Anesthesia-Related Pharmacology and Toxicology
The use of rocuronium in a patient with cystic fibrosis and end-stage lung disease made safe by sugammadex reversal
Porter MV, Paleologos MS (Royal Prince Alfred Hosp, New South Wales, Australia) Anaesth Intensive Care 39:299-302, 2011§
While the pharmacology of sugammadex has been extensively reviewed, there is limited literature regarding its use in specific clinical settings. Several case reports describe its use in patients with the potential for postoperative respiratory dysfunction; in the settings of myasthenia gravis, Duchenne muscular dystrophy and myotonic dystrophy. We describe the use of sugammadex in a patient with severe bronchiectasis related to cystic fibrosis who required neuromuscular block for percutaneous endoscopic gastrostomy insertion. The use of rocuronium for neuromuscular block was preferred in order to avoid the potential complications associated with the use of suxamethonium. However, we wished to ensure complete neuromuscular block reversal for this short duration procedure in this high-risk patient and also to avoid the side-effects of traditional reversal agents. We therefore planned in advance to use sugammadex for neuromuscular block reversal, and this approach proved successful. Overall, the combination of rocuronium and sugammadex improved perioperative surgical and anaesthetic management in this patient.
Postoperative residual neuromuscular block results in decreased hypoxic drive,1 increased incidence of postoperative pulmonary complications,2,3 and decreased coordination of the musculature involved in swallowing.4 While estimates are that postoperative residual neuromuscular block occurs in 10% to 40% of patients receiving a general anesthetic with neuromuscular blockade, it is generally not appreciated in the clinical setting.5 There is, however, a subset of patients that will tolerate this compromise of muscle strength more poorly than the general population. The authors of this case report mention some of these, including patients with myasthenia gravis and patients with compromised pulmonary function, especially those needing to have a short surgical procedure where complete recovery from neuromuscular blockade (even after the administration of an anticholinesterase) is unlikely.
These authors describe the successful use of the combination of rocuronium and sugammadex, the selective-relaxant binding agent, in a patient with cystic fibrosis requiring placement of a percutaneous endoscopic gastrostomy to allow for improvement of her nutritional status. She received approximately 0.75 mg/kg rocuronium for a rapid sequence induction of anesthesia and appropriately, with the return of 2 twitches in response to train-of-four stimulation, 5 mg/kg sugammadex for reversal of residual neuromuscular block. The patient’s trachea was extubated, and her postoperative course uneventful.
Sugammadex binds to rocuronium so that the neuromuscular blocking agent is unable to bind to the acetylcholine receptor of the neuromuscular junction. The rocuronium-sugammadex complex is eliminated in the urine.6 Because of its mechanism of action, sugammadex will cause more rapid recovery of neuromuscular function than an anticholinesterase administered at the same point in spontaneous recovery.7 Because complete recovery of neuromuscular function (a train-of-four ratio >0.9) is increasingly recognized as adequate recovery, this type of rapid and complete recovery profile will become increasingly necessary. In addition to decreasing the incidence of postoperative pulmonary complications, complete recovery of neuromuscular function after the administration of sugammadex results in shorter postanesthesia care unit stays and shorter times to discharge from the hospital. Whether the savings in medical care costs will be enough to off set the acquisition cost of sugammadex will have to be determined. Because sugammadex is not available for use in the United States, clinicians practicing here will have to continue to optimize care using agents that are available.