Unexpected failure of rocuronium-mediated neuromuscular blockade

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Sugammadex is effective in rapidly reversing rocuronium- and vecuronium-induced neuromuscular blockade, the combination providing fast onset and rapidly reversible blockade [1], but anaesthesiologists should be aware of the possible prolonged duration of action of sugammadex in patients with renal failure.

A 93-year-old man underwent nephrostomy under general anaesthesia at our institution. He subsequently developed acute renal failure and was scheduled for an emergency nephrectomy 16 h after the first operation, to be performed by different surgical and anaesthesia teams. We induced anaesthesia with 100 mg propofol, 0.2 mg fentanyl and 50 mg rocuronium, and performed tracheal intubation. After skin incision the surgeon noted unusual twitching of the intercostal muscles in response to electrocauterisation. We then performed relaxometry with a S/5M-NMT NeuroMuscular Transmission Module® (Datex-Ohmeda Division, Instrumentarium Corp., Helsinki, Finland), which to our surprise did not indicate any neuromuscular blockade. After an additional dose of 30 mg rocuronium the train-of-four ratio remained 100%. Careful inspection of the previous anaesthesia record revealed that the neuromuscular blockade achieved with 30 mg rocuronium the evening before had been reversed with 200 mg sugammadex. Unfortunately, this information had not been transferred personally from one anaesthesia team to the next.

In healthy patients, the mean cumulative percentage of sugammadex excreted in the urine over 24 h is 48–86% [2]. Therefore, a period of 24 h is recommended before a second administration of rocuronium. The package insert of sugammadex discourages its administration to patients with severe renal dysfunction. De Boer et al. modelled free rocuronium levels at different dose combinations of rocuronium and sugammadex and recommended doses of rocuronium between 750 and 1500 μg.kg−1 to re-establish neuromuscular blockade following sugammadex administration [3]. In our case, 80 mg rocuronium (1100 μg.kg−1) was not sufficient to produce neuromuscular blockade. Staals et al. showed the efficacy of sugammadex in patients with a creatinine clearance of less than 30 ml.min−1 [4], but impaired renal function significantly reduced the plasma clearance of sugammadex and the sugammadex-rocuronium complex [5]. Recently, it was shown that neuromuscular blockade could be re-established with 1.2 mg.kg−1 rocuronium as early as 5 min after 4 mg.kg−1 sugammadex. Onset time and duration of neuromuscular blockade block varied according to the time interval between sugammadex reversal and re-administration of rocuronium [6]. The effectiveness of a second dose of rocuronium following sugammadex has yet to be investigated in patients with renal failure.

KSKB has received speaker′s fees from Merck, Sharp & Dohme. No other competing interest declared. Published with the written assent from the patient’s relatives (patient unfortunately deceased).

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