Case report: sugammadex used to successfully reverse vecuronium‐induced neuromuscular blockade in a 7‐month‐old infant

SIR—We would like to present a case report of sugammadex used successfully in a failed intubation scenario involving an infant weighing 6 kg. A 7-month-old child weighing 6 kg was listed for elective cleft palate repair. She had Pierre Robin sequence with a hypoplastic left mandible. Difficult intubation was predicted. Two specialist anesthetists were involved in her management. The planned approach was to perform inhalational induction with sevoflurane. If mask ventilation was possible, an attempt at direct laryngoscopy would be performed, initially with a Miller size 0 blade, then to use a Benjamin Holinger Tucker (BHT) anterior commissure laryngoscope for intubation. If this technique proved unsuccessful, the backup plan was to perform fiber-optic laryngoscopy and intubation. A selection of pediatric difficult airway equipment was prepared. Inhalational induction was achieved with sevoflurane, nitrous oxide, and oxygen. Venous access was obtained after induction. Mask ventilation was awkward but achieved so 0.7 mg of vecuronium was given. After 2 min, laryngoscopy was attempted, and a grade 4 view was obtained. The child showed some movement during laryngoscopy, so a further 0.3 mg of vecuronium was administered. Using a BHT laryngoscope, a second attempt at laryngoscopy was performed. The view was generally poor, and the larynx could not be clearly visualized. There appeared to be a polyp on the lateral wall of the pharynx obscuring the view. An attempt at intubation was unsuccessful. A return was made to mask ventilation while the fiberoptic scope was prepared. On the first attempt, no view of the larynx could be obtained. On the second attempt, a view of the larynx was obtained but the endotracheal tube could not be passed as it was insufficiently lubricated. The field was noted to be bloody at this stage. Mask ventilation was becoming more difficult with an extended period of mask ventilation expected. It was now 15 min since induction. A discussion took place about the potential role of sugammadex. It was decided to administer 4 mgÆkg in the first instance, with the option to increase the dose if required. Twenty-five milligram of sugammadex was administered intravenously, with very rapid return of airway tone and strong respiratory effort. After approximately 1 min, the child was able to breathe adequately without airway adjuncts. The operation was postponed. Tracheostomy was not proposed at this stage since the airway was already threatened and consent for tracheostomy had not been sought.