Advertisement

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

  • Lori Olivieri
  • Gilles Plourde
Cardiothoracic Anesthesia, Respiration and Airway

Abstract

Purpose

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.

Clinical features

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.

Conclusion

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.

Keywords

Intensive Care Unit Admission Sufentanil Pancuronium Rocuronium Magnesium Sulphate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Un blocage neuromusculaire prolongé (plus de dix heures) après une intervention en cardiochirurgie: présentation de deux cas

Résumé

Objectif

Présenter deux cas de blocage neuromusculaire prolongé (BNM) après une intervention cardiaque. Selon nos connaissances, c’est la première publication de cas de paralysie complète qui dure plus de dix heures après l’opération.

Éléments cliniques

Nous croyons que la durée prolongée du BNM (plus de dix heures) est le résultat de fortes doses de médicaments de BNM combinées au sulfate de magnésium et à une insuffisance rénale modérée. L’âge avancé, la maladie hépatique, l’exposition aux aminoglycosides, l’hypocalcémie et une interaction possible entre le rocuronium et le pancuronium peuvent avoir jouer des rôles mineurs.

Conclusion

Nous devons éviter d’administrer de fortes doses d’agents de BNM, même quand une ventilation postopératoire planifiée. Si le BNM n’est pas surveillé chez les patients à risque de BNM prolongé, la réponse en train-de-quatre doit alors être mesurée à l’unité des soins intensifs. Une sédation adéquate doit être donnée jusqu’à ce qu’une reprise convenable de la fonction neuromusculaire soit prouvée.

References

  1. 1.
    Saldien V, Vermeyen KM, Wuyts FL. Target-controlled infusion of rocuronium in infants, children, and adults: a comparison of the pharmacokinetic and pharmacodynamic relationship. Anesth Analg 2003; 97: 44–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Van Oldenbeek C, Knowles P, Harper NJ. Residual neuromuscular block caused by pancuronium after cardiac surgery. Br J Anaesth 1999; 83: 338–9.PubMedGoogle Scholar
  3. 3.
    McEwin L, Merrick PM, Bevan DR. Residual neuromuscular blockade after cardiac surgery: pancuronium vs rocuronium. Can J Anaesth 1997; 44: 891–5.PubMedGoogle Scholar
  4. 4.
    Murphy GS, Szokol JW, Marymont JH, et al. Recovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium. Anesth Analg 2003; 96: 1301–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Donnelly AJ, Cunningham FE, Baughman VL. Anesthesiology and Critical Care Drug Handbook, 3rd ed. Hudson: Lexi-Comp Inc.; 2000.Google Scholar
  6. 6.
    Naguib M, Samarkhandi H, Bakhamees HS, Magboul MA, El-Bakry AK. Comparative potency of steroidal neuromuscular blocking drugs and isobolographic analysis of the interaction between rocuronium and other aminosteroids. Br J Anaesth 1995; 75: 37–42.PubMedGoogle Scholar
  7. 7.
    Fuchs-Buder T, Ziegenfub T, Lysakowski K, Tassonyi E. Antagonism of vecuronium-induced neuromuscular block in patients pretreated with magnesium sulphate: dose-effect relationship of neostigmine. Br J Anaesth 1999; 82: 61–5.PubMedGoogle Scholar
  8. 8.
    Kwan WF, Lee C, Chen BJ. A noninvasive method in the differential diagnosis of vecuronium-induced and magnesium-induced protracted neuromuscular block in a severely preeclamptic patient. J Clin Anesth 1996; 8: 392–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Kussman B, Shorten G, Uppington J, Comunale ME. Administration of magnesium sulphate before rocuronium: effects on speed of onset and duration of neuromuscular block. Br J Anaesth 1997; 79: 122–4.PubMedGoogle Scholar
  10. 10.
    Pinard AM, Donati F, Martineau R, Denault AY, Taillefer J, Carrier M. Magnesium potentiates neuromuscular blockade with cisatracurium during cardiac surgery. Can J Anesth 2003; 50: 172–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Feldman S, Karalliedde L. Drug interactions with neuromuscular blockers. Drug Saf 1996; 15: 261–73.PubMedCrossRefGoogle Scholar
  12. 12.
    Wong J, Brown G. Does once-daily dosing of aminoglycosides affect neuromuscular function? J Clin Pharm Ther 1996; 21: 407–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Heier T, Steen PA. Awareness in anaesthesia: incidence, consequences and prevention. Acta Anaesthesiol Scand 1996; 40: 1073–86.PubMedGoogle Scholar
  14. 14.
    Murphy GS, Szokol JW, Vender JS, Marymont JH, Avram MJ. The use of neuromuscular blocking drugs in adult cardiac surgery: results of a national postal survey. Anesth Analg 2002; 95: 1534–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Hemmerling TM, Michaud G, Babin D, Trager G, Donati F. Comparison of phonomyography with balloon pressure mechanomyography to measure contractile force at the corrugator supercilii muscle. Can J Anesth 2004; 51: 116–21.PubMedGoogle Scholar

Copyright information

© Canadian Anesthesiologists 2005

Authors and Affiliations

  1. 1.Department of AnesthesiaMUHC - Royal Victoria HospitalMontrealCanada

Personalised recommendations