P062: PERIOPERATIVE MANAGEMENT OF SUBCUTANEOUS ADMINISTRATION OF ROCURONIUM DUE TO PIV INFILTRATION: A CASE REPORT
Adriana L Grossman, MD, MPH, MHA; Cosmin Guta, MD
University of Miami/Jackson Memorial Hospital
Introduction: Peripheral Intravenous line (PIV) infiltration is a common complication of PIV placement1. When PIV’s infiltrate during induction and medications are administered to subcutaneous tissues, literature lacks discussion as to the management of subcutaneous administration of Rocuronium. Two concerns predominate: The time to onset of the subcutaneous rocuronium and the time to complete absorption, ensuring all subcutaneous rocuronium has been reversed 2. Guidelines from the Zemuron company in vivo animal trials indicated a subcutaneous absorption time of 2 hours with recommended recovery time to TOF >80% of 4 hours that was also dose dependent3.
Methods: A 55 year-old male with a PMH of nephrolithiasis and COPD presented for cystoscopy and stent placement. Preoperatively the patient had a functional 20 G PIV in the hand that flushed easily and ran fluids well to gravity. ASA monitors were applied including a quantitative TOF monitor and the patient was induced through the PIV. After successful mask ventilation, 50 mg of rocuronium was administered. The patient was then noted to not be relaxed after 1 minute and 30 seconds with a TOF of 80%. The PIV was then determined to have infiltrated after the induction medications were given. A second 20 G PIV was placed in the wrist by the attending while the intubation proceeded without incident.
Results: Within 26 minutes, the patient’s TOF had decreased to 46%. After approximately 42 minutes the TOF had decreased to 21%. Finally at approximately 1 hour and 50 minutes, the TOV reached 70% and the patient was reversed with Sugammadex. When reversed, the patient was breathing without support to tidal volumes over 6 mL/kg. The patient was then extubated and kept in PACU for 1 hour with BiPAP available should the patient require ventilatory support due to weakness. The patient was then transferred to ICU care for close monitoring and was discharged within 24 hours of admission.
Discussion/Conclusion: Given the high frequency of use for Rocuronium, the absence of a protocol for accidental subcutaneous administration is notable. A review of European literature yielded expectant management of a prolonged onset time of 20 mins and a prolonged effect and observation time of 4 hours (median)3. However original in-vivo studies from Zemuron that include subcutaneous administration have not been published for public use.
1. Marsh N, Webster J, Flynn J, Mihala G, Hewer B, Fraser J, Rickard CM. Securement methods for peripheral venous catheters to prevent failure: a randomised controlled pilot trial. J Vasc Access. 2015 May-Jun;16(3):237-44. doi: 10.5301/jva.5000348. Epub 2015 Feb 4. PMID: 25656258.
2. Navare SR, Garcia Medina O, Prielipp RC, Weinkauf JL. Sugammadex Reversal of a Large Subcutaneous Depot of Rocuronium in a Dialysis Patient: A Case Report. A A Pract. 2019 May 15;12(10):375-377. doi: 10.1213/XAA.0000000000000934. PMID: 30575607.
3. Nietvelt, Frederik; Van Herreweghe, Imré; Godschalx, Vincent; Soetens, Filiep. Extravascular injection of neuromuscular blocking drugs: A systematic review of current evidence and management. European Journal of Anaesthesiology 41(5):p 367-373, May 2024. | DOI: 10.1097/EJA.0000000000001967