Increased sensitivity to rocuronium and atracurium in mitochondrial myopathy

Abstract

Increased sensitivity to rocuronium and atracurium in mitochondrial myopathyPurpose: To describe the prolonged effect of the intermediate-acting, non-depolarising neuromuscular blocking agents rocuronium and atracurium in a 29-yr-old apparently healthy woman. Clinical features: Because of abdominal pain the patient was scheduled for explorativelaparoscopic pelvic examination. General anaesthesia was induced with fentanyl, midazolam and propofol. Muscle relaxation was achieved with 0.6 mg.kg-' rocuronium. Anaesthesia was maintained with nitrous oxide and propofol. Two Hz train-of-four stimulation every 15 sec evoked no twitch responses until 60 min after rocuronium. Further relaxation was achieved with 0.075 mg.kg-' atracurium after which twitch responses recurred after 45 min. Fifteen minutes later neuromuscular blockade was successfully reversed with atropine and neostigmine. The postanaesthetic course was uneventful. Because of the increased sensitivity to rocuronium and atracurium the patient was re-evaluated postoperatively. History revealed occasional double vision, fatigue, muscle cramps, stiffness and myoglobinuria. Clinical neurological examination showed ptosis, tremor, ataxia and bradydiadochokinesia. A standardised lactate stress testing on a bicycle was pathological and, after muscle biopsy, the diagnosis of mitochondrial myopathy was established. Conclusion: An increased sensitivity to rocuronium and atracurium may occur in patients with mitochondrial myopathy. In these patients appropriate dosing of muscle relaxants and adequate monitoring of the neuromuscular blockade are required. If an increased sensitivity to rocuronium and atracurium occurs in an apparently healthy subject, further neurological investigations should follow.Objectif : D&rire I'effet prolong~ des inhibiteurs neuromusculaires non d~polarisants ~ action interm~diaire, rocuronium et atracurium, chez une femme de 29 ans apparemment en bonne sant~. Aspects cliniques : La patiente a 6t~ admise pour un examen laparoscopique exploratoire du bassin ~ la suite de douleurs abdominales. I'anesth&ie g~n&ale a ~t~ induite avec du fentanyl, du midazolam et du propofol. La relaxation musculaire a ~t~ obtenue avec 0,6 mg'kg ~ de rocuronium. I'anesth&ie a ~t~ maintenue avec du protoxyde d'azote et du propofol. Une stimulation de deux Hz en train-de-quatre ~ toutes les 15 secondes n'a pas d&lench~ de contraction musculaire avant 60 minutes suivant radministration du rocuronium. Une relaxation suppl6mentaire a ~t~ obtenue, avec 0,075 mg.kg -~ d'atracurium, apr~s laquelle les contractions musculaires ont reparu 45 minutes plus tard. Apr~s quinze minutes, le bloc neuromusculaire &ait renvers~ avec succ& avec ratropine et la n(.~ostigmine. I'~volution postanesth~sique a ~t~ sans complication. La patiente a ~t6 ~valu6e de nouveau apr& I'intervention ~ cause de la sensibilit~ accrue au rocuronium. I'histoire a r~v~l~ une diplopie occasionnelle, de la fatigue, des crampes musculaires, de la raideur et de la myoglobinurie. ~examen neurologique clinique a ...

Anesthetic management of an obstetric patient with MELAS syndrome: case report and literature review

“…Nevertheless, succinylcholine should probably be avoided in patients with underlying myopathy because of the risk of hyperkalemia after its administration. Patients with mitochondrial myopathy may also be more sensitive to non-depolarizing neuromuscular blockade, 15,16 so neuromuscular blockade should be closely monitored and shorter-acting non-depolarizing muscle relaxants should be considered.…”

A Case of Mitochondrial Myopathy with Cardiac Involvement: Management in the Same Day Surgery Setting

“…Nevertheless, it is important to recognize that even a brief procedure, such as upper endoscopy, can potentially lead to complications [14]. Patients with mitochondrial myopathies may have a prolonged recovery time after non-depolarizing neuromuscular blocking agents [15]. There were no complications in a cohort of 16 children with mitochondrial defects, one of them with Leigh disease, who received general anesthesia with sevoflurane in 100% oxygen, supplemented with fentanyl, during brief surgical procedures, mostly muscle biopsy [16].…”

Considérations anesthésiques lors d’un syndrome d’encéphalomyopathie mitochondriale avec acidose lactique et épisodes ressemblant à des accidents vasculaires cérébraux: une série de cas

“…13 In several MELAS cases, increased sensitivity to NMBDs was reported for vecuronium, 9 mivacurium, 10 rocuronium, and atracurium. 8 In contrast, one report described resistance to cisatracurium. 7 Finally, a patient with an undefined mitochondrial myopathy developed hyperkalemia in response to succinylcholine.…”

“…These associated morbidities may increase the risk for perioperative complications. [7][8][9][10][11] Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome patients need anesthesia for diagnostic (muscle biopsy, electrophysiology studies) and therapeutic procedures (cochlear implant, cardiac surgery, pacemaker implantation). Since MELAS is rare (12.5 per 100,000), 12 it is not feasible to perform prospective studies to define anesthetic risk, but potential specific anesthetic concerns have been raised in response to anecdotal reports.…”

“…For example, controversy exists regarding patient sensitivity to nondepolarizing muscle relaxants (NDMR). [7][8][9][10]13 In addition, the avoidance of lactated intravenous fluids has been advocated because of impaired lactate metabolism. 14,15 As with other mitochondrial disorders, there is the concern of increased susceptibility to malignant hyperthermia (MH).…”