Asystole after intravenous neostigmine in a heart transplant recipient

Abstract

305Purpose: To describe a heart transplant recipient who developed asystole after administration of neostigmine which suggests that surgical dennervation of the heart may not permanently prevent significant responses to anticholinesterases.Clinical features: A 67-yr-old man, 11 yr post heart transplant underwent left upper lung lobectomy. He developed asystole after intravenous administration of 4 mg neostigmine with 0.8 mg glycopyrrolate for reversal of the muscle relaxant. He had no history of rate or rhythm abnormalities either prior to or subsequent to the event.Conclusion: When administering anticholinesterase medications to heart transplant patients, despite surgical dennervation, one must be prepared for a possible profound cardiac response.Objectif : Décrire le cas d'un receveur de greffe cardiaque qui a développé une asystole après l'administration de néostigmine, ce qui laisse croire que la dénervation cardiaque ne préviendrait pas de façon permanente des réactions significatives aux anticholinestérases.Éléments cliniques : Un homme de 67 ans, receveur d'une greffe cardiaque 11 ans plus tôt, a subi une lobectomie pulmonaire supérieure gauche. Il a développé une asystole après l'administration intraveineuse de 4 mg de néostigmine et de 0,8 mg de glycopyrrolate pour renverser l'effet du myorelaxant. Il n'a jamais présenté quelque anomalie de la fréquence ou du rythme cardiaque que ce soit avant ou après l'incident.Conclusion : Quand on administre une médication anticholinestérasique aux patients receveurs de greffe cardiaque, il faut être prêt, malgré une dénervation chirurgicale, à faire face à une réponse cardiaque marquée possible.

Drug-induced bradycardia

“…There are case reports of acetylcholinesterase inhibitor-induced bradycardia, preceding another dysrhythmia resulting in asystole. 20 One study found that cholinesterase inhibitor therapy was associated with more than twice the risk of hospitalization for bradycardia when compared with no therapy. 21…”

The Anesthetic Management of Adult Patients with Organ Transplants Undergoing Nontransplant Surgery

“…There are several case reports suggesting reinnervation months to years after heart transplantation [39]. One dramatic report describes asystole after administration of neostigmine [40]. It is recommended that a muscarinic antagonist be administered in conjunction with an anticholinesterase in all heart transplant patients.…”

The Safety of Neuromuscular Blockade Reversal in Patients With Cardiac Transplantation

“…The "HR decrease" after NMB reversal was defined as the difference between the HR immediately before NMB reversal (defined as the time neostigmine was administered) and the lowest HR within 5 minutes thereafter; therefore, positive values represent a decrease in HR after NMB reversal and negative values an increase in HR after NMB reversal. This time frame for HR decrease in cardiac transplantation patients was chosen after review of the literature, [3][4][5][6]8,9 demonstrating that cardiac arrests and associated HR decreases were typically reported in the first 5 minutes after NMB reversal administration and to avoid confounding causes for HR decreases following a longer time duration after NMB reversal (eg, emergence from anesthesia, extubation, and so on).…”

“…3 However, 6 individual cases of asystolic cardiac arrest typically preceded by bradycardia patients after administration of neostigmine and glycopyrrolate for NMB reversal in heart transplantation have been reported. [3][4][5][6] To our knowledge, no studies have examined NMB reversal in patients with histories of heart transplantation.…”