a 21-year - old man ( height = 180 cm , weight = 95 kg , body mass index = 29.3 kg / m ) presented to the outpatient department with a long history of frequent and severe snoring . on physical exam ,
after a diagnosis of obstructive sleep apnea was made , a bilateral tonsillectomy and uvulopalatopharyngoplasty was planned for treatment .
prior to surgery , the patient had normal laboratory results with hemoglobin ( hb ) of 15.8 g / dl and no systemic or hematological diseases or history of bleeding disorders . on the day of the surgery , the patient received no premedication due to the history of sleep apnea .
intraoperative monitors included electrocardiogram , non - invasive blood pressure ( bp ) , pulse oximetry ( spo2 ) , and end - tidal co2 .
pre - anesthetic vital signs were bp 120/82 mmhg , hr 68 bpm , and spo2 96% .
general anesthesia was induced with remifentanil 0.5 g / kg / min and propofol 180 mg iv at 10:10 am . at loss of eyelash reflex ,
cisatracurium 16 mg was administered , and the trachea was intubated after a short period of facemask ventilation .
anesthesia was maintained with sevoflurane 2 vol% in 50% oxygen - enriched air and remifentanil 0.2 g / kg / min .
the neuromuscular block was antagonized with glycopyrrolate 0.6 mg and pyridostigmine 15 mg iv without neuromuscular monitoring upon the completion of the surgical procedure at 11:25 am .
postoperatively , a physical examination confirmed the presence of acute bleeding in the left inferior pole of the tonsillectomy site in the post anesthetic care unit .
the surgeon requested an emergent re - operation under general anesthesia for the control of bleeding .
a rsi for a second round of general anesthesia was performed with propofol 120 mg , midazolam 5 mg , and rocuronium 100 mg at 11:55 am .
the surgeon confirmed active bleeding due to an aberrant arterial blood supply in the left inferior pole of the tonsillectomy site .
after the completion of the surgical procedure , no twitch was shown after train - of - four ( tof ) stimulation ( tof = 0 ) with neuro - stim ( model ns-3cc , houston , tx , usa ) at 12:40 pm . the neuromuscular block was then antagonized with sugammadex 200 mg iv and the rocuronium - induced nmb was completely reversed within 2 min .
the patient was transferred to the recovery room , and there were no specific findings on physical exam .
a post - operative laboratory assessment showed hb of 14.6 g / dl ( table 1 ) .
after 6 h and 20 min , the surgeon again requested emergent anesthesia and re - operation for control of bleeding .
the surgeon attempted to control bleeding at the ambulatory otolaryngology clinic but was unable to do so .
when the patient arrived at the operating room ( or ) , vital signs were within normal limits and hb was found to be 13.2 g / dl .
a third round of general anesthesia was induced with propofol 120 mg and rocuronium 40 mg by the on - call resident at 19:00 pm .
the neuromuscular block was antagonized with sugammadex 200 mg iv and a tof = 0 at 20:00 pm .
the patient was again extubated successfully and transferred to the recovery room with no specific findings ( table 1 ) . after 2 h and 35 min ,
when the patient arrived at the or , vital signs were stable and hb was 11.6 g / dl .
a fourth induction of general anesthesia was performed with propofol 120 mg and rocuronium 40 mg by the same resident at 22:35 pm . during tof stimulation
, 1 twitch was seen , and an additional dose of rocuronium 10 mg was given due to bucking 20 min after the induction of anesthesia . at the end of the procedure ,
the neuromuscular block was antagonized with glycopyrrolate 0.4 mg and pyridostigmine 10 mg iv with a tof = 1 at the end of the surgical procedure at 0:20 am .
extubation was carried out after confirming the recovery of consciousness , regular respiration , and the absence of fade on tof monitoring .
after extubation , the patient vomited a large amount of blood on the operating table ( approximated to be more than 200 ml ) .
however , the patient was alert and aware of his surroundings and had regular respirations ( table 1 ) .
after 20 min , the surgeon requested a re - induction of general anesthesia for additional bleeding control .
an rsi for a fifth round of general anesthesia was performed with propofol 120 mg and rocuronium 100 mg at 0:40 am .
the neuromuscular block was antagonized with glycopyrrolate 0.4 mg and pyridostigmine 10 mg iv with a tof = 1 after the surgical procedure was completed at 1:30 am .
approximately 15 min passed after the nmb was antagonized as above , but no evidence of recovery from the rocuronium - induced nmb was seen .
therefore , we injected a bolus of iv sugammadex 200 mg to reverse the residual nmb .
once again , the nmb was completely reversed within 2 min , and tracheal extubation was performed in the or uneventfully ( table 1 ) .
a decision by surgeon was made to perform angiography of the left external carotid artery with subsequent embolization of the bleeding vessel .
embolization of the left ascending pharyngeal artery was performed with polyvinyl alcohol particle ( 350 m ) and tornado embolization microcoil ( cook , bloomington , usa ) ( 3/2 mm ) ( fig .
the patient 's postoperative course was uneventful , and hb was found to be 10.5 g / dl .
pth occurs in approximately 1 in 20 adults ( 5.1% ) , and more than half of patients who bleed are likely to require a procedure of some type to control their hemorrhage .
aberrant arterial blood supply to the tonsillar region derived from the internal carotid artery or the carotid bulb may be present .
to control bleeding , electrocauterization , packing of the pharynx , or angiographic embolization of the feeding artery may become necessary .
the endovascular embolization due to refractory bleeding after tonsillectomy proved to be a valuable treatment method as an effective alternative to surgical intervention .
it is a safe and permanent treatment option in this potentially life - threatening complication . in a case such as this ,
the aberrant arterial blood supply in the left inferior pole of tonsillectomy site caused continuous bleeding .
the anesthesiologist has experienced difficulties , because an experienced surgeon has embarrassed due to repetitive bleeding . in the first induction of anesthesia
, no problems were encountered with conventional anesthesia , although neuromuscular monitoring was not performed .
the most common anesthetic used for rsi during the management of children with pth is succinylcholine . since the introduction of sugammadex , rsi with rocuronium followed by reversal with sugammadex allowed for earlier establishment of spontaneous ventilation than with succinylcholine , which has many adverse side events . during the second round of anesthesia , rocuronium 100 mg ( 1 mg / kg )
was injected for rsi , followed by reversal with sugammadex 200 mg ( 2 mg / kg ) at deep nmb ( tof = 0 ) . during the operation ,
nmb monitoring was difficult due to problems attaching leads to the arms during the operation .
tof stimulation was applied at the ulnar nerve using conventional instrumental monitoring rather than quantitative monitoring due to convenience .
deep nmb was maintained for bleeding control in an attempt to not disturb the procedure . during nmb reversal
, we found an absence of fade on tof monitoring just 2 min after sugammadex was administered .
re - administration of 0.6 mg / kg rocuronium could then be given after sugammadex at the recommended waiting time of 6 h . during the third anesthesia induction ,
an on - call resident used rocuronium 40 mg for muscle relaxation during intubation followed by reversal with sugammadex 200 mg at deep nmb ( tof = 0 ) .
an absence of fade on tof monitoring was shown 2 min after sugammadex was given . for the fourth round of anesthesia , the same resident used rocuronium 40 mg for intubation 2 h and 35 min after the previous nmb reversal with sugammadex .
however , we believe this decision was made without considering the recent sugammadex use . when rocuronium is used within a short time interval ( less than 6 h ) after sugammadex administration , the onset time of rocuronium may be prolonged and may also have an unpredictable duration of action .
we suspect that the additional dose of rocuronium 10 mg due to bucking may be related to the short time interval between sugammadex and rocuronium administration . in situations such as these ,
the benzylisoquinoline class of medications are recommended instead of re - administering rocuronium within 6 h after sugammadex .
when considering this case , cisatracurium for muscle relaxation and intubation may have been a better choice for the fourth round anesthesia . however , one drawback of cisatracurium is the slower onset time than rocuronium .
reversal of the rocuronium - induced nmb with pyridostigmine at a moderate nmb ( tof = 1 ) was uneventful .
after extubation , the patient vomited more than 200 ml of blood on the operating table ; however , he was alert and showed regular respirations .
postoperative nausea and vomiting ( ponv ) after an operation for pth is common due to blood swallowed during the procedure .
therefore , patient awareness and complete reflexes are important , but aspiration must be avoided and monitored closely during the recovery period . however , ponv increases the risk of primary hemorrhage and unexpected postoperative hospital admissions . in this case
the patient did not aspirate , but did have an increased risk of pth due to ponv .
for the fifth round of anesthesia , rocuronium 100 mg ( 1 mg / kg ) was injected for rsi after a time interval from sugammadex administration of 4 h and 40 min .
it has been reported that re - administration of 1.2 mg / kg rocuronium could have been given after sugammadex 2 mg / kg without a waiting time .
however , neuromuscular monitoring did not show the expected recovery , and the patient had residual paralysis after 15 min .
it has been shown previously that the reversal of nmb with anticholinesterase drugs may not be complete after a large dose of a neuromuscular blocking agent .
sugammadex resolved the residual nmb within 2 min , even after reversal with anticholinesterase agents , and is a safe alternative to reversal of nmb induced by steroidal non - depolarizing agents . in this case , deep rocuronium - induced nmb can be reversed successfully with sugammadex at doses of 2 mg / kg and in as little as 2 min .
re - administration of rocuronium within a short time interval after sugammadex may result in unpredictable effects of the nmb agent .
sugammadex made it possible to perform a rapid , complete reverse when the residual block was maintained by an incomplete reversal of anticholinesterase .
 post - tonsillectomy hemorrhage ( pth ) is the most frequent complication of tonsillectomy , and occasionally results in a lethal outcome . 
 a 21-year - old man ( height 180 cm , weight 95 kg ) was scheduled for a bilateral tonsillectomy and uvulopalatopharyngoplasty for treatment of obstructive sleep apnea . 
 he required 5 rounds of general anesthesia due to recurrent pth . 
 the anesthesiologist used sugammadex a total of 3 times to achieve the successful reversal of the deep neuromuscular blockade ( nmb ) induced by rocuronium . 
 after sugammadex 2 mg / kg was administered , the nmb was reversed in 2 minutes each time . 
 re - administration of rocuronium within a short time interval after sugammadex may result in unpredictable effects of neuromuscular blocking agents . 
 sugammadex made it possible to perform a rapid , complete reverse when the residual block was maintained by an incomplete reversal of anticholinesterase . 
Case Report
Discussion