Cardiac Arrest after Neuromuscular Blockade Reversal in a Heart Transplant Infant

The Safety of Neuromuscular Blockade Reversal in Patients With Cardiac Transplantation

“…10,[14][15][16][17][18] Six case reports of cardiac arrest in heart transplant patients after NMB reversal exist. [3][4][5][6] In all cases, neostigmine and glycopyrrolate were used for NMB reversal, and all arrests were asystolic in nature. However, we found no instances of cardiac arrest among 118 instances of NMB reversal in cardiac transplantation patients using neostigmine and glycopyrrolate.…”

“…Reported cases of cardiac arrest after NMB reversal with neostigmine and glycopyrrolate in heart transplantation patients occurred 1 month to 12 years after transplantation. [3][4][5][6] In animal models, neostigmine has been reported to have a direct effect on cardiac parasympathetic postganglionic muscarinic acetylcholine receptors, thereby decreasing the HR in newly denervated hearts. 22,23 In a study of 31 patients, Backman et al 11 reported neostigmine administration (without concurrent muscarinic anticholinergic administration) to result in HR decreases in all patients who had recently (<8 weeks) or remotely (>8 months) undergone heart 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).…”

“…We used the same technique to test for differences in HR change by time since transplantation. Because of the wide variability in published classifications of "recent" or "remote" time since transplantation on review of the literature, [3][4][5][6][8][9][10][11] we chose to categorize this time as 0 to 90 days, 91 to 365 days, 366 to 720 days, and 721 or more days in analyzing HR decreases after NMB reversal.…”

“…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.…”