Sugammadex related atypical laryngospasm with unusual rescue A case report

doi:10.21203/rs.3.rs-5226686/v1

Download PDF

Case Report

Sugammadex related atypical laryngospasm with unusual rescue A case report

https://doi.org/10.21203/rs.3.rs-5226686/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Purpose To describe our experience using rocuronium to rescue sugammadex related atypical laryngospasm during a case under general anesthesia.

Clinical features A patient was a 56-year-old, who was admitted for fungal keratitis and underwent a Penetrating Keratoplasty (PKP) on 12^th June 2024. The procedure was smooth and took about 100 minutes. An airway spasm just happened after 120mg sugammadex was provided at the end of the procedure and manual ventilation did few work. Then 30mg rocuronium was provided for intubation, about 30 seconds later the ventilation became into effect and intubation successfully. We saw half-closed vocal cords during the intubation.

Conclusions Laryngospasm remains a tenacious problem for unpredictable causes and atypical signs, furthermore rocuronium may be an unusual and brilliant choice for the laryngospasm especially when it was related tosugammadex and presented atypically.

Sugammadex

atypical laryngospasm

airway spasm

rocuronium

airway complication

Laryngospasm, a continue adduction of vocal cords, is an airway complication during insufficient anesthesia with an overall incidence of 8.7/1,000.¹ And it is mainly stimulated by excessive secretions, manipulation of the airway or anesthetic agents.² Sugammadex, a modified γ-cyclodextrin, provides rapid and complete reversal for neuromuscular blocking drugs (NMBDs), especially rocuronium.³ It has been presenting a lower residual paralysis,⁴ a lower incidence of hospital readmission,⁵ a safe and reliable reversal,⁶ and with an excellent application scenario of the “cannot intubate, cannot ventilate” (CICV) state.^7-9 However, with the usage of sugammadex increasing since when it was approved by the Food and Drug Administration (FDA) in 2015, its related airway complications reports has been increased, such as laryngospasm.^10,11

Consent was obtained from the patient for publication of this case report.

The patient was a 56-year-old man, who was admitted for fungal keratitis and underwent a Penetrating Keratoplasty (PKP) on 12th June 2024, with a height of 168cm and weight 65kg (BMI = 24.1). He was classified as American Society of Anesthesiology (ASA) physical status Ⅱ due to being a heavy smoker for more than 30 years and a medical history of snore, bullae of lung, and hypertension maintained under regular medication. Airway assessment revealed a Mallampati score of 2, with a 5.5 cm mouth opening (about 3 fingers), thyromental distance of 7 cm and full dentition.

General anesthesia was induced with midazolam 2mg, etomidate 20mg, sufentanil 15µg and rocuronium 40mg, and maintained with propofol (2-3mgkg^− 1hour^− 1) combined with remifentanyl (0.1–0.2µgkg^− 1min^− 1). A laryngeal mask airway (LMA) was provided as a supraglottis airway device (SAD). The rocuronium was provided intermittently at 0.15mgkg^− 1 to keep the train of four (TOF) at zero. We stopped the continuous anesthetic agents infusing just at the end of the procedure, and 120mg sugammadex (Haian Pharmaceutical Co., Ltd, Jiangsu, China )was given intravenous. About 30–40 seconds later, the peak inspiratory pressure (PIP) was increased to 32 H₂Ocm sharply, and up to 40H₂O just in several seconds, and the ventilation hardly performed.

We checked the anesthesia machine and the respiratory circulation immediately for whether there were mechanical obstructions, and change to manual ventilation with 100% oxygen at 10L/min, but with few help. Then we removed the LMA, tried to ventilating through a pressure face mask combined with an oropharyngeal airway but failed. Then we prepared endotracheal intubation, propofol (60mg) and rocuronium (30mg) were provided for preventing hemodynamics fluctuation. About 30 seconds later, mannul ventilation came into play and intubation was preformed successfully with a No.7 endotracheal tube (EET) by using a Macintosh laryngoscope (Fig. 1 time point 13), at that time the saturation of pulse oximetry (SPO₂) was78%, and the end tidal carbon dioxide pressure (ETCO₂) was 65mmHg, the Heart Rate(HR) was 78min^− 1(up 33% from baseline ), a slight change of the noninvasive blood pressure (NIBP) (the time interval of NIBP was 3 minutes, so we just recorded 2 data), and the TOF score was zero. (Fig. 1 time point 14) During the intubation(Fig. 1 time point 9–13, without records of ETCO₂ and PIP), the vocal cords were half-closed and there were few secretion and no blood or foreign body in the oropharyngeal cavum. Then the ETCO₂ began to decrease gradually, the SPO₂ ascended to 90 after about 30 seconds’ manual ventilation (Fig. 1 time point 15). About five minutes later, the patient regained consciousness with stable vital signs. EET was removed after a regularly ventilation, and the patient was sent to the post-anesthesia care unit (PACU) with a full consciousness for future care.

We got a positive skin test results three days after the procedure, we did the intradermal test (IDT) at a 1/100 dilution of 0.1 mg/mL sugammadex.¹²Figure 2

Laryngospasm is a rare but potentially life-threatening complication of general anesthesia, which may lead to cardiac arrest, aspiration, and negative pressure pulmonary edema.¹³ The mechanism of laryngospasm was the related afferent limb of the reflex arc will still take effects without appropriate anesthesia depth after the muscle return to normal,¹⁰and lead to a physiological exaggeration of the glottis closure reflex.¹⁴ Laryngospasm often simulated by laryngoscopes, blood or secretion, anesthetic agents,¹⁵ and always presented several obvious clinical signs: paradoxical breathing, stridor, and ineffective chest wall movement.^2,16

However, our case presented atypically: no instrument (laryngoscopes) involved, not an insufficient anesthesia, no certain stimuli (aspirating food, foreign bodies, blood or secretion), total intravenous anesthesia without any inhalational agents. Moreover, sugammadex was observed with no superiorities than neostigmine in reducing risk of any individual pulmonary complication, ^17,18 and the previous reports¹⁹ had confirmed the sugammadex related larygonspasm. Nobuyasu Komasawa²⁰ suggested that sugammadex administration after recovery of consciousness can decrease the incidence of laryngospasm. Compare our case to a previous reported case about sugammadex induced laryngospasm,¹⁴ there were several similarities: an elder man with a long smoking history, combined with lung disease, and laryngospasm happened just after the injection of sugammadex with a sharply increased PIP. Therefore, we highly suspected the atypical laryngospasm was induced by sugammadex and did a comparation among the previous reports and ours. Table.1

During the enmergency, the airway spasm followed close behind the provide of sugammadex, we experienced an atypical laryngospasm, but we were not sure if there was a bronchospasm for the previous reports.^21,22 The mechanism of the obstruction could be the sugammadex induced hypersensitivity and anaphylaxis,^23–25 and the associated allergic actions were concealed under a deep neuromuscular blockade until muscle tone reversed by sugammadex to normal, the efferent never impulses cross the neuromuscular junctions increased relatively and finally caused an adduction of the vocal cords.²⁶ Moreover, the positive IDT and the significant hemodynamics fluctuation (HR increased by 30%) also can state the anaphylaxis to some extent.

Fortunately, the ventilation came into effect just seconds after the rocuronium provided, and sugammadex revealed a high capacity in binding non-depolarizing neuromuscular blockade(NMB) and a fast reversion of rocuronium induced muscular relaxation usually take effect within 1–2 minutes,^27,28 then excreted in urine in prototype.²⁹ It may be the rapid, effective, reliable and predictable feature on NMBDs reversion ^30–32 that makes rocuronium as a key to relieve the sugammadex induced Laryngospasm.

Although it is well known that the sugammadex could cause hypersensitivity and anaphylaxis, the following adverse events, especially the atypical laryngospasm after the muscular relaxation reversion should be highly regarded among all the anesthetic members. And simultaneously, it may not be optimal rescue with rocuronium for such an enmergency, which at least is an option,

Laryngospasm remains a tenacious problem for unpredictable causes and atypical signs, furthermore rocuronium may be an unusual and brilliant choice for the sugammadex related laryngospasm especially when it was atypical.

Ethics approval and consent to participate
Not applicable

Consent for publication
The patient had signed inform consent for publication

Competing interests

No potential conflict of interest relevant to this article was reported.

Funding

Funded by Tianjin Key Medical Discipline ( Specialty ) Construction Project(TJYXZDXK-037A)

Author Contribution

Hongyuan Ren and Yan liu wrote the main manuscript text ,Yuechun Lureviewed the manuscript.

Acknowledgments

The authors would like to extend their sincere thanks to Liu Wei ( Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China ) for the help with Engilsh spelling and grammar.

Availability of data and materials

Not applicable

G L O, B H: Laryngospasm during anaesthesia. A computer-aided incidence study in 136,929 patients. Acta Anaesthesiol Scand 1984; 28
I S L: Mechanisms and treatment of laryngospasm. Int Anesthesiol Clin 1997; 35
G DR, L P, C PDP, S T, C M, P B, A T, S M, L Z, A G, P M, L F, P DM: Reversal of rocuronium induced neuromuscular block with sugammadex or neostigmine: a large observational study. Acta Anaesthesiol Scand 2013; 57
Alday E, Muñoz M, Planas A, Mata E, Alvarez C: Effects of neuromuscular block reversal with sugammadex versus neostigmine on postoperative respiratory outcomes after major abdominal surgery: a randomized-controlled trial. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2019; 66: 1328–1337
Togioka B, Yanez D, Aziz M, Higgins J, Tekkali P, Treggiari M: Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery. British journal of anaesthesia 2020; 124: 553–561
Ana-Marija H, Patricia D, Mikkel A, Arash A: Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev 2017; 8
L P, S G, D B: Successful use of sugammadex in a 'can't ventilate' scenario. Anaesthesia 2013; 68
Bogumiła W-G, Lidia Z-G, Jerzy L, Bożena Dorota S, Iwona R: Two cases of the "cannot ventilate, cannot intubate" scenario in children in view of recent recommendations. Anaesthesiol Intensive Ther 2014; 46
C M: Sugammadex to rescue a 'can't ventilate' scenario in an anticipated difficult intubation: is it the answer? Anaesthesia 2013; 68
Ji Hyeon L, Jae Ho L, Min Hyun L, Hyun Oh C, Soon Eun P: Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report. Korean J Anesthesiol 2017; 70
Amao R, Zornow M, Cowan R, Cheng D, Morte J, Allard M: Use of sugammadex in patients with a history of pulmonary disease. Journal of clinical anesthesia 2012; 24: 289–97
María L S, J P M, P M G, A O, I D, A L dW: Flow cytometric basophil activation test: a review. J Investig Allergol Clin Immunol 2003; 12
Mallar B, Richard H K, Lorraine B W, Michael A M: Negative-Pressure Pulmonary Edema. Chest 2016; 150
S G, S S, M D: Sugammadex and laryngospasm. Anaesthesia 2017; 72
Hobaika A, Lorentz M: [Laryngospasm]. Revista brasileira de anestesiologia 2009; 59: 487 – 95
T V, M T K, R K W, R N W: Crisis management during anaesthesia: laryngospasm. Qual Saf Health Care 2005; 14
Han J, Ryu J, Koo B, Nam S, Cho S, Oh A: Effects of Sugammadex on Post-Operative Pulmonary Complications in Laparoscopic Gastrectomy: A Retrospective Cohort Study. Journal of clinical medicine 2020; 9
Yun Jeong C, Han Bum J, Juyeon O, Eunyoung L, In Kyong Y: Thirty-Day Postoperative Outcomes Following Sugammadex Use in Colorectal Surgery Patients; Retrospective Study. J Clin Med 2019; 8
B M, A J D: Sugammadex, airway obstruction, and drifting across the ethical divide: a personal account. Anaesthesia 2016; 71
Nobuyasu K, Isao N, Toshiaki M: Relationship between timing of sugammadex administration and development of laryngospasm during recovery from anaesthesia when using supraglottic devices: A randomised clinical study. Eur J Anaesthesiol 2016; 33
Keito K, Takeshi O, Saiko W, Sonoko S: A case in which a capnometer was useful for diagnosing laryngospasm following administration of sugammadex. JA Clin Rep 2018; 3
Trivedi K, O'Brien V, Rochetto R: Sugammadex-Associated Bronchospasm. American journal of therapeutics 2021; 29: e139-e141
Masaki O, Kazuhiro N, Tomonori T: Does sugammadex have multiple mechanisms for causing anaphylaxis? J Allergy Clin Immunol Pract 2020; 8
C LU, L NV, S MM, A RR, M BT: Sugammadex-Induced Anaphylaxis: 2 Case Reports. J Investig Allergol Clin Immunol 2021; 32
Hajime I, J Ross R, Takayuki K, Sorin J B: Preparing for the unexpected: special considerations and complications after sugammadex administration. BMC Anesthesiol 2017; 17
N C: Did sugammadex cause, or reveal, laryngospasm? Anaesthesia 2016; 71
Iben F S, Kathrine N, Per Bo L, Jakob S, Doris O, Martine E P, Jørgen V-M: Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study. Anesthesiology; 104
Abola R, Romeiser J, Rizwan S, Lung B, Gupta R, Bennett-Guerrero E: A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2020; 67: 959–969
Karin S K-B, Magnus W, Bernard F V, José I L-T, Henk R, José A A-G: Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg 2009; 110
Lu I, Chang P, Su M, Chen P, Chen H, Chiang F, Wu C: The feasibility of sugammadex for general anesthesia and facial nerve monitoring in patients undergoing parotid surgery. The Kaohsiung journal of medical sciences 2017; 33: 400–404
Lu I, Lin I, Wu C, Chen H, Lin Y, Chiang F, Chang P: Preoperative, intraoperative and postoperative anesthetic prospective for thyroid surgery: what's new. Gland surgery 2017; 6: 469–475
Ombeline EdV, Denis S, Laurent B, Thomas F-B: Recurrent Laryngeal Nerve Monitoring and Rocuronium: A Selective Sugammadex Reversal Protocol. World J Surg 2017; 41

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Sugammadex related atypical laryngospasm with unusual rescue A case report

Status:

Version 1

Abstract

Figures

Introduction

Case description

Discussion

Conclusion

Declarations

Ethics approval and consent to participate
Not applicable

Consent for publication
The patient had signed inform consent for publication

Competing interests

Funding

Author Contribution

Acknowledgments

Availability of data and materials

References

Additional Declarations

Status:

Version 1

Sugammadex related atypical laryngospasm with unusual rescue A case report

Status:

Version 1

Abstract

Figures

Introduction

Case description

Discussion

Conclusion

Declarations

Ethics approval and consent to participate Not applicable

Consent for publication The patient had signed inform consent for publication

Competing interests

Funding

Author Contribution

Acknowledgments

Availability of data and materials

References

Additional Declarations

Status:

Version 1

Ethics approval and consent to participate
Not applicable

Consent for publication
The patient had signed inform consent for publication