Billups Kelsey, Collins Charlotte, Weber Aimee
Medical University of South Carolina, Department of Pharmacy, Charleston, South Carolina.
Medical University of South Carolina, Department of Emergency Medicine, Charleston, South Carolina.
Clin Pract Cases Emerg Med. 2023 Aug;7(3):136-139. doi: 10.5811/cpcem.1548.
The use of paralytics during rapid sequence intubation (RSI) in patients with myasthenia gravis (MG) remains a controversial topic in emergency medicine. Due to fewer functional acetylcholine receptors, these patients can be both sensitive and resistant to different types of neuromuscular blocking agents (NMBA). Their atypical sensitivity to non-depolarizing NMBAs such as rocuronium can increase both the duration and depth of paralysis after its use at typical RSI doses. However, the extent of rocuronium's prolonged duration of effect in patients with MG has yet to be quantified in an emergency department setting.
We describe a case wherein a full RSI dose of 1.2 milligrams per kilogram of rocuronium led to a prolonged 232-minute duration of paralysis in a patient with MG. This sustained paralysis was suspected but only confirmed after the patient received the reversal agent sugammadex. Once administered, an acute change in neurologic function was seen, and the patient was emergently taken to the operating room for neurosurgical intervention.
When intubating patients with MG, many emergency physicians are aware that using paralytics during RSI provides several challenges. If not properly dose-reduced, rocuronium may exert its paralytic effects for up to four hours in patients with MG. This unique case highlights the importance of personalizing care for this patient population before, during, and after RSI.
在重症肌无力（MG）患者的快速顺序插管（RSI）过程中使用麻痹剂，在急诊医学中仍是一个有争议的话题。由于功能性乙酰胆碱受体较少，这些患者对不同类型的神经肌肉阻滞剂（NMBA）可能既敏感又有耐受性。他们对罗库溴铵等非去极化NMBA的非典型敏感性，可能会在以典型RSI剂量使用后增加麻痹的持续时间和深度。然而，在急诊科环境中，罗库溴铵在MG患者中延长作用持续时间的程度尚未得到量化。
我们描述了一例病例，其中每公斤体重1.2毫克的全量RSI剂量罗库溴铵导致一名MG患者出现长达232分钟的麻痹延长。这种持续性麻痹在患者接受逆转剂舒更葡糖之前就已被怀疑，但直到那时才得到证实。一旦给药，就观察到神经功能的急性变化，患者被紧急送往手术室进行神经外科干预。
在为MG患者插管时，许多急诊医生都意识到在RSI期间使用麻痹剂会带来诸多挑战。如果不减量使用，罗库溴铵在MG患者中可能会产生长达四小时的麻痹作用。这个独特的病例凸显了在RSI之前、期间和之后对这一患者群体进行个性化护理的重要性。
