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A6892 - Immediate Reversal of Neuromuscular Blockade in a Patient with Super-Morbid Obesity Using Sugammadex
Author Block: L. Lombardi-Karl, E. Vail, M. Patel; Anesthesiology, Columbia University, New York, NY, United States.
Introduction: Sugammadex is a modified y-cyclodextrin used to reverse aminosteroid neuromuscular blocking (NMB) agents, particularly rocuronium. At high doses, sugammadex reverses profound rocuronium-induced neuromuscular block in less time than it takes to recover from succinylcholine. Given this rapid reversal, sugammadex has been adopted by anesthesiologists to restore spontaneous ventilation during management of difficult airways in the operating room.
Case Report: A 45 year-old woman with super-morbid obesity (BMI 65 kg/m2) status-post sleeve gastrectomy was transferred to the ICU with an anastomotic leak. Her hospital course was complicated by hypercarbic respiratory failure requiring intubation. She had no previous anesthetic records at our institution but was an easy intubation by report. We induced anesthesia with propofol, midazolam, and rocuronium (0.6mg/kg based on her ideal body weight (IBW) of 67kg). After multiple attempts at laryngoscopy, we were unable to intubate or ventilate with a laryngeal mask airway. Given increasing difficulty with mask ventilation, we administered sugammadex 16mg/kg IBW, for a total of 1g. Approximately one minute later she had spontaneous chest wall movement and sustained arm lift without evident adverse drug effects. We supported spontaneous breathing efforts with bag mask ventilation until the airway was secured using a Glidescope-assisted fiberoptic bronchoscope intubation technique. Adequate oxygen saturation was maintained throughout the procedure.
Discussion: This case demonstrates the successful use of sugammadex to immediately reverse a standard intubating dose of rocuronium in a critically ill, morbidly obese patient. The use of sugammadex in airway management for patients in the ICU has not been well described. Given this patient’s body habitus and suspected airway edema after large volume blood transfusion, we anticipated a potentially difficult intubation and kept sugammadex at the bedside, allowing for rapid administration and avoidance of surgical airway placement.
Timely administration and appropriate dosing is critical to the efficacy of sugammadex in “can’t ventilate, can’t intubate” scenarios. Although the manufacturer recommends dosing of sugammadex by actual body weight, available studies present conflicting dosage recommendations for obese patients. Moreover, there are few published reports describing immediate NMB reversal using sugammadex in obese patients. Further work is needed to determine optimal dosing for these patients. This case illustrates the utility of sugammadex for reversal of neuromuscular blockade in a “can’t ventilate, can’t intubate” scenario involving a critically ill, morbidly obese adult patient. Intensivists should consider sugammadex as a rescue agent when administering induction doses of aminosteroid neuromuscular blocking drugs for airway management.