Authors: Yoshioka K, et al.
Cureus 17(9): e91997, September 10, 2025. doi:10.7759/cureus.91997
This case report describes a 50-year-old hemodialysis patient who experienced rocuronium extravasation during induction for occipitocervical fixation. Despite administration of additional intravenous rocuronium, prolonged neuromuscular blockade occurred. Train-of-four (TOF) monitoring revealed unstable counts ranging from 0 to 4 between 37 and 90 minutes after drug administration, complicating interpretation. However, the first twitch height (T1) remained consistently low (average 2 ± 2%) and later increased steadily in parallel with recovery, ultimately reaching 33% with a TOF ratio of 94% at 162 minutes. Sugammadex 200 mg (3.17 mg/kg) was administered after spontaneous respiratory recovery, and the patient was extubated safely without recurarization.
What You Should Know:
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Rocuronium extravasation can prolong and complicate neuromuscular recovery, particularly in patients with renal failure.
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TOF count may fluctuate significantly, making depth assessment unreliable.
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T1 (first twitch height) is a more stable and scalable indicator of blockade depth, reflecting recovery even when TOF counts are inconsistent.
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Safe extubation can be guided by combining T1 trends, TOF ratio, and clinical respiratory parameters.
Clinical Relevance:
This report underscores the importance of T1 monitoring as a practical and reliable tool when TOF counts are unstable, especially in high-risk patients with impaired drug clearance. For anesthesiologists, careful quantitative monitoring and judicious use of sugammadex can help avoid both premature extubation and postoperative recurarization in cases of extravasation.
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