Rev. Bras. Anestesiol. vol.66 número4

RevBrasAnestesiol.2016;66(4):430---432

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Rocuronium

and

sugammadex

in

a

3

days

old

neonate

for

draining

an

ovarian

cyst.

Neuromuscular

management

and

review

of

the

literature

Ricardo

Vieira

Carlos

_,

_Marcelo

_Luis

_Abramides

_Torres

_,

_Hans

_D.

_de

_Boer

a_{DepartmentofAnesthesiology,InstitutodaCrianc¸a,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo,}

SãoPaulo,SP,Brazil

b_{DepartmentofAnesthesiologyandPainMedicine,MartiniGeneralHospitalGroningen,Groningen,TheNetherlands}

Received17December2014;accepted27January2015

Availableonline26September2015

KEYWORDS

Neonates; Ovariancyst; Sugammadex; Rocuronium; Reversalagent

Abstract Acaseisreportedinwhicha3-daysoldneonatewithagiantovariancystwas sched-uledforsurgery.Thepatientreceivedadoseofsugammadextoreversearocuronium-induced neuromuscularblock. Afastandefficient recoveryfrom neuromuscularblock wasachieved within90s.Noadverseeventsorothersafetyconcernswereobserved.Furthermore,areview oftheliteratureontheuseofsugammadexinneonateswasperformed.

© 2015 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Recém-nascidos; Cistoovariano; Sugammadex; Rocurônio;

Agentedereversão

Rocurônioesugamadexemrecém-nascidode3diasparadrenagemdeumcisto

ovariano.Controleneuromuscularerevisãodaliteratura

Resumo Relatodocasodeumacrianc¸arecém-nascidade3diasdeidadecomumcisto ovar-ianogigante programadaparaacirurgia. Apaciente recebeu umadosede sugamadexpara reverterobloqueioneuromuscularinduzidoporrocurônio.Umarecuperac¸ãorápidaeeficiente dobloqueioneuromuscularfoiobtida dentrode90segundos.Nãoforamobservadosefeitos adversosououtrosproblemasdeseguranc¸a.Alémdisso,umarevisãodaliteraturasobreouso desugamadexemrecém-nascidosfoirealizada.

© 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença de CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

∗_{Correspondingauthor.}

E-mail:ricardovieirac@gmail.com(R.V.Carlos). http://dx.doi.org/10.1016/j.bjane.2015.01.004

Rocuroniumandsugammadexina3daysoldneonatefordraininganovariancyst 431

Introduction

Neonatal ovarian cysts are uncommon. The incidence of thesecystsis1/2500livebirthandareoftendetectedduring antenatalechographyinthelatepregnancy.1---3_Thesecysts

are associated with prenatal and postnatal complications likeovariantorsionwhichcouldleadtoovarianloss, espe-ciallyinvoluminouscysts.1 _{Therefore,themanagementof}

theseovariancystsincludeobservationandsurgical inter-ventionwhensymptomatic.1,2

Rocuronium is a commonly used neuromuscular block-ing agent (NMBA) in clinical anesthesiaand administered in allage groups, includingneonates. Sugammadex is the first selective relaxant binding agent designed to reverse a neuromuscular block (NMB) induced by either rocuro-niumorvecuronium.Sugammadexhasbeeninvestigatedin adults and children older than 4 years of age, but there is limited data available about the efficacy and safety of sugammadex reversal of a rocuronium-induced NMB in neonates.3,4

We reportacase inwhicha 3daysoldneonatewitha giantovariancystreceivedadoseofsugammadextoreverse arocuronium-induceddeepNMB.Thesafetyandefficacyof sugammadexarediscussed. Furthermore,a review of the literatureontheuseofsugammadexinneonateswas per-formed.

Case

report

A3days-oldfemaleneonate(weight2.98kg)presentedwith agiantovariancystwithavolumeof180mLconfirmedby ultrasonography.Physicalexaminationrevealed apalpable massintheabdominalregion.Furtherexaminationshowed nootherpathology.Afterobtaininginformedconsentfrom themother,theneonatewasscheduledforopensurgeryto drainthecystundergeneralanesthesia.

Anintravenous(IV)linewasinsertedpreviously.Standard intraoperativemonitoringincludedECG,NIBP,pulse oxime-try, capnography,anesthetic gas analyzer and esophageal thermometer. The neuromuscular function wasmonitored usingtrain-of-four(TOF)stimulationoftheulnarnerveand wasquantitatedwithacceleromyography(TOF-WatchTM_SX,

Schering-PloughIrelandLtd.,Dublin,Ireland).Theprimary efficacyvariableforreversalwasdefinedasthetimefrom thestartoftheadministrationofsugammadex,torecovery oftheTOF-ratioto0.9.

After preoxygenation, anesthesia was induced with sevoflurane through facial mask and intravenous opioid. Procedures for theset-up, calibrationand stabilizationof neuromuscularmonitoringwereexecuted.Thepatientthen received an IV bolus injection of rocuronium0.9mgkg−1_. Thiswasfollowedbyendotrachealintubation,andthelungs were ventilated with a mixture of oxygen and air in a ratioof2:3.Thesurgicalprocedurewasuneventful,240mL of fluid was drained from the ovarian cyst and a partial oophorectomywasperformed. The durationof anesthesia was 75min. At the end of the procedure neuromuscular monitoringshowedonepost-tetaniccount(PTC1), indicat-ingadeepNMB.Reversal ofrocuronium-inducedNMBwas performed by administration of 4.0mgkg−1 _sugammadex (12mg). The time to recovery from rocuronium-induced

NMBtoaTOF-ratioof0.9was90s. Nochangesfrom base-line were observed in blood pressure or heart rate after administration of the sugammadex dose. Eighth minutes after the administrationof sugammadexthe trachea was extubatedandthepatientwasdischargedtotheneonatal care.Thepatient’srecoveryfromanesthesiawas unevent-ful and no signs of residual NMB or recurarization were observed.

Reviewoftheliterature

ThereviewoftheliteraturewasperformedinPubMedandin personalarchives ofbothauthorswithsearchcriteria sug-ammadexandneonates. Inclusioncriteriawere: neonates treated with sugammadex, articles in English language. These publications were collected and analyzed. The lit-eraturesearchonsugammadexandneonates showedonly twopublicationswhich mettheinclusioncriteria(nonein Pubmed)in which24 patients weredescribed andwillbe discussedinSection‘‘Discussion’’.4,5

Discussion

The reversal of a rocuronium-induced profound NMB with sugammadex4.0mgkg−1_{inourpatientwasfast,complete} and without signs of postoperative residual curarization (PORC) or recurarization. Sugammadexwas safeand well tolerated. Reversal of NMBis important for the accelera-tionofthepatient’srecoveryandthepreventionofPORC. Rocuronium-inducedNMBcanbereversedbycholinesterase inhibitors. However, reversal of NMB with cholinesterase inhibitors(incombinationwithmuscarinicantagonists)has limitations due to its mechanism of action (ineffective againstprofound NMB)andis oftenassociated with unde-sirablecholinergicside-effects.

Sugammadex is able to bind the steroidal NMB drug rocuroniumorvecuronium,formingacomplex. Encapsula-tionoftherocuroniummoleculebysugammadexresultsin arapiddecreaseinfreerocuroniumintheplasmaand sub-sequentlyatthenicotinicreceptoratthemotorendplate, leadingto a rapid reappearance of muscle activity.After encapsulation, rocuroniumis not available to bind tothe nicotinicreceptorintheneuromuscularjunction.This pro-motestheliberationofacetylcholinereceptors,andmuscle activityreappears.

Discussionofthereviewoftheliterature

Intwopublications24neonatalcasesinwhichsugammadex wasadministered were described.4,5 _{In one publication a}

20 day-oldpatient (weight 2.6kg) received 12mg sugam-madextoreversearocuronium-induceddeepneuromuscular block.Within2minthe TOF-ratiorecovered >0.9.No con-cernsaboutsafetyrelatedtosugammadexwerereported.5

Intheotherpublication23patientswerereportedwhowere dividedintotwogroups:A,1dayold(n=8,meanweight[kg andSD]2.8[0.8])andB,1---7daysold(n=15,meanweight [kgandSD]2.4[0.8]).4_{Allneonatesreceivedsugammadex}

432 R.V.Carlosetal.

andwelltolerated.Inallpatientstherecoverywasfastand complete.

The resultsofourpatientwerein linewiththeresults foundintheliteratureanddosesofsugammadex4.0mgkg−1 produced similar recovery times as in other age groups.3

Thereforedosingandrecoverytimesareidenticalinallage groupsandtheuseofsugammadexinneonatesmaybealso comparablebeneficialasshowninotherpatientsagegroups. Thishastobeconfirmedinmorecasesor dedicated stud-ies.Furthermore,neuromuscularmanagementinneonates shouldalsoconsistof thechoiceof an appropriateNMBA, objectiveneuromuscularmonitoringandadequatereversal topreventPORC.

Disclosure

Ethical approval: no ethical approval was necessary; the motherconsentedherapprovalforpublication.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

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2.PapicJC,BillmireDF,RescorlaFJ,etal.Managementofneonatal ovariancystsand itseffectonovarianpreservation. JPediatr Surg.2014;49:990---4.

3.PlaudB,MeretojaO,HofmockelR,etal.Reversalof rocuronium-inducedneuromuscularblockadewithsugammadexinpediatric andadultsurgicalpatients.Anesthesiology.2009;110:284---94. 4.AlonsoA,deBoerHD,BooijL.Reversalofrocuronium-induced

neuromuscularblockbysugammadexinneonates.EurJ Anaes-thesiol.2014;31Suppl.52:163.