Postoperative recurrence of paralysis following extravascular injection of rocuronium bromide in an elderly patient with normal renal and hepatic function

Dear Editor,
Extravasation is an unintended injection or leakage of liquid or drug extravascularly or subcutaneously. After placing an intravenous (IV) catheter, anaesthesiologists should check its insertion site. Often, it can be difficult to determine whether the catheter is positioned in a vein [1]. While there have been a few reports on extravasation of rocuronium, almost all reports have shown successful perioperative management of an intubating dose of rocuronium with neuromuscular monitoring [2–5]. Such reports have recommended objective monitoring of neuromuscular blockade as soon as possible if unintended subcutaneous leakage of rocuronium is suspected. However, some studies have found that poor acceptance of neuromuscular devices in clinical practice is due to their steep learning curve and limited accuracy [6]. For example, neuromuscular monitoring for muscle relaxants, which has not yet been calibrated, has a negative predictive value of 40%, so it may not be possible to identify the presence of neuromuscular blocking agents (NMBAs) and prevent dyspnoea [5].
In our present case, we found postoperative reparalysis following extravascular injection of rocuronium because of a lack of neuromuscular monitoring in an elderly patient with normal renal and liver function. In our hospital, neuromuscular monitoring was not available in all operating rooms until our institution increased its availability in response to the present case. Therefore, based on our present case, two things need to be emphasized: (1) try to avoid giving rocuronium that infiltrates through an IV line by first checking if the propofol is working, and (2) use nerve monitoring in all such cases, especially following the extravasation of rocuronium.
An 84-year-old female patient (height 150 cm and weight 40 kg) was admitted for emergency surgery due to small bowel obstruction in the setting of a strangulated inguinal hernia. She has approved the publication of her case. Based on her physical examination, she had dementia and hypertension. She was taking amlodipine besylate for the hypertension. Her past medical history was unremarkable except for surgery for acute appendicitis. Laboratory findings noted hypoalbuminaemia (2.3 γ dL-1). Her renal function and liver function were normal. An IV cannula was already in the right antecubital fossa from her admission to the previous hospital. Oedema was observed in her extremities. An IV drip was put in place before...


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