AB173. SOH24AB_048. Can’t ventilate…—Remembering the role for sugammadex

Background: A primigravida (gravida 1, para 0) patient presented with reduced fetal activity and bradycardia at 40 weeks’ gestation during on-call hours. The obstetrician scheduled her for an emergency category 1 caesarean section, and she presented to theatre. Anaesthetic preassessment revealed she was not fasting, having recently eaten some crackers, cheese, and grapes. She had a grade 1 Mallampati score.

Methods: A rapid sequence general anaesthetic including rocuronium as a paralytic was performed. A grade 1 Cormac & Lehane view of the vocal cords was seen, and the patient was intubated easily. However, shortly after intubation the anaesthetic doctor noticed no end tidal CO₂ trace and that the parturient’s chest wasn’t rising. He took the endotracheal tube out and reintubated the patient, but the problem persisted. He called for senior help. He rechecked the tubing connections. By now, the parturient’s oxygen levels started to drop. Sugammadex 500 mg was administered.

Results: After the sugammadex, the parturient coughed up a food bolus that included grapes. An end-tidal CO₂ trace appeared and the parturient’s oxygen saturations returned to normal. The baby was delivered shortly after. By this time, the consultant anaesthesiologist was on-site and performed a bronchoscopy which revealed a clean trachea and no sign of additional aspirated food. Later that evening, the patient was extubated without further sequalae, and open disclosure was done.

Conclusions: We describe a can’t-ventilate scenario rescued by sugammadex. There is debate in the current literature about its routine inclusion in a difficult emergency airway. We believe this case adds weight to Motamed et al.’s 2023 statement in, “Sugammadex in Emergency Situations”: “If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion”.

Keywords: Aspiration; emergency surgery; non-fasting; sugammadex; difficult intubation