CR3-192
Sugammadex to reverse neuromuscular blockade in an unexpected cannot intubate/cannot ventilate situation in an 850 gram premature infant
Efune P, Spain T, Khan U, Alex G
UT Southwestern Medical Center/Children's Health, Dallas, Texas, USA
An 850 gram premature infant presented to the operating room for ileal atresia repair. Induction of anesthesia began with pre-oxygenation and pretreatment with 20 mcg of atropine. Hypnosis was achieved with 2 mg of propofol and neuromuscular blockade was achieved with 1 mg of rocuronium. Mask ventilation was initially easy. Direct laryngoscopy (DL) with a Miller 00 blade revealed no view of the glottic structures. The infant experienced rapid oxyhemoglobin desaturation and mask ventilation was resumed, which subsequently proved very difficult despite an oral airway, significant jaw thrust, and high airway pressures. She remained hypoxemic and became bradycardic requiring both epinephrine and atropine. Second DL by the attending anesthesiologist again revealed a grade IV view and help was requested. Two more attempts by DL were made by two different attending anesthesiologists. Each attempt, the endotracheal tube (ETT) was placed through what appeared to be the vocal cords, but an end tidal CO2 waveform was not reliably seen and hypoxemia persisted. Mask ventilation between attempts continued to be very difficult. Oxygen saturation fell to 50%, and mask ventilation became impossible. The smallest laryngeal mask airway was deemed too large for the infant. General surgery was preparing for tracheostomy while 16 mg/kg of sugammadex was administered. The infant resumed spontaneous ventilation and was able to maintain normal oxygenation on 100% FiO2 by face mask. The decision was made to cancel both the tracheostomy and laparotomy. Otolaryngology performed direct laryngoscopy and bronchoscopy, which revealed a 2b view with an edematous glottis and severe long segment tracheomalacia. She was intubated with a 2.5 uncuffed ETT. The baby was transported to the NICU. No adverse reactions were noted due to sugammadex administration.
While other case reports and case series have described the safe and successful use of sugammadex in neonates,1-4 to our knowledge, this is the first report of successful reversal of neuromuscular blockade in an unanticipated cannot intubate/cannot ventilate situation in an extremely low birthweight infant. Sugammadex is not currently FDA approved for pediatric use due to a lack of safety and efficacy data. An important lesson learned is that sugammadex can be a very valuable tool in extremely low birthweight infants in which our standard adjuncts to difficult airway management are unsuitable due to size constraints.
References
1. Langley RJ, McFadzean J, McCormack J. The presumed central nervous system effects of rocuronium in a neonate and its reversal with sugammadex. Pediatr Anaesth 2016;26:109-111.
2. Vieira Carlos R, Abramides Torres ML, de Boer HD. Rocuronium and sugammadex in a 3 days old neonate for draining an ovarian cyst. Neuromuscular management and review of the literature. Rev Bras Anestesiol. 2016;66(4):430-432.
3. Ozmete O, Bali C, Ergenoglu P, Andic C, Aribogan A. Anesthesia management and sugammadex experience in a neonate for Galen vein aneurysm. J Clin Anesth 2016;31:36-37.
4. Alonso A, de Boer HD, Booij L. Reversal of rocuronium-induced neuromuscular block by sugammadex in neonates. Eur J Anaesthesiol 2014;31(Suppl 52):163-165.
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