PURPOSE: Myasthenia gravis (MG) is an autoimmune disease interfering with neuromuscular transmission. Patients are at risk of postoperative residual curarization (PORC) if nondepolarizing muscle relaxants are used. Clinically inapparent insufficient muscle strength may result in hypoventilation and postoperative bronchopneumonia. We describe a cohort of 117 cases in which sugammadex was used in MG patients undergoing surgery with muscle relaxation with rocuronium. METHODS AND PATIENTS: We anesthetized 117 patients with MG using rocuronium and sugammadex as neuromuscular blockade reversal agent. One hundred five patients underwent surgical thymectomy and 12 underwent cholecystectomy (five laparotomic and seven laparoscopic). We measured time from sugammadex administration to recovery and to extubation, using the TOF-Watch(®) (series of four consecutive electrical impulses [the train-of-four] >0.9). We tracked peripheral capillary oxygen saturation (SpO2) <95%, elevation of partial pressure of carbon dioxide (pCO2) >10% above baseline, number of reintubations within the first 48 hours, and number of pneumonias within 120 hours, postoperatively. Results were processed as average, minimum, and maximum values. RESULTS: The period needed to reach train-of-four of 0.9 following sugammadex administration was on average 117 seconds (minimum of 105 seconds/maximum of 127 seconds) and differed within deviation <10%. The time to extubation following sugammadex administration was on average 276 seconds (minimum of 251 seconds/maximum of 305 seconds) and differed minimally among patients as well. We observed no SpO2 <95%, no pCO2 elevation >10% above a baseline, no emergent reintubation within the first 48 hours, and no pneumonia diagnosed on clinical basis within 120 hours, postoperatively in all 117 patients. CONCLUSION: In this cohort of MG patients undergoing surgery using rocuronium and sugammadex, we did not observe any signs of postoperative residual curarization and respiratory depression. The neuromuscular blockade recovery was reliable, predictable, and rapid.

3rd Surgical Department of 1st Faculty of Medicine Charles University Prague and Motol University Hospital Prague Czech Republic

Department of Anaesthesiology and ICM 2nd Faculty of Medicine Charles University Prague and Motol University Hospital Prague Czech Republic

See more in PubMed

Drachman DB. Harrison’s Principles of Internal Medicine. New York, NY: McGraw-Hill Companies, Inc; 2008. Myasthenia gravis and other diseases of the neuromuscular junction; pp. 2672–2677.

Valenstein E, Musulin M. Civetta, Taylor & Kirby’s Critical Care. Philadelphia, PA: Lippincott Williams and Wilkins, A Wolters Kluwer Business; 2009. Neuromuscular disorders; pp. 2235–2241.

Bailey PD. Pearson’s Thoracic and Esophageal Surgery. New York, NY: McGraw-Hill Companies, Inc; 2008. Surgical approach to myasthenia gravis; pp. 655–668.

Fennema H, Woo T, Jones K, et al. Sugammadex for rocuronium-or vecuronium-induced blockade reversal: a pooled analysis of 26 controlled studies; Poster presented at: sASA 2013 American Society of Anesthesiologists Annual Meeting; San Francisco, CA. Abstract A4013.

Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core Evid. 2013;8:57–67. PubMed PMC

Adamus M, Gabrhelik T, Marek O. Influence of gender on the course of neuromuscular block following a single bolus dose of cisatracurium or rocuronium. Eur J Anaesthesiol. 2008;25:589–595. PubMed

Racca F, Mongini T, Wolfler A, et al. Recommendations for anesthesia and perioperative management of patients with neuromuscular disorders. Minerva Anesthesiol. 2013;79:419–433. PubMed

Sundman E, Witt H, Olsson R, et al. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology. 2000;92:977–984. PubMed

Eikermann M, Groeben H, Husing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade. Anesthesiology. 2003;98:1333–1337. PubMed

Eriksson LI, Sato M, Severinghaus JW. Effect of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. Anesthesiology. 1993;78:693–699. PubMed

Bessinger U, Schimek F, Lenz G. Postoperative residual paralysis and respiratory status: a comparative study of pancuronium and vecuronium. Physiol Res. 2000;49:455–462. PubMed

Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98:1042–1048. PubMed

Baillard C, Bourdiau S, Le Toumelin P, et al. Assessing residual neuromuscular blockade using acceleromyography can be deceptive in postoperative awake patients. Anesth Analg. 2004;98:854–857. PubMed

Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fast-track bariatric surgery. Obes Surg. 2013;23:1558–1563. PubMed

Cerny V, Herold I, Cvachovec K, Sevcik P, Adamus M. Guidelines for managing neuromuscular block: not only Czech beer deserves a taste. Anesth Analg. 2011;112:482. PubMed

Bartkowski RR. Incomplete reversal of pancuronium neuromuscular blockade by neostigmine, pyridostigmine, and edrophonium. Anesth Analg. 1987;66:594–598. PubMed

Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41(9):1095–1103. PubMed

Sugawara A, Sasakawa T, Hasegawa N, Takahata O, Iwasaki H. Administration of sugammadex to a patient with myasthenia gravis with fade of the train-of-four ratio. Masui. 2011;60:1082–1085. PubMed

de Boer HD, van Egmond J, Driessen JJ, Booij LH. Sugammadex in patients with myasthenia gravis. Anaesthesia. 2010;65:653. PubMed

Petrun AM, Mekis D, Kamenik M. Successful use of rocuronium and sugammadex in a patient with myasthenia. Eur J Anaesthesiol. 2010;27:917–918. PubMed

Unterbuchner C, Fink H, Blobner M. The use of sugammadex in a patient with myasthenia gravis. Anaesthesia. 2010;65:302–305. PubMed

Garcia V, Diemunsch P, Boet S. Use of rocuronium and sugammadex for caesarean delivery in a patient with myasthenia gravis. Int J Obstet Anesth. 2012;21:286–287. PubMed

Komasawa N, Noma H, Sugi T, Sukenaga N, Kakiuchi H. Effective reversal of muscle relaxation by rocuronium using sugammadex in a patient with myasthenia gravis undergoing laparoscopic cholecystectomy. Masui. 2011;60:476–479. PubMed

Porter MV, Paleologos MS. The use of rocuronium in a patient with cystic fibrosis and end-stage lung disease made safe by sugammadex reversal. Anaesth Intensive Care. 2011;39:299–302. PubMed

Argiriadou H, Anastasiadis K, Thomaidou E, Vasilakos D. Reversal of neuromuscular blockade with sugammadex in an obese myasthenic patient undergoing thymectomy. J Anesth. 2011;25:316–317. PubMed

de Boer HD, van Egmond J, Driessen JJ, Booij LH. A new approach to anesthesia management in myasthenia gravis: reversal of neuromuscular blockade by sugammadex. Rev Esp Anestesiol Reanim. 2010;57:181–184. PubMed

Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in postoperative period. Minerva Anestesiol. 2006;72:97–109. PubMed