Reactions 1680, p301 - 2 Dec 2017 uneventful. Author comment: "This report presents 2 examples of prolonged or unexpected responses to rocuronium, documented by continuous quantitative monitoring, in Prolongation of neuromuscular blockade and otherwise completely healthy individuals." "[T]he first patient breathing difficulty: 2 case reports might have been given a much larger dose of [rocuronium In a case report, a 39-year-old woman developed bromide], with resultant adverse consequences that may or prolongation of neuromuscular blockade and breathing may not have been recognized as relaxant related." difficulty following the administration of rocuronium bromide due to a medication error. A 54-year-old woman developed Leonard PA, et al. Quantitative neuromuscular blockade monitoring: Two pictures prolongation of neuromuscular blockade following the of unexpected rocuronium effect: A case report. A and A Case Reports 9: 190-192, No. 7, 01 Oct 2017. Available from: URL: http://doi.org/10.1213/ administration of rocuronium bromide [not all routes stated]. XAA.0000000000000568 - USA 803284683 Case 1: A 39-year-old woman presented for an urgent laparoscopic salpingostomy and salpingectomy for ectopic pregnancy. An endotracheal intubation was planned with intense opioid effect rather than neuromuscular blockade. Rocuronium bromide was to be administered only as needed to facilitate the laparoscopy. However, timing of the first dose of the muscle relaxant was not clarified to the trainee by the staff anaesthesiologist. Hence, the trainee inadvertently administered IV rocuronium bromide 5mg (0.08 mg/kg) along with midazolam and lidocaine for endotracheal intubation. The anaesthesiologist thought the error was minor and did not intervene. She appeared to rest quietly, but postoperatively, she volunteered that she was unable to communicate the sudden difficulty in breathing. She was then administered propofol, remifentanil and ketamine. Her trachea was intubated without additional administration of rocuronium bromide. Following endotracheal intubation, electromyographic (EMG) neuromuscular blockade monitoring was performed, by both the monitor recording and manual palpation methods, which showed that the stimuli elicited only a weak response. Due to the known possibility for problems with the monitoring system and the lack of a baseline recording, the electrodes were replaced. At approximately 17 minutes following the first dose of rocuronium bromide, a reproducible, high-quality EMG waveform was noted, with a train-of-four (TOF) ratio of approximately 0.1. Over the next 22 minutes, her TOF ratio progressively increased to >0.8. By the time, her oesophageal temperature decreased from 36.3 °C to 36.2 °C. She was administered a second dose of rocuronium bromide 5mg, due to which TOF ratio decreased to 0 (two twitches). Further, rocuronium bromide was not administered. Sixty seven minutes after the second dose, TOF ratio recovered to 0.91 and the temperature decreased from to 35.4 °C. The tracheal extubation was performed uneventfully. She was maintained on anaesthesia with propofol, remifentanil and isoflurane with a continuous EMG monitoring. She might have been administered a much larger dose of rocuronium bromide, i.e., an additional dose administered for the first time, which led to the adverse consequences. Case 2: A 54-year-old woman was scheduled for an acoustic neuroma resection. After placing the routine monitors, including the EMG neuromuscular blockade monitor, anaesthesia was induced with propofol and fentanyl and maintained with desflurane and supplemental doses of fentanyl. The lowest recorded rectal temperature was 34.8 °C, which later raised to 35.8 °C. Prior to rocuronium bromide administration, her TOF ratio was 1.0. Following the induction, she was administered a muscle relaxant namely, rocuronium bromide 40mg (0.4 mg/kg; 0.7 mg/kg IBW) for endotracheal intubation. All the twitches disappeared after two minutes. However, one twitch was elicited, 30 minutes following administration of rocuronium bromide and four twitches (with a TOF ratio of 0.2) were elicited, 55 minutes after the initial dosing. Further, rocuronium bromide was not administered. The spontaneous recovery of neuromuscular function was extremely prolonged. At 9.5 hours following the administration of rocuronium bromide, her TOF ratio was 0.87–0.89. She was administered neostigmine and her TOF ratio increased to 0.96 after 5 minutes. Another dose of neostigmine was administered. Five minutes later, the TOF ratio was 1.00–1.03. The temperature remained stable. Emergence from anaesthesia and tracheal extubation were 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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