Luis Llamas, MD
Assistant Professor
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
San Antonio, Texas, USA
Steven Lindauer, MD
Assistant Professor
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
San Antonio, Texas, USA
Rachel Maldonado, MD
CA-2 Anesthesiology Resident
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
San Antonio, Texas, USA
Blanche Hensgens, MD
CA-3 Anesthesiology Resident
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
San Antonio, Texas, USA
The purpose of this case report is to educate and reinforce anesthesiologists in the United States about the availability and utility of sugammadex (Bridion, Merck) as an emergency rescue agent to prevent hypoxic brain injuries and emergent surgical airways with the associated morbidity, mortality, and costs. This case report describes a successful rescue reversal administration of 16 mg/kg of IV sugammadex—a reversal agent that acts as a selective antagonist of neuromuscular blockade induced by rocuronium and vecuronium—in a patient we could not intubate and who deteriorated into a “cannot ventilate” scenario.
The patient was a 56-year-old male, American Society of Anesthesiologists (ASA) physical status class III, with a medical history of hypertension, warfarin therapy for recurrent lower extremity deep vein thrombosis, and anxiety, who was scheduled for elective MRI of the head to evaluate recent vision changes. Two prior attempts to undergo MRI without anesthesia support were unsuccessful because the patient was claustrophobic and did not tolerate the MRI scanner.
The anesthesiology service was then consulted, and we agreed to provide anesthesia for the patient. We were informed by the MRI technician that the imaging study would take 3 hours to complete, so we elected to intubate him. On physical exam, the patient weighed 106 kg, was 6 ft 1 in tall, and had a Mallampati class III airway, approximately a 3-fingerbreadth mouth opening, a 6-cm thyromental distance, and full neck range of motion.
The patient was consented for general anesthesia and was premedicated with 2 mg of IV midazolam. He was then brought inside the MRI suite and preoxygenated for 5 minutes with standard monitors on. He was induced with 200 mg of IV propofol. After induction, we verified that he could tolerate face mask ventilation and administered 50 mg of IV rocuronium.
Using direct laryngoscopy with an MRI-compatible MAC 4 laryngoscope, we were unable to visualize the epiglottis. We then attempted direct laryngoscopy with an MRI-compatible Miller 2 laryngoscope, but we still did not see the epiglottis. We passed a bougie, which seemed to be in the esophagus, so we did not advance an endotracheal tube over it. Next, we attempted a bag-valve-mask ventilation, which was more difficult because the patient was producing large amounts of blood-tinged secretions. We attempted to place a size 4 LMA (Teleflex), which would not seat, and we could not ventilate or detect any end-tidal carbon dioxide on capnography.
At this point, we removed the LMA, but we could not manage to ventilate him using a 2-handed jaw thrust maneuver with the oral and nasal airways. We decided to call for help. I asked my colleague to bring 1,600 mg of sugammadex immediately. Our intubation and ventilation attempts lasted for approximately 8 minutes, during which time the patient’s oxygen (O2) saturation gradually dropped from 100% to 93%. The sugammadex arrived 8 minutes after induction of anesthesia, and we drew up eight 200-mg vials into a 20-mL syringe and administered a 1,600-mg IV bolus.
The patient then immediately sat up, spit out his oral airway, and asked us whether the MRI was over. He was alert, oriented and had an oxygen saturation of 100%, so we transported him to the recovery room with supplemental oxygen and pulse oximetry monitoring. We administered 12 mg of IV dexamethasone in the PACU to treat any airway edema from the direct laryngoscopies. He was discharged from the PACU with an Aldrete score of 10.
Stocked Just in Time
Two weeks before this case, our anesthesia department convinced our hospital pharmacy and therapeutics committee to add sugammadex to our formulary. Structurally, sugammadex is a modified cyclodextrin with a lipophilic core and hydrophilic periphery.1 It resembles a cup or a hoop that sequesters steroidal muscle relaxants for excretion via the kidneys.
According to the manufacturer’s package insert, the recommended dose is 2 mg/kg intravenously if there is a second twitch in train-of-four stimulation. The dose is increased to 4 mg/kg intravenously if spontaneous recovery of the twitch response has reached 1 to 2 post-tetanic counts and there are no twitch responses to train-of-four stimulation. Finally, 16 mg/kg intravenously is recommended if there is a need to reverse neuromuscular blockade soon (approximately 3 minutes) after administration of a single dose of 1.2 mg/kg of rocuronium.2
The FDA initially rejected sugammadex 3 times (2008, 2012 and 2014), but approved the medication for use in the United States on December 15, 2015. Sugammadex was approved for use in Australia and Europe in 2008 and in Japan in 2010.3,4 Prior case reports described the successful use of a rescue dose of sugammadex in the United Kingdom5 and Brazil,6 predating its FDA approval.
References
- Paton F, Paulden M, Chambers D, et al. Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block. Br J Anaesth. 2010;105(5):558-567.
- Bridon [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp; 2017. merck.com/ product/ usa/ pi_circulars/ b/ bridion/ bridion_pi.pdf. Accessed July 11, 2017.
- Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscularblock: an evidence-based review. Core Evid. 2013;8:57-67.
- Ledowski T. Sugammadex: what do we know and what do we still need to know? A review of the recent (2013 to 2014) literature. Anaesth Intensive Care. 2015;43(1):14-22.
- Paton L, Gupta S, Blacoe D. Successful use of sugammadex in a ‘can’t ventilate’ scenario. Anaesthesia. 2013;68(8):861-864.
- Barbosa FT, da Cunha RM. Reversal of profound neuromuscular blockade with sugammadex after failureof rapid sequence endotracheal intubation: a case report. Rev Bras Anestesiol. 2012;62(2):281-284.
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