2024 FSA Podium and Poster Abstracts
P091: ORBITAL HEMATOMA FOLLOWING ENDOSCOPIC SINUS SURGERY REQUIRING IMMEDIATE RE-INTUBATION AFTER REVERSAL WITH SUGAMMADEX
Cayla Suthumphong, MD; Nathalie Abitbol, MD, MBA; University of Miami/Jackson Memorial Hospital
Introduction/Background: While rare, ophthalmic complications are a well-documented risk of endoscopic sinus surgery that anesthesia providers should be cognizant of. If not recognized and addressed timely, they may lead to blindness.
Methods: Patient is a 65-year-old, 76 kg, male, with history of chronic rhinosinusitis who presented for revision of an endoscopic sinus surgery. The patient underwent standard induction and intubation via DL with a Grade III view. Upon completion of surgery and TOF assessment with 4/4 twitches, sugammadex 200mg (~2.6 mg/kg) was administered. After removal of the drapes, the anesthesiologist noted the patient’s right eye to be swollen. After discussion with the surgical team, decision was made to continue with extubation, which occurred smoothly and uneventfully. Three minutes following extubation, the right eye swelling was noted to be worsening, the orbit tense to touch and purple discoloration of upper eyelid was evident. It was determined that emergent exploration under general anesthesia was necessary.
Results: The patient was re-induced with high dose propofol and without neuromuscular blockade (NMB) fifteen minutes after extubation. Given the prior Grade III view and lack of muscle relaxation, video laryngoscopy was used: Grade I view was obtained with atraumatic intubation. Surgical exploration revealed a partially lacerated anterior ethmoid artery and medial orbital wall decompression was performed. A formal ophthalmologic consultation was performed in the PACU with no acute findings. Upon follow-up, the patient reported doing well with no changes in vision.
Discussion/Conclusion: Providers should be able to promptly recognize the symptoms of orbital complications to prevent significant morbidity. Orbital hematomas are considered an ophthalmic emergency as they can rapidly lead to orbital compartment syndrome and permanent optic nerve injury. Early signs of orbital hematoma include ecchymosis, preseptal edema, and orbital proptosis.
In our case, re-establishment of NMB was not necessary for the surgical exploration. However, if needed for surgical conditions, the options for re-establishing NMB after sugammadex administration include (1) re-administration of rocuronium or vecuronium, (2) use of benzylisoquinolinium NMBA, such as cisatracurium, or (3) use of succinylcholine. As sugammadex is excreted in urine unmetabolized, unbound sugammadex molecules in circulation have the potential to bind with rocuronium, if administered soon after reversal. This may lead to unpredictable re-onset times and shortened blockade times. Clinical studies show that when rocuronium 1.2 mg/kg is administered within 30 minutes after reversal with sugammadex, the onset of NMB is delayed approximately 4 minutes and the duration of NMB is shortened approximately 15 minutes. Sugammadex insert recommends a dosage of 1.2 mg/kg rocuronium if given 5 minutes after reversal (up to 4 mg/kg) and 0.6 mg/kg rocuronium or 0.1 mg/kg vecuronium if after 4 hours of reversal. However, if the patient has mild or moderate renal impairment or sugammadex 16 mg/kg was administered, a 24-hour waiting time is recommended before the re-use of rocuronium or vecuronium. An advantage of re-administration of rocuronium following sugammadex is antagonism by another dose of sugammadex when blockade is no longer needed.