Management of subcutaneous infiltration of rocuronium: A case report

Timmermann, Tia N; Mongan, Paul D.; Hoefnagel, A. L.; Braunecker, Stefan

doi:10.1016/j.jclinane.2021.110203

Cited by 4 publications

(16 citation statements)

References 9 publications

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“…6,8 Three cases reported difficult insertion of the intravenous cannula. 7,8,10 Table 2 shows the characteristics of the subcutaneous injection of NMBDs. Rocuronium was used in nine cases, [4][5][6][7][8]11 vecuronium in two cases 9,10 and pancuronium in one case.…”

Section: Resultsmentioning

confidence: 99%

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Extravascular injection of neuromuscular blocking drugs

Nietvelt,

Van Herreweghe,

Godschalx

et al. 2024

European Journal of Anaesthesiology

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Extravascular injection of neuromuscular blocking drugs (NMBDs) can cause a neuromuscular block because of systemic absorption. Currently, there are no guidelines available on managing extravasation of NMBDs. This article reviews the available literature on extravasation of NMBDs. Medline and Embase databases were searched for studies concerning the paravenous or subcutaneous injection of NMBDs. Nine articles were included consisting of seven case reports, one case series and one clinical trial. Rocuronium was used as primary NMBD in nine cases, vecuronium in two cases and pancuronium in one case. Although there exists significant heterogeneity between the reported information in the included studies, the majority of the case reports describe a slower onset, with a median delay of 20 min and prolonged duration of the neuromuscular block. Nine patients had a residual neuromuscular block at the end of the surgery. Postoperative monitoring in the recovery room was prolonged (median time 4 h). Most studies suggest that the delay in NMBD onset and recovery is caused by the formation of a subcutaneous depot, from which the NMBD is slowly absorbed into the systemic circulation. According to the current literature, extravasation of NMBDs results in an unpredictable neuromuscular block. Strategies to prevent potentially harmful side effects, such as frequent train-of-four (TOF) monitoring, the use of NMBD reversal agents and prolonged length of stay in the postanaesthesia care unit (PACU), should be considered. This article suggests a clinical pathway that can be used after extravascular injection of NMBDs.

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Section: Resultsmentioning

confidence: 99%

“…7,8,10 Table 2 shows the characteristics of the subcutaneous injection of NMBDs. Rocuronium was used in nine cases, [4][5][6][7][8]11 vecuronium in two cases 9,10 and pancuronium in one case. 12 No case reports were retrieved describing the extravasation of atracurium, cisatracurium, mivacuror succinylcholine.…”

Section: Resultsmentioning

confidence: 99%

Extravascular injection of neuromuscular blocking drugs

Nietvelt,

Van Herreweghe,

Godschalx

et al. 2024

European Journal of Anaesthesiology

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“…While the exposure of rocuronium to the eye has not been reported, there are case reports of insidious and prolonged neuromuscular blockade with subcutaneous exposure after intravenous infiltration. [3][4][5] The most life-threatening sign of rocuronium exposure would be respiratory depression requiring intervention. While our patient only exhibited local signs and symptoms that self-resolved within 2 hours, patients with mucosal absorption must be carefully monitored given the potential for systemic paralysis and unknown duration of effects.…”

Section: Accidental Ocular Rocuronium Exposurementioning

confidence: 99%

Accidental Ocular Rocuronium Exposure

Pierce¹,

Batra

Norberg

2021

Annals of Emergency Medicine

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“…Often, it can be difficult to determine whether the catheter is positioned in a vein [1]. While there have been a few reports on extravasation of rocuronium, almost all reports have shown successful perioperative management of an intubating dose of rocuronium with neuromuscular monitoring [2][3][4][5]. Such reports have recommended objective monitoring of neuromuscular blockade as soon as possible if unintended subcutaneous leakage of rocuronium is suspected.…”

mentioning

confidence: 99%

“…Moreover, it should be noted that rocuronium becomes more potent in an acidotic state [9]. Recurarization of rocuronium after extravasation is caused not only by the effects of systemic administration of the drug but also by drug absorption at the site of extravasation [2][3][4][5].…”

mentioning

confidence: 99%