(892) Prolonged Paralytic Effects of Vecuronium in the Setting of Acute Kidney Injury and Shock Liver

Introduction: Critically ill patients benefit from neuromuscular blockade (NMB) in specific cases. Patient specific characteristics affect vecuronium half-life, specifically renal and hepatic impairment. We discuss a patient with severe acute kidney injury (AKI) who received an infusion of vecuronium and experienced prolonged paralysis and recurarization after discontinuation, despite reversal agents.

Description: A 17-year-old female presented with hemorrhagic shock due to a ruptured ectopic pregnancy. She underwent emergent oophorectomy, complicated by severe AKI, rhabdomyolysis, and shock liver. She was transferred after five days at an outside facility. On arrival, she was intubated, sedated, and paralyzed. Vecuronium was discontinued given her AKI and shock liver. Over 24 hours after discontinuation, she remained fully paralyzed. Sugammadex was administered with immediate reversal of paralysis. However, she experienced recurarization 12-24 hours after each dose, requiring four total doses of sugammadex over five days. She was successfully extubated six days after discontinuing vecuronium. Recovery was temporarily complicated by delirium and weakness.

Discussion: Vecuronium is primarily hepatically metabolized with 30% renal elimination. Hepatic dysfunction can lead to prolonged paralysis; however, typically renal metabolism compensates to clear vecuronium. Uremia decreases hepatic elimination of the active metabolite 3-hydroxy. Although sugammadex temporarily freed her motor endplate receptors of enough NMB to allow short periods of function, reaccumulation of vecuronium resulted in recurarization. This recurred until she received enough sugammadex to bind and excrete the full amount of vecuronium in her system. This case highlights the importance of serial train of four testing, paralytic holidays, and monitoring hepatic and renal function when using vecuronium. Consider non-renally cleared NMB such as cisatracurium in any patient with evidence of hepatic or renal dysfunction. In patients with concern for vecuronium accumulation that reverses after sugammadex, providers should have a high level of suspicion for recurarization. It may be prudent to delay extubation until sufficient time has elapsed to ensure further recurarization will not recur.