Sugammadex; D017211:Treatment Failure; D047408:gamma-Cyclodextrins / Q000627:therapeutic use*
D000732:Androstanols; D002800:Cholinesterase Inhibitors; D003473:Neuromuscular Nondepolarizing Agents; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D009388:Neostigmine; D000077123:Rocuronium