Pediatric Critical Care Medicine Fellow University of Florida Gainesville, Florida, United States
Abstract: Introduction Adverse cardiovascular effects of acetylcholinesterase inhibiting agents for neuromuscular blockade reversal on the transplanted heart have been reported in literature, ranging from bradycardia to cardiac arrest. Sugammadex is a newer reversal agent with the theoretical potential to avoid the parasympathomimetic effects of acetylcholinesterase inhibition. Literature is limited on any hemodynamically significant adverse effects of Sugammadex in the unique population of pediatric heart transplant recipients.
Description A 13-year-old patient with a history of hypoplastic left heart syndrome now status post two orthotopic heart transplantations presented to the pediatric cardiac intensive care unit (PCICU) in cardiogenic shock following a cardiac arrest in the operating room after uvuloplasty and teeth extraction under general anesthesia. The most recent heart transplant was two years prior to presentation. A routine echocardiogram and cardiac catheterization with biopsy two months prior to surgery showed normal biventricular function, normal hemodynamics, and no evidence of cell-mediated rejection. Upon arrival to the operating room, the patient was induced with fentanyl (2mcg/kg), propofol (3mg/kg), and rocuronium (0.8mg/kg). Anesthesia was maintained with sevoflurane. There were no intraoperative complications and the patient was hemodynamically stable throughout the procedure. Shortly after administration of Sugammadex (2mg/kg) during emergence, the patient became acutely bradycardic and progressed to cardiac arrest with pulseless electrical activity requiring cardiopulmonary resuscitation with one round of chest compressions and two epinephrine boluses prior to return of spontaneous circulation. Tryptase was immediately collected and eventually resulted as normal. Due to persistent hypotension and an echocardiogram demonstrating severely reduced left ventricular systolic function after the arrest, the patient was started on an epinephrine infusion and transferred to the PCICU for further management. Upon arrival to the PCICU, an echocardiogram demonstrated normal left ventricular systolic function with mildly reduced right ventricular systolic function. The patient was weaned off inotropic support and extubated after two days. The child subsequently developed a fever of unclear etiology with worsening respiratory status and ventricular dysfunction. An endomyocardial biopsy was not consistent with cell-mediated rejection. After a 32 day hospitalization, the child died of refractory cardiogenic shock. An autopsy revealed hemorrhagic pancreatitis with large-volume hemoperitoneum and no evidence of cell-mediated rejection.
Discussion Sugammadex directly encapsulates neuromuscular blocking agents, rather than competitive reversal by increasing acetylcholine concentration. However, there is still potential for profound hemodynamic instability as noted in our patient, other similar case reports, and preclinical trials. No clear mechanism has been proposed for this adverse response. Sugammadex should be used with caution in pediatric heart transplant recipients. Future investigation is needed to clearly define the mechanism of the action of Sugammadex and the safety of its use in this vulnerable population.
