Reactions Weekly

, Volume 1714, Issue 1, pp 286–286 | Cite as

Multiple drugs

Prolongation of neuromuscular block, hypotension and bradycardia: case report
Case report
Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

  • * death

  • * life-threatening

  • * hospitalisation

  • * disability

  • * congenital anomaly

  • * other medically important event

  • * Drug interaction

A 74-year-old man developed hypotension during treatment with tamsulosin, bradycardia during treatment with remifentanil, and prolongation of neuromuscular block during the concomitant administration of epinephrine and rocuronium bromide [time to reactions onset not stated].

The man was scheduled for transurethral resection of a benign prostatic hyperplasia. He was receiving tamsulosin for benign prostatic hyperplasia [route and dosage not stated]. At the time of transurethral resection, his HR was 36 beats/minute and BP was 115/70mm Hg. Anaesthesia was induced with propofol and fentanyl and the ulnar nerve was stimulated supramaximal with repeated train-of-four (TOF) stimuli. He received a single dose of IV rocuronium bromide 50mg over five seconds and was subsequently intubated. The BP was 121/74mm Hg and HR was 75 bpm. Following induction of anaesthesia, the mean arterial pressure dropped slightly, but increased with the beginning of surgery. He subsequently received remifentanil infusion at the rate of 0.35 µg/kg/min. The remifentanil infusion was titrated at the rate of 0.15 µg/kg/min. HR and BP dropped continuously. The remifentanil infusion was stopped and atropine was administered, but no effect was noted. The BP dropped to 75/45mm Hg and the HR dropped to 39 bpm.

The man received a single IV bolus of epinephrine 5µg, following which the HR increased to 62 bpm and the BP increased to 15/67mm Hg. Three minutes after the epinephrine administration, twitch (T1) response disappeared and returned after four minutes. He received two more bolus doses of epinephrine 5µg to maintain the BP and HR. After each epinephrine bolus, an increase of the first and the second twitches was observed within two minutes for a short time, which was followed by a decreased in the T1 response. The TOF ratio decreased during the second and third administration of epinephrine. The T1 value returned to the pre-epinephrine level 10 minutes after the second and 7 minutes after the third epinephrine administration. The TOF ratio recovered to 90% after 111 minutes of rocuronium bromide administration. He subsequently gained spontaneous breathing and was transferred to the recovery room.

Author comment: "In conclusion this report documents possible modulation of the recovery characteristics of a rocuronium-induced [neuromuscular blockade] by low dose of epinephrine." "Tamsulosin like other alpha1-adrenergic-receptorantagonists may cause hypotension by vasodilatation. This could explain the recorded hypotension. The bradycardia might have been caused by remifentanil a known side-effect of this drug."


  1. Schmitt HJ. Small doses of epinephrine prolong the recovery from a rocuronium-induced neuromuscular block: A case report. BMC Anesthesiology 18: 82, No. 1, 2018. Available from: URL: -Germany

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