Residual paralysis caused by 50mg rocuronium after reversal with 4mg/kg sugammadex: a case report

BackgroundRocuronium-induced neuromuscular blockade can be quickly and completely reversed by administration of an optimal dose of sugammadex. Sugammadex antagonizes rocuronium-induced neuromuscular blockade by encapsulating rocuronium. Herein, we report a case of residual neuromuscular paralysis in which the recommended dose of sugammadex (4mg.kg(-1)) failed to antagonize a rocuronium-induced blockade.Case presentationA 71-year-old man (body mass index: 26.7kg.m(-2)) underwent endoscopic submucosal dissection of early-stage gastric cancer. He had no known factors that may have affected the effects of rocuronium and sugammadex. He received rocuronium (50mg; 0.7mg.kg(-1)) for anesthesia induction. No additional rocuronium was administered during the 71-min procedure. Ninety-four minutes after rocuronium administration, neuromuscular monitoring showed 20 twitches in response to post-tetanic count stimulation. The train-of-four (TOF) ratio was not measurable despite sugammadex (280mg; 4mg/kg) administration, although four weak twitches in response to TOF stimulation appeared in 3 min. The TOF ratio became detectable following administration of an additional dose of sugammadex (120mg; 1.7mg.kg(-1)), and it recovered to 107% 8 min after the second dose. The patient opened his eyes; moved his neck, arms, and limbs; and regained consciousness. The trachea was extubated and the patient was transferred to the ward.ConclusionsNeuromuscular monitoring should be used if a neuromuscular blockage agent is administered, even if the recommended dose of sugammadex is administered.

Automated summary

In this case, the recommended dose of sugammadex failed to completely reverse the rocuronium-induced neuromuscular blockade, requiring an additional dose of sugammadex to return to normal levels.