Effective Use of Sugammadex for Incomplete Pyridostigmine Reversal
of Muscle Relaxation by Rocuronium: A Case Report
394
tidal CO2. Her pre-anesthetic vital signs were BP 130/82
mmHg, HR 73 bpm, and SpO2 96%. General anesthesia
was induced with remifentanil 0.5 μg/kg/min and propo-
fol 80 mg IV. After the loss of eyelash reflex was con-
firmed, neuromuscular monitoring began immediately.
For the calibration of acceleromyography (TOF-Watch
SX®, Organon Ltd., Dublin, Ireland), a 5-s 50-Hz supra-
maximal tetanic stimulus was administered over both
ulnar nerves [6]. A supramaximal current was obtained
after the initial single twitch calibration. After stabiliza-
tion of control responses, rocuronium 30 mg (0.43 mg/kg)
was administered due to an estimated short surgical time,
and tracheal intubation was performed at the disappear-
ance of the TOF response. Anesthesia was maintained
with desflurane 6% by volume in 50% oxygen-enriched
air and remifentanil 0.2 μg/kg/min, and this mixture was
titrated to maintain a bispectral index (BIS) of approxi-
mately 40. At 45 minutes after induction of anesthesia,
the patient bucked in response to surgical traction, so ro-
curonium 10 mg was injected. At that time, the TOF re-
sponse showed three twitches. The surgical procedure
ended 10 minutes after receiving the last dose of rocuro-
nium. The neuromuscular block was antagonized with
glycopyrrolate 0.4 mg and pyridostigmine 10 mg IV,
when one twitch was shown at TOF stimulation. Fifteen
minutes passed after the reversal with no indication that
the patient was recovering from the rocuronium-induced
NMB. Only one twitch was not changed at TOF stimula-
tion. At that point, a bolus of IV sugammadex 140 mg (2
mg/kg) was injected to remove the residual NMB. A TOF
ratio of 1.0 was confirmed by acceleromyography within
2 minutes. Tracheal extubation was performed unevent-
fully in the operating room. The patient’s postoperative
recovery course was unremarkable.
3. Discussion
The recovery time from rocuronium may be increased in
elderly and female patients [7]. Due to this fact and an
estimated short surgical time, low-dose rocuronium 30
mg (0.43 mg/kg) was injected initially for this patient.
However, an additional dose of rocuronium 10 mg was
required once the surgical time was prolonged, and the
patient began bucking in response to surgical traction.
The surgical procedure ended abruptly 10 minutes after
receiving the last dose of rocuronium. Initially, we de-
cided to use glycopyrrolate 0.4 mg and pyridostigmine
10 mg IV after the confirmation of one twitch at TOF
stimulation, which have an onset of 2 - 5 minutes, a peak
activity occurring at about 10 - 20 minutes, and a 2 - 4
hour duration [8]. After fifteen minutes from the reversal,
the TOF response of one twitch was not changed. Pyri-
dostigmine does not achieve complete reversal of muscle
blockade compared to neostigmine at 10% of initial first
twitch height during pancuronium-induced NMB [9].
The incidence of residual block (TOF ratio < 0.7) after
reversal using pyridostigmine 10 mg is 21.5% in the re-
covery room [4]. Moreover, the time to obtain a TOF
ratio of 0.9 is extended greatly [10]. Only in Korea
pyridostigmine is still used as a reversal agent in clinical
practice (more than 80%) [11]. We think that the stan-
dard of care for reversal of rocuronium-induced NMB in
Korea should be changed from pyridostigmine, with its
lower potency and slower onset, to neostigmine. The rea-
son of prolonged paralysis after reversal of neuromuscu-
lar blockade was not known, but we suspect that the con-
comitant drugs (local anesthetics, antibiotics, and cal-
cium channel blockers, etc) have also been affected.
Sugammadex is a modified γ-cyclodextrin that forms
tight one-to-one complexes with rocuronium and, to a
slightly lesser extent, vecuronium, resulting in rapid ter-
mination of NMB [12]. Sugammadex is a fast and predi-
ctable dose-dependent reversing agent of any degree of
block induced by rocuronium, a property that cannot be
replicated with neostigmine/glycopyrrolate [13]. In mod-
erate degrees of neuromuscular block (reappearance of
two twitches), significantly faster recovery (1.5 min) to a
TOF ratio of 0.9 occurred after administration of sugam-
madex 2 mg/kg compared to neostigmine 50 µg/kg (18.6
min) [14]. Sugammadex (4.0 and 8.0 mg/kg) reversed
profound NMB (post-tetanic count 1 or 2) induced by ro-
curonium in a mean time of 1.7 minutes [13]. Sugam-
madex has the potential to be cost-effective compared
with neostigmine/glycopyrrolate for the reversal of ro-
curonium-induced moderate or profound NMB and po-
tentially provides increased patient safety due to the in-
creased predictability of recovery from NMB [15]. In this
case, moderate rocuronium-induced NMB was success-
sfully reversed within 2 minutes with sugammadex at
doses of 2 mg/kg. Sugammadex made it possible that the
predictable effectiveness of a reversal agent, and which
fully prevents residual block, is therefore highly desir-
able.
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