Article Notes
- Need to prevent aortocaval compression.
- Early securing of the airway.
- Rapid perimortem Caesarean delivery.
- Likelihood of a non-cardiac/pregnancy cause.
An interesting CICO case study highlighting that while sugammadex will rapidly and completely reverse paralysis, this is only one consideration when managing an airway crisis. The use of any reversal agent in an airway crisis should be considered within the context of the case and a clear understanding of the objective of our actions.
Neuromuscular reversal will only improve a CICO scenario if spontaneous ventilation will improve patient oxygenation, otherwise return of muscle function may actually make other CICO interventions more difficult.
A reminder that hypersensitivity reactions are possible with almost any drug or chemical. At the time of this publication, the risk of anaphylaxis to sugammadex appeared to be lower than that for muscle relaxants – however newer studies from Merck (Kam 2018 and Min 2018) worryingly suggest that sugammadex sensitivity may be a lot more common than we thought.
The FDA’s caution now no longer seems quite so unwarranted...
Possibly... but with some important caveats.
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.” – RD Miller (2007).
Sugammadex (Bridion®) is a remarkable drug – and the anaesthesia community has moved very quickly to embrace the potential of this first ‘selective relaxant binding agent’ (SRBA), despite it’s considerable cost.
Sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular from rocuronium. The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex’s onset is 10 times faster than neostigmine and three times faster than edrophonium.
Though beyond the parlour-trick of speedy action, or the possibility of rescuing a cannot-intubate-cannot-ventilate crisis – the biggest benefit of sugammadex for our patients may be in the dramatic reduction of post-operative residual paralysis. A common problem with serious consequences that the anaesthetic community has ignored for far too long.
Chazot et al. describe a 25 yo undergoing a Nissen fundoplication, receiving TCI propofol/remifentanil (targets of 2.3 ug/mL & 4 ng/mL respectively) along with rocuronium. The deep neuromuscular block was reversed with sugammadex 4 mg/kg and the patient awoke within 80 seconds (clinically and BIS > 90) despite TCI targets continuing. No awareness was noted.
A very practical review of the evidence, indications and rationale for the perimortem cesarean section. Richard Parry describes the specific steps required to perform a PMCS, along with discussion of the pros and cons of different approaches. The importance of multidisciplinary training is emphasised.
A review of all published perimortem cesarean section case reports by Vern Katz, following up his article in 1986 first recommending this procedure.
While this does not offer proof of benefit (huge survival selection bias), of the 38 cases reported, 34 neonates survived (includes multiple gestations), and of the 20 cases with reversible causes, 13 mothers were discharged from hospital.
Katz writes:
In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery.
This is the first published recommendation for perimortem cesarean sections in maternal cardiac arrest – from Katz, Dotters and Droegemueller (1986).
It was this recommendation that lead to the ‘4 minute rule’ for deciding to commence a CS in a resuscitation scenario, with the aim of delivering the baby within 5 minutes.
McDonnell makes a concerning observation regarding the ageing maternity population and subsequent potential for increasing rates of maternal arrest:
With the change in the obstetric population characteristic to women being older, heavier, and having more complex medical problems during pregnancy, the number of women who become seriously unwell while pregnant is likely to increase.
McDonnell highlights the differences in managing the collapsed parturient, namely:
The two cases presented include arrest due to ruptured uterus and arrest possibly due to iatrogenic magnesium overdose. Both resulted in favorable, though not perfect, outcomes for mother and baby.
The need for delivery suite ‘perimortem cesarean section packs’ is also discussed, as well as the use of regular simulation training.