A Case Series

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Medically Complex

57-year-old female

5’5”

120 lb

Hx CVA left and hemiplegia

Myasthenia gravis with poor respiratory effort, dyspnea at rest on home oxygen, medically optimized

Scheduled for outpatient diagnostic laparoscopy: r/o ovarian malignancy

Overnight stay if respiratory function poor postoperatively

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Midazolam 2 mg in holding for severe anxiety

Induction with propofol 150 mg

Fentanyl 100 mcg

Rocuronium 30 mg

Standard antiemetic prophylaxis

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Uneventful intraoperative course

At conclusion of surgery patient had PTC of 4

Reversed with sugammadex 200 mg

Full TOF and sustained tetanus

Extubated uneventfully

Discharged home that day

5 PTC=post tetanic count; TOF=train of four.

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Sugammadex is a modified gamma cyclodextrin. It forms a complex with the neuromuscular blocking agents rocuronium and vecuronium, and it reduces the amount of neuromuscular blocking agent available to bind to nicotinic cholinergic receptors in the neuromuscular junction. This results in the reversal of neuromuscular blocking induced by rocuronium and vecuronium.

7 www.FDA.gov

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Reprinted with permission from Gijsenbergh F, Ramael S, Houwing N, van Iersel T. First human exposure of Org 25969, a novel agent to reverse

the action of rocuronium bromide. Anesthesiology. 2005;103(4):695-703. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1924456.

Copyright © 2017 American Society of Anesthesiologists. Wolters Kluwer, Publisher.

Cavity created by the cyclodextrin ring is lipophilic; exterior is hydrophilic. Encapsulated lipophilic drugs therefore remain soluble in water.

Sugammadex/NMBA complex is then excreted by the kidneys.

Renal clearance of the NMBA is enhanced by sugammadex encapsulation.

9 Ach=acyetylcholine; SDEX=sugammadex.

Reprinted with permission from A Harris, M Welliver, R Redfern, N Kalynych, J McDonough.

Orthopaedic Surgery Implications Of A Novel Encapsulation Process That Improves Neuromuscular

Blockade And Reversal. The Internet Journal of Orthopedic Surgery. 2006 Volume 7 Number 2.

Internet Scientific Publications Web site. http://ispub.com/IJOS/7/2/7856. Accessed May 11, 2017.

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Cannot Ventilate Intubated Patient in Outpatient Surgical Center

43-year-old female for septoplasty, turbinate reduction, endoscopic sinus surgery

5’4”

185 lb (BMI: 31.8)

PMHx: asthma (prn albuterol, no formal diagnosis); migraines; anxiety; former smoker (quit 2 years ago)

PSHx: unremarkable

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Induction: midazolam 2 mg, fentanyl 50 mcg, Pre-O2, standard monitors

Propofol 200 mg, rocuronium 50 mg (0.6 mg/kg) – while mask ventilating, O2 sat drops to 70%, ventilation is easy and sats return to mid-90’s. Otherwise unremarkable

Intubation: Mac 3 – G1 view, LTA, 7.0 Oral RAE ETT + CO2, on Vent

TV 500 ml, Rate 20, PIP 29. Change to 400 ml x 12 and PIP to 27

Turned bed 90 degrees and noticed CO2 trace flat; VSS Checked anesthesia circuit – intact; called for surgeon to OR Turned bed back, attempted manual ventilation – could not

ventilate; called for anesthesia help

12 ETT=endotracheal tube; LTA=local tracheal anesthesia; PIP=peak inspiratory pressure; RAE=Ring,

Adair, and Elwyn; TV=tidal volume; VSS=vital signs stable.

Manual ventilation – high resistance – thinking possible severe bronchospasm – increased volatile, IV lidocaine, decadron – no change

Consider possibility of kinked or obstructed ETT – extubated, oral A/W – now 2-hand mask and still cannot ventilate. Try nasal A/W – still very little to no ventilation, no breath sounds present

HR increases to 120’s, BP approximately 100 systolic, O2 saturation starts to drift downward

ENT surgeon marks neck and has 15 blade in his hand – preparing for emergency cricothyrotomy

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Sugammadex 200 mg given, followed immediately by 300 mg IV O2 saturation at 62%; surgeon states that if he sees an O2

saturation beginning with a 5, he is making a hole in the neck

15 seconds later, patient takes a deep breath and resumes spontaneous ventilation. Gas turned off, albuterol administered via ETT; patient with end expiratory wheezes bilaterally; sats mid 90s

Case cancelled Patient taken to PACU Albuterol nebulizer in PACU CXR – PA/Lateral – unremarkable

14 PA=posterior-anterior; PACU=post anesthesia care unit.

Short answer: Not entirely clear

DDX: Bronchospasm (Reactive Airway Disease)

Allergic Reaction – Rocuronium?

Airway Obstruction – Mediastinal Mass?

?????????

15 DDX=differential diagnosis.

Patient is doing well

Continues to have mild dry cough, no fevers

Patient seen by pulmonologist. PTTs performed

Results:

Mild airway obstruction present Significant response to bronchodilators Normal diffusion capacity and lung volumes Elevated airway resistance (upper limit of normal) Diagnosis: Asthma. Will start steroid inhaler therapy Will consider CT to rule out mediastinal pathology

Appointment to see allergist for skin testing

Diagnosis TBD

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Cannot Intubate! Cannot Ventilate!

A 76-year-old male, 124 kg, with a history of CAD, MI, paroxysmal A-fib

AICD in 2009

OSA, on CPAP at home

Laryngeal carcinoma (r) s/p surgery, chemotherapy, and radiation. C/O increasing hoarseness from microlaryngoscopy and laser treatment left cord

He is the definition of a difficult airway!

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A-fib=atrial fibrillation; AICD=acute ischemic coronary disease; CAD=coronary artery disease;

C/O=complains of; CPAP=continuous positive airway pressure; MI=myocardial infarction;

OSA=obstructive sleep apnea; s/p=status post.

The patient is anxious and wishes to be asleep for airway manipulation

Big neck, sleep apnea, Mallampati 3 view. Good candidate for awake intubation

Patient really does not like this idea. On the positive side, we have an experienced anesthesiologist and a head nurse anesthetist (with more than 30 years experience) assigned to the room. Additionally, we have an ENT surgeon who will be present for induction

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We convince the patient that we will briefly put him to sleep, and if we can ventilate him easily, we will proceed with an intubation under anesthesia

If we cannot, we will wake him up and proceed with him awake. Surgeon to be in the room at all times as will be the difficult airway cart

GlideScope will be device of choice for intubation

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Patient given 80 mg of propofol and easily ventilated. Decided to proceed with intubation under general anesthesia

70 mg more of propofol given and 50 mg of rocuronium. Masked for 4 minutes so that the small dose of rocuronium (slightly greater than 1X ED95) would work. 0 twitches after 4 minutes

GlideScope stylet fits poorly on a #7 Laser endotracheal tube

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Experienced CRNA using GlideScope cannot direct the laser tube anterior enough. Anesthesiologist tries, with similar result. Attempts now to mask, and patient is not ventilatable. 4-handed ventilation unsuccessful. Regular ET tube and GlideScope used. Unable to see glottis now. LMA inserted. No CO2 tracing. Anesthesia assistance requested. 4-handed ventilation attempted until help comes

22 CRNA=certified registered nurse anesthetist; ET=endotracheal; LMA=laryngeal mask airway.

SpO2 falling now to 70’s. In light of poor cardiac functions and likely surgical difficulty, surgeon asked to start tracheostomy

One anesthesiologist who came in to help is asked to get the fiberoptic scope ready for use

Another anesthesiologist is asked to find the sugammadex in the Pyxis. Only one 2-cc bottle found and the contents administered

SpO2 is now in the 30’s and tone is deepening fast

23 Sp02=peripheral capillary oxygen saturation.

As surgeon enters the airway, the patient starts to breathe and is now easy to assist. O2 sats start to rise. Surgeon asked to abandon tracheostomy, but claims that she has reached a point of no return. O2 sat rise to upper 90’s while surgeon readies the trachea for a tracheostomy tube. Unable to easily pass this (takes a few minutes), but patient is spontaneously breathing with sats in the 90’s

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Finally a tracheostomy tube is placed and the patient ventilated through it

Atracurium is administered and procedure is completed

A bad airway cannot be overcome by years of experience

Just because you can be ventilated easily now does mean it will hold true 5 minutes from now

When you truly have a CNI CNV patient, 2 anesthesia professionals will be tied up with the mask. Securing drugs and preparing the next step in the difficult airway algorithm requires more hands on deck

Make sure you have a supply of reversal agents for drugs you administered

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Flumazenil “erases” midazolam

Naloxone “erases” opioids

Sugammadex “erases” rocuronium

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PACU Rescue

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Patient in extremis

Nonresponsive

Code called

Saturation in 80’s and dropping

Heart rate in 50’s and dropping

Diaphoretic

Immediately commenced mask ventilation

47-year-old male for laparoscopic ventral hernia repair

Hypertensive

6’5”

390 lb

No other significant medical history

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Uneventful anesthetic course

Total of rocuronium 40 mg for duration of procedure

Reversed with neostigmine 5 mg and glycopyrrolate 0.4 mg 80 minutes after dosing with rocuronium

Sustained tetanus and full TOF at orbicularis oculi

Breathing adequate tidal volumes

Awake

Extubated in OR

Taken to PACU extubated

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Pupils pinpoint

Poor respiratory efforts

Nonresponsive

Hemodynamically stable

Saturation in mid 90’s with mask ventilation

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Naloxone administered – no response

Flumazanil administered – no response

TOF evaluated: poor response to TOF and tetanus

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Sugammadex 100 mg IV

Recovery of respiratory function within minutes

Neuromuscular function testing showed return to baseline

Saturation normalized

Hemodynamically stable

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SUGAMMADEX DOSE LEVEL OF NMB WITH ROCURONIUM OR

VECURONIUM

2 mg/kg

If spontaneous recovery has reached the reappearance of the second twitch (T2) in response

to TOF stimulation

4 mg/kg

If spontaneous recovery of the twitch response has reached 1-2 PTCs, no twitch responses to TOF

37 www.FDA.gov

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Robot Day in GYN!

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A heavyset 53-year-old African American woman very nervous about her surgery. She looks to be an easy airway and the nursing staff placed an #18G IV easily

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Image courtesy of

Scott Groudine, MD

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Robotic hysterectomy and BSO for fibroid uterus and CIN2 (moderate dysplasia)

ASA3 for hypertension, diabetes, and morbid obesity

ASA=American Society of Anesthesiologists; BSO=bilateral salpingo-oophorectomy;

CIN=cervical intraepithelial neoplasia.

Bupropion, lisinopril, metformin

Blood sugar preop 132, all others WNL

Hb1Ac 7%

Allergic to seafood, but no medications

Past surgical history significant for right knee arthroscopy, and a gastric bypass at outside hospital (2015), weight loss of 85 lb since then

42 WNL=within normal limits.

Rapid sequence induction with rocuronium. HOB elevated 30 degrees

Sevoflurane; minimize opioids because patient is undiagnosed but might have some degree of sleep apnea

43 HOB=head of bed.

Induction propofol (200 mg), rocuronium (50 mg, primed 5/45), cefazolin sodium (2 mg), fentanyl (100 mcg)

BP quickly falls to 60’s systolic. Treated with fluid bolus, phenylephrine hydrochloride drip, and frequent ephedrine boluses

Surgeon encouraged to help the pressor response by starting surgery sooner rather than later. BPs maintained in the 80’s with fluid and pressor drip

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Ready to insufflate the abdomen

20 mg of rocuronium given to facilitate incision

Veress needle introduced for insufflation. CO2 starts to flow. BP goes down rather than up

ETCO2 falls from 31 to 18

BP systolic 50’s

SpO2 in the low 80’s

45 ETCO2=end-tidal carbon dioxide.

1. CO2 embolism: Hypotension occurring with CO2 insufflation

2. Myocardial dysfunction: HOCM

3. Anaphylaxis: Antibiotic, fentanyl, and muscle relaxants were given (no rash observed or wheezing)

46 HOCM=hypertrophic obstructive cardiomyopathy.

1. Stop surgery and insufflation

2. Increase IV fluids

3. Call for assistance

4. Treat hypotension

With neosynephrine drip running, the patient still required doses of epinephrine to keep BP above 70 systolic. After 15 minutes decision to cancel surgery.

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BP remains low, anesthesia is turned off and the decision is made to get patient breathing spontaneously

A TEE is called for and sugammadex 500 mg (approximately 4 mg/kg) is given

As TEE machine arrives patient is breathing spontaneously and BP has risen to 120’s systolic

A normal TEE examination follows

48 TEE=transesophageal echocardiogram.

ABGs, cardiac enzymes, tryptase are drawn.

Cardiology sees patient

Patient wants to know what happened and why surgery was cancelled

49 ABGs=arterial blood gases.

Patient may be very dehydrated from bowel prep. Made worse by brief episode of increased intra-abdominal pressure

Treatment similar: Fluids, support, and echo!

HOCM: Up to 0.5% of population

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No wheezing

No rash observed, but patient has very dark pigmentation

Hypotension, tachycardia, and timing close to the administration of multiple drugs and chlorhexidine gluconate

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Cancelling surgery, fluid, epinephrine, pressors worked

Echo unremarkable. Cardiac enzymes normal; cardiology is not impressed. Tryptase is available from an outside laboratory in a few days

What happened??

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49.7

Reference range : 2.2–13.2

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Allergic reaction to: Rocuronium, cefazolin sodium, propofol, prep, latex!

Most common anesthetic agent for anaphylaxis is rocuronium (1:2500)

9.6% of patients with anaphylaxis test positive on skin test to chlorhexidine

54 Reddy JI et al. Anesthesiology. 2015;122(1):39-45; Sharp G et al. ANZ J Surg. 2016;86(4):237-243. Plaud

B. Can J Anesth. 2014;61:511-518

Probably rocuronium, but cannot be sure. Test for cisatracurium also at the allergist because significant cross reactivity

Interesting that the patient did not improve with epinephrine, but that things started improving dramatically after reversing the block with sugammadex

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Cases of rocuronium and vecuronium allergy have been treated with sugammadex

In several, treatment with epinephrine was not effective, but the patient started to improve after the administration of sugammadex

In some, it took multiple doses of sugammadex, as the process usually appears just after induction

Plaud B. Can J Anaesth. 2014;61(6):511-518.

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Some patients are allergic to rocuronium

Some patients are allergic to sugammadex

Some patients are allergic to sugammadex only when it is bound to rocuronium

Some patients allergic to sugammadex are not allergic to sugammadex-rocuronium complex

Ho et al. A+A Case Reports. 2016 Aug; Sadleir PH et al. Anaesth Intensive Care. 2014;42(1):93-96.

In summary, our case series does not support the hypothesis that sugammadex modifies the immunological cascade of anaphylaxis. An alternative hypothesis, that sugammadex administration in anaphylaxis improves cardiac preload, is more plausible, but is not without potential risk in its clinical implementation, compared with known effective methods of increasing venous return.

58 Platt PR et al. Anaesthesia. 2015;70(11):1264-1267.

59 Thompson C. www.anaesthesia.med.usyd.edu.au

http://sydney.edu.au/medicine/anaesthesia/resources/lectures/nmj_monitoring_clt/nmjonitoring.html

Image courtesy of

Chris Thompson, MD

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Based on body weight

Studies ongoing exploring dosing based on ideal weight

www.clinicaltrials.gov

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Succinylcholine after sugammadex

Succinylcholine after neostigmine

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Known hypersensitivity

Renal failure

www.FDA.gov

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Hormonal contraceptives

www.FDA.gov

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