Prolonged (more than ten hours) neuromuscular blockade after cardiac surgery: report of two cases

Abstract

P Pu ur rp po os se e: : We examine two cases of prolonged neuromuscular blockade (NMB) after cardiac surgery. To the best of our knowledge, these are the first reported cases of complete paralysis lasting more than ten hours after surgery.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : We attribute the extended durations of NMB (more than ten hours) to high doses of NMB drugs in combination with magnesium sulphate and moderate renal failure. Advanced age, hepatic disease, aminoglycoside exposure, hypocalcemia, and possible interaction between rocuronium and pancuronium may have played minor roles.C Co on nc cl lu us si io on n: : We should avoid administering large doses of NMB agents, even in the context of planned postoperative ventilation. If NMB is not monitored intraoperatively in patients who are at risk of prolonged NMB, then train-of-four response should be measured in the intensive care unit. Adequate sedation should be provided until proper recovery of neuromuscular function is documented. E examine two cases of prolonged neuromuscular blockade (NMB) after cardiac surgery. We attribute the extended durations of complete paralysis (more than ten hours) to high doses of NMB drugs in combination with magnesium sulphate and moderate renal failure. ObjectifC Ca as se e 1 1 A 67-yr-old woman was referred to the anesthesia service for prolonged NMB after mitral valve replacement.The patient had been transferred to our hospital for surgical treatment of bacterial endocarditis and critical mitral stenosis. The patient was treated initially for two weeks with ampicillin and gentamicin and one week of ampicillin alone. Her past medical history included rheumatic mitral valve stenosis (with previous commissurotomy), pulmonary hypertension and chronic atrial fibrillation. Height and weight were 165 cm and 63 kg. Laboratory investigations revealed anemia, hypokalemia, and mild pre-renal failure (Table I). Preoperative medications included furosemide, digoxin, ramipril, iv heparin, flurazepam, ampicillin, and potassium chloride.

Extremely prolonged neuromuscular blockade after rocuronium: a case report

“…Cases similar to our own are exceptional 4 . Only the case reported by Olivieri et al, 5 involving a10‐h duration of block was similar.…”

Influence of acute normovolaemic haemodilution on the dose–response relationship, time-course of action and pharmacokinetics of rocuronium bromide

“…25 Hypokalaemia and hypocalcaemia were shown to augment neuromuscular block, as a recent report laid emphases to the fact that hypokalaemia and hypocalcaemia could have significantly contributed to rocuronium prolonged paralysis that lasted for several hours after surgery. 26 In our study, patients manifested dilutional Table 3 Rocuronium time-course of action. Data are given as mean (SD) for n=14 in each group.…”

A surgeon′s assessment of inadequate neuromuscular antagonism in a case of prolonged neuromuscular blockade

“…Prolonged neuromuscular blockade is rare, but not unique. Similar cases[2–4] have demonstrated that even a single intubating dose of an intermediate-acting neuromuscular blocking agent can cause prolonged neuromuscular blockade, which should mandate the need for neuromuscular assessment every time additional neuromuscular blocking agent is considered. Failure to objectively assess neuromuscular function may result in prolongation of a profound neuromuscular blockade, as was seen in our case.…”