scimitar.pdf
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Scimitar Syndrome and Inadvertent Subcutaneous Rocuronium Injection Kareem Kassel M.D. 1 , Melissa Ehlers M.D. 1 , Harm Velvis M.D. 2 1 Department of Anesthesiology, Albany Medical College 2 Department of Pediatrics, Section of Cardiology, Albany Medical College Case Summary • An 11 kg, 18 month-old female with suspected Scimitar syndrome presented for cardiac catheterization • Inhalational induction with sevoflurane • Peripheral IV placed in hand with minor difficulties during threading. • IV site immediately infiltrated upon injection of 10 mg (0.91 mg/kg) rocuronium. • Proceeded with tracheal intubation which was smooth, and another vein, the left saphenous, was cannulated successfully. • Reversed with 0.02mg/kg neostigmine after 2 hours. Uneventful recovery Findings Ulnar TOF twitches: • 4/4 until 45 mins • Nadir = 2/4 for 30 mins • Return to normal 4/4 at 90 min after dose Cardiac Catheterization: • Dextroposition, marked rotation of heart • Smallish right pulmonary artery • Small right-sided pulmonary veins (to RA) • Bronchial collateral from celiac plexus-RLL • An aberrant right subclavian artery • Qp:Qs = 1.4:1 • Mild pulmonary HTN Discussion • Scimitar syndrome is a rare (3-6%) variant of partial anomalous pulmonary vein connection (PAPVC) defined as anomalous drainage of the right-sided pulmonary veins to the IVC or RA, right pulmonary hypoplasia, cardiac dextroposition, and anomalous systemic arterial supply to the right lung. • Anesthetic Considerations include: – right lung hypoplasia, – CHF, pulmonary HTN • Although pancuronium and vecuronium have been described, this is the first reported case of rocuronium injected subcutaneously to our knowledge. • The duration of effect of subcutaneous rocuronium in this case was likely attenuated by manual compression and placing a bair hugger® to the infiltrated site to speed local absorption/metabolism References 1. Canter CE, et al. Scimitar syndrome in childhood. Am J Cardio. 1986;58(7):652-4 2. Tarmey N, et al. (2011), Prolonged neuromuscular block following accidental subcutaneous injection of vecuronium. Anesthesia, 66: 956–957 3. Iwasaki H, et al. Neuromuscular effects of subcutaneous administration of pancuronium. Anesthesiology 1992; 76: 1049–51 Figure 2: Aberrant abdominal aorta collateral to RLL Figure 1: CXR showing pulmonary vein resembling a scimitar Figure 3: 3 PAPVC to RA and RA/IVC junction Figure 4: Left pulmonary veins and ASD RA LA Right Pulmonary Veins
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Transcript of scimitar.pdf
Scimitar Syndrome
and Inadvertent Subcutaneous
Rocuronium Injection ! !Kareem Kassel M.D.1, Melissa Ehlers M.D.1, Harm Velvis M.D.2 ! !1Department of Anesthesiology, Albany Medical College!2Department of Pediatrics, Section of Cardiology, Albany Medical College!
"!!Case Summary!• An 11 kg, 18 month-old female with suspected
Scimitar syndrome presented for cardiac catheterization!
• Inhalational induction with sevoflurane!• Peripheral IV placed in hand with minor
difficulties during threading.!• IV site immediately infiltrated upon injection
of 10 mg (0.91 mg/kg) rocuronium. !• Proceeded with tracheal intubation which was
smooth, and another vein, the left saphenous, was cannulated successfully.!
• Reversed with 0.02mg/kg neostigmine after 2 hours. Uneventful recovery!
Findings!Ulnar TOF twitches:!• 4/4 until 45 mins!• Nadir = 2/4 for !
30 mins !• Return to normal 4/4 at 90 min after dose
Cardiac Catheterization:!• Dextroposition, marked rotation of heart!• Smallish right pulmonary artery!• Small right-sided pulmonary veins (to RA)!• Bronchial collateral from celiac plexus-RLL!• An aberrant right subclavian artery!• Qp:Qs = 1.4:1!• Mild pulmonary HTN!
Discussion!• Scimitar syndrome is a rare (3-6%) variant of partial
anomalous pulmonary vein connection (PAPVC) defined as anomalous drainage of the right-sided pulmonary veins to the IVC or RA, right pulmonary hypoplasia, cardiac dextroposition, and anomalous systemic arterial supply to the right lung. !
• Anesthetic Considerations include:!– right lung hypoplasia, !– CHF, pulmonary HTN!
• Although pancuronium and vecuronium have been described, this is the first reported case of rocuronium injected subcutaneously to our knowledge.!
• The duration of effect of subcutaneous rocuronium in this case was likely attenuated by manual compression and placing a bair hugger® to the infiltrated site to speed local absorption/metabolism!
References!1. Canter CE, et al. Scimitar syndrome in childhood. Am J Cardio.
1986;58(7):652-4 !2. Tarmey N, et al. (2011), Prolonged neuromuscular block
following accidental subcutaneous injection of vecuronium. Anesthesia, 66: 956–957!
3. Iwasaki H, et al. Neuromuscular effects of subcutaneous administration of pancuronium. Anesthesiology 1992; 76: 1049–51!
Figure 2: Aberrant abdominal !aorta collateral to RLL!
Figure 1: CXR showing pulmonary !vein resembling a scimitar!
Figure 3: 3 PAPVC to RA!and RA/IVC junction!
Figure 4: Left pulmonary veins!and ASD!
RALA
RightPulmonary
Veins
