LETTER TO THE EDITOR Reversal of neuromuscular blockade with sugammadex in an obese myasthenic patient undergoing thymectomy Helena Argiriadou • Kyriakos Anastasiadis • Evanthia Thomaidou • Dimitrios Vasilakos Received: 23 November 2010 / Accepted: 24 January 2011 / Published online: 25 February 2011 Ó Japanese Society of Anesthesiologists 2011 To the Editor: Myasthenia gravis (MG) is an autoimmune disease often characterized by circulating antibodies that block acetyl- choline receptors at the postsynaptic neuromuscular junc- tion.The resulting modified neuromuscular transmission leads to an unpredictable response in the administration of neuromuscular blocking agents in case of surgery. We challenged the use of sugammadex, a modified c-cyclodextrin, to reversea deeprocuronium-induced blockade in a 31-year-old obese [95 kg; 1.60 m; body mass index (BMI) 37 kg/m 2 ] female myasthenic patient. The patient was literally disabled, mainly from severe weakness affectinglimb muscles,resultingin repetitivefalls [Myasthenia Gravis Foundation of America (MGFA) class IVa]. She was referred for transsternal thymectomy due to a grossly hyperplastic thymus gland.Her daily dose of pyridostigmine was 240 (60 9 4) mg. Preoperative blood gasesin room airwere satisfactory: partialpressure of arterialoxygen(PaO 2 ) 93 mmHgand carbondioxide (PaCO 2 ) 36 mmHg,pH 7.43, saturationofperipheral oxygen (SpO 2 ) 96%.Sugammadex encapsulates the ste- roidal neuromuscular-blocking agents (NMBAs) rocuroni- um and vecuronium, resulting in prompt reduction of free NMBA plasma concentration and rapidrestorationof muscular activity. It lacks endogenous targets and is unli- kely to cause any major adverse effects [ 1]. The patientwasnot premedicated; she received her usualdose of pyridostigmine. After induction (140 mg propofol, 0.25 mg fentanyl intravenously), neuromuscular monitoring was applied [baseline train-of-four (TOF) ratio T4/T1 0.92–1.02). NMBAs have variable sensitivity in MG. Thus,dosage has to be carefully titrated and neuro- muscular function continuously monitored [ 2, 3]. For this reason, repetitive TOF stimulation (TOF-Watch SX) was applied intraoperatively. Anesthesia was initially main- tained with propofol 5 mg/kg per hourand then titrated according to bispectral index (BIS) values (target 40–50). A single bolus of rocuronium 0.5 mg/kg was administered to facilitate tracheal intubation. No maintenance doses of rocuronium were given. The neuromuscular blockade was considered adequate throughout surgery. At the end of the 70-min surgical procedure (extended thymectomy), the TOF ratio was 0.3. The neuromuscular blockade was considered as deep compared with preoper- ative values, and a dose of2 mg/kg sugammadex was administered intravenously. Within 3 min, the TOF ratio was 0.92; 7 min later, it was 1.02. The patient returned to spontaneous breathing (pressure support 15 cm/H 2 O, tidal volume 700 ml, respiratory rate 14 breaths/min) with sat- isfactory blood gases (PaO 2 297 mmHg, PaCO 2 41 mmHg, pH 7.42, SpO 2 98%). Clinically, the patient was able to lift her head, open her eyes, and protrude her tongue. She wa extubated in the operating room 10 min after the end of surgery. The patient had a 24 h-stay in the intensive care unit and had an uneventful recovery. She left the hospital a good condition on the seventh postoperative day. This case demonstrates that sugammadex effectively an safely reversed a deep rocuronium-induced neuromuscula blockade in an obese MG patient and allowed prompt weaningfrom mechanicalventilationpostoperatively. Moreover, the surgical procedure (transsternal approach) H. Argiriadou (&) E. Thomaidou D. Vasilakos Department of Anesthesia and Intensive Care Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece e-mail: argiriadouhelena@hotmail.gr K. Anastasiadis Department of Cardiothoracic Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece 123 J Anesth (2011) 25:316–317 DOI 10.1007/s00540-011-1101-z