Recurarization after sugammadex reversal in a patient with amyotrophic lateral sclerosis: Case report

Amyotrophic lateral sclerosis (ALS) confers heightened and unpredictable sensitivity to nondepolarizing neuromuscular blocking agents and a high risk of postoperative respiratory failure. Although sugammadex reliably reverses rocuronium, recurarization may occur and is likely under-recognized in ALS. We report 2 ALS patients undergoing percutaneous endoscopic gastrostomy, one of whom developed delayed recurarization after apparent reversal.

Both women (67 and 68 years) presented with progressive dysphagia requiring percutaneous endoscopic gastrostomy. Case 1 had dyspnea, dysarthria, and long-standing noninvasive positive-pressure ventilation; Case 2 had bulbar signs without preoperative ventilatory support. The key perioperative concern in both cases was ventilatory failure from residual neuromuscular block.

ALS had been established clinically. In Case 2, recurarization was diagnosed shortly after extubation when acute hypercapnic respiratory failure and clinical weakness followed an earlier recovery to a train-of-four (TOF) ratio of 92%.

Intravenous anesthesia with propofol and remifentanil was used. Case 1 received rocuronium 10 mg (0.2 mg/kg) and was reversed with sugammadex 90 mg (2 mg/kg) at TOF count 0, achieving a TOF ratio of 98% within 3 minutes before extubation and postoperative noninvasive ventilation. Case 2 received rocuronium 30 mg (0.6 mg/kg) and sugammadex 200 mg (3.8 mg/kg) at TOF count 1, recovered to a TOF ratio of 92% at 4 minutes, but developed respiratory failure 3 minutes after extubation; mask ventilation and neostigmine 2 mg with atropine 0.25 mg were given.

Case 1 recovered uneventfully and was discharged on postoperative day (POD) 6. Case 2 required intensive care unit admission, re-intubation on POD 1, and re-extubation on POD 3; she was discharged on POD 23 without new neurologic deficits.

In ALS, recurarization can occur despite seemingly adequate sugammadex reversal. When rocuronium is used, sugammadex is recommended for reversal, with vigilant quantitative neuromuscular monitoring and extended post-extubation observation to detect delayed weakness.