Chun Hea Rim, Chung Jinhun, Kim Nan Seol, Kim A Joo, Kim Suro, Kang Kyu Sik
Department of anesthesiology and pain medicine, Soonchunhyang University Hospital Cheonan, 31, Soonchunhyang 6gil, Dongnam-gu, Cheonan, Chungcheongnam-do, Korea.
Medicine (Baltimore). 2020 Jan;99(3):e18867. doi: 10.1097/MD.0000000000018867.
Patients with motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), have higher sensitivity to nondepolarizing neuromuscular blocking agents (NMBAs) and are at higher risk for a residual block. For this reason, the use of NMBAs such as rocuronium has been limited owing to the delayed reversal of muscle relaxation. It was recently reported that rapid and effective reversal of muscle relaxation occurs when sugammadex, a muscle relaxant reversal drug, is administered to patients in ALS with rocuronium-induced muscle relaxation. However, in this paper, we report the incomplete recovery and recurarization of muscle relaxation after sugammadex administration in ALS patients, and delayed recovery of muscle relaxation after additional administration of sugammadex.
A 71-year-old male patient with ALS received general anesthesia for laparoscopic nephroureterectomy.
The patient was diagnosed with ALS 2 years earlier, and scheduled to undergo laparoscopic nephroureterectomy for ureteral cancer.
We used sugammadex for the reversal of deep neuromuscular block. We measured a train-of-four (TOF) count of 4 and a TOF ratio of 54% at about 8 min after administration of 4 mg/kg sugammadex. However, then the TOF count decreased to 1 to 3 and tidal volume (TV) decreased to < 100 mL. Therefore, an additional 50 mg sugammadex was administered intravenously 12 min after the first dose of sugammadex was injected.
The patient's vital signs were stable and his recovery from anesthesia was uneventful. Therefore, he was discharged to the intensive care unit. The patient had aspiration pneumonia symptoms owing to dysphagia on the third postoperative day, but after the symptoms improved he was transferred to the hospital for rehabilitation of dysphagia and dyspnea.
It is critical to monitor whether muscle relaxation is sufficiently reversed when using sugammadex in ALS patients. Further research is needed to determine the appropriate dose of sugammadex for muscle relaxation reversal.
运动神经元疾病患者，如肌萎缩侧索硬化症（ALS）患者，对非去极化神经肌肉阻滞剂（NMBAs）更为敏感，发生残余阻滞的风险更高。因此，由于肌肉松弛逆转延迟，罗库溴铵等NMBAs的使用受到限制。最近有报道称，在使用罗库溴铵诱导肌肉松弛的ALS患者中，给予肌肉松弛逆转药物舒更葡糖钠后，肌肉松弛能迅速有效逆转。然而，在本文中，我们报告了舒更葡糖钠给药后ALS患者肌肉松弛恢复不完全和再次出现肌松的情况，以及再次给予舒更葡糖钠后肌肉松弛恢复延迟的情况。
一名71岁的ALS男性患者接受腹腔镜肾输尿管切除术的全身麻醉。
该患者2年前被诊断为ALS，计划因输尿管癌接受腹腔镜肾输尿管切除术。
我们使用舒更葡糖钠逆转深度神经肌肉阻滞。给予4mg/kg舒更葡糖钠后约8分钟，我们测得四个成串刺激（TOF）计数为4，TOF比值为54%。然而，随后TOF计数降至1至3，潮气量（TV）降至<100mL。因此，在首次注射舒更葡糖钠12分钟后，静脉追加50mg舒更葡糖钠。
患者生命体征稳定，麻醉恢复顺利。因此，他被转入重症监护病房。患者在术后第三天因吞咽困难出现吸入性肺炎症状，但症状改善后，他被转至医院进行吞咽困难和呼吸困难康复治疗。
在ALS患者中使用舒更葡糖钠时，监测肌肉松弛是否充分逆转至关重要。需要进一步研究以确定舒更葡糖钠逆转肌肉松弛的合适剂量。
