P025: RESPIRATORY FAILURE IN POST-ANESTHESIA CARE UNIT IN A 11-WEEK OLD PATIENT UNDERGOING CLEFT LIP REPAIR
Anny Santana Beard, MD; Tarun Uppalapati
HCA Florida Westside Hospital
Patient is a 4.3kg, 11-week old female that underwent a bilateral cleft lip/nasal deformity repair. Patient has past medical history of bilateral cleft lip and palate and recent upper respiratory infection. Patient was noted to be symptom free from the recent upper respiratory infection. She has no past surgical history. Patient had a term delivery with no complications or neonatal intensive care unit stay at birth.
During the intraoperative course, patient had a mask inhalation induction with sevoflurane. After proper depth of anesthesia was acquired, patient had a 24-guage IV placed. Patient had 5 milligrams of rocuronium given and was intubated with a microcuffed 3.0mm endotracheal tube using CMAC Miller 0. Patient had a grade 1 view. Rocuronium of 5 milligrams was re-dosed at the start of the procedure. Once the procedure ended, sugammadex was given at the dose of 2 milligrams per kilogram for neuromuscular blockade reversal, which was about 1 hour since the re-dose of rocuronium. Patient was later extubated once awake and was spontaneously breathing with tidal volumes of about 11-12 mL/kg.
On arrival to PACU, patient taking shallow breaths and needed support to ventilate. Patient started desaturating. After going to list of items to reverse such as naloxone and glycopyrrolate, patient did not respond. We re-dosed suggamadex and patient improved instantly. This brings the possibility of residual rocuronium blockade in the receptors.
It is important to note there are incidents of residual paralysis after reversal in the past with patients less than one year old. There are multiple case reports of this upon research. It is important to discuss how inadequate nerve monitoring is for twitches in infants. They require a much more enhanced nerve monitoring. There are new monitoring devices coming out that can more accurately check accurate reversal of paralysis.