Sugammadex and the cannot intubate / cannot ventilate scenario in patients with predicted difficult airway ( 1 )

Editor—Curtis and colleagues presented an interesting case in which a patient with anticipated difficult intubation was paralysed with rocuronium and developed a cannot intubate/cannot ventilate (CI/CV) situation. Sugammadex was administered, resulting in successful recovery of the patient’s motor strength, but ventilation was still impossible, presumably due to swelling of the airway and bleeding caused by repeated intubation attempts. The patient’s life was saved by timely performing of transtracheal needle oxygenation followed by an emergency tracheostomy. In the article, the authors claim they report what they believe ‘to be the first case of the use of sugammadex in a CI/CV scenario’. However, we found a case published before by Desforges and McDonnell, of sugammadex administration in a CI/CV scenario. In their case, a patient with a BMI of 38.5 kg m and Mallampati class 3 undergoing sleeve gastrectomy received rocuronium to facilitate tracheal intubation which proved to be impossible. Considering that ‘no convincing capnography trace could be detected while the SpO2 decreased to 69%’, sugammadex was administered and successfully reversed the CI/CV condition, enabling effective spontaneous ventilation within 45 s of sugammadex administration. We consider the case report by Curtis and colleagues important for three reasons. First, we congratulate the authors for their systematic, step-by-step planning of anaesthesia and airway interventions in this case. Secondly, this case demonstrates that sugammadex will not recover effective spontaneous ventilation in all CI/CV cases. Repeated laryngoscopy and intubation attempts may cause airway oedema with obstruction and difficult ventilation even with regained motor strength. Furthermore, the patient may not be able to ventilate spontaneously due to the administration of central nervous system depressants (i.e. midazolam, fentanyl) during induction of anaesthesia. Thirdly, this case re-emphasizes the need for considering the performance of an awake intubation technique whenever facing a predicted airway management difficulty. It is our routine to opt for awake fibreoptic intubation whenever we expect a difficult-to-manage airway. The use of a short-acting neuromuscular blocking agent such as succinylcholine, hoping for a quick recovery of spontaneous ventilation in case a CI/CV will develop, seems unsafe as well. The time to functional recovery (i.e. 50% recovery of the control single twitch height of the adductor pollicis brevis muscle), a time that should permit adequate spontaneous ventilation with a patent airway, after 1 mg kg succinylcholine was reported as 8.5 min. They also mention that the majority of patients will develop life-threatening desaturation before functional recovery.