2019 FSA Posters

P075: WHEN TO REVERSE: CASE REPORT OF CHRONIC GBS AND THE USE OF SUGAMMADEX FOR REVERSAL AFTER NO POST-TETANIC TWITCHES.
Brandon Duffin, DO; University of Florida

Introduction: Guillian-Barre Syndrome (GBS) is part of a group of inflammatory neuropathies that can have both acute and chronic effects on the nervous system that can influence our anesthesia management. GBS is characterized by skeletal muscle weakness that begins in the legs and ascends with the most serious problem being ventilatory insufficiency. Patients with GBS present a distinct challenge to anesthesiologist when considering neuromuscular blockers.  In these cases, succinylcholine is contraindicated and non-depolarizing muscle relaxants can have a varied response from extreme sensitivity to resistant to its effects.  This presents a bigger challenge when a patient with GBS presents needing rapid sequence induction for airway protection.

Case: A 59 y.o 113 kg male with past medical history of GBS two years prior with initial symptoms of lower extremity weakness, absent lower extremity reflexes and diminished upper extremity reflexes. Pt had an eight-day hospital admission requiring IVIG and eight days of rehab before he had recovered sufficiently to be discharged home. He subsequently continued to endorse right hand weakness, neuropathic tremor and decreased sensation in bilateral lower extremities. Pt presented to the ED with foreign body GI obstruction.  He was emergently taken for upper GI endoscopy and rapid sequence induction was done with the use of rocuronium given risk of hyperkalemia from the use of succinylcholine due to his chronic GBS symptoms. The EGD revealed congestion and inflammation and no food bolus was seen.  From time of rocuronium given to endoscope out was 16 minutes. A twitch monitor was placed to stimulate the right adductor pollicus muscle which revealed 0/4 twitches and no post-tetanic twitch.  At this point the dose of reversal for sugammadex was discussed.  After testing for 90 minutes from time endoscope was out, no twitches and no post-tetanic twitches could be identified. It was decided to give a 500mg dose of Sugammadex and within 3 minutes the patient had 4/4 twitches and five seconds of sustained tetanus. He was promptly extubated and was able to be discharged home soon after.

Discussion: Sugammadex has changed anesthesia practice in the timing and ability to reverse paralytics. The presentation will discuss anesthesia time cost vs cost of higher dose of sugammadex, as well as time to sustained tetanus with varying dosages of sugammadex. A discussion in regards to GBS and sugammadex will also be discussed.

References:

de Boer HD, Carlos RV, Brull SJ. Is lower-dose sugammadex a cost-saving strategy for reversal of deep neuromuscular block? Facts and fiction. BMC Anesthesiol. 2018;18(1):159. Published 2018 Nov 6. doi:10.1186/s12871-018-0605-6

Otomo S, Iwasaki H, Takahoko K, et al. Prediction of optimal reversal dose of sugammadex after rocuronium administration in adult surgical patients. Anesthesiol Res Pract. 2014;2014:848051.