Postoperative reparalysis after rocuronium following nebulized epinephrine

Abstract

Postoperative reparalysis after rocuronium following nebulized epinephrinePurpose: We report a case of postoperative reparalysis in the recovery room, following nebulized epinephrine. The patient was pharmacologically reversed with edrophonium after paralysis with rocuronium.Clinical findings: A 12-yr-old girt developed postoperative reparalysis following the intraoperative administration of rocuronium. A total of 0.92 mg.kg -~ rocuronium was administered. After surgery, pharmacological reversal was achieved with 20 mg edrophonium with 0,15 nag. atropine sulfate iv 35 min after the last administration of rocuronium. Muscular relaxation was monitored using an ulnar peripheral nerve stimulator (PNS). After reversal, a full train-of-four and sustained tetanus at 50 Hz were present. In the recovery room, following nebulized epinephrine, the patient became apneic. The patient was paralyzed and an ulnar PNS demonstrated only one faint twitch. The paralysis was reversed with 1.5 mg neostigmine with 0.3 mg glycopyrrolate.Conclusion: Postoperative reparalysis following rocuronium may be a cause of postoperative respiratory distress. The definitive diagnosis is made using PNS and observing the response to pharmacological reversal. Nebulized epinephrine may have a previously undescribed role in the development of postoperative reparalysis.Object.if : Les auteurs d&rivent un cas de recurarisation survenue en salle de r~veil ~ la suite d'une n~bulisation d'EpinEphdne. La curadsation produite par le rocuronium avait &6 neutraJisc~e par I'administration d'~adrophonium.

Small doses of epinephrine prolong the recovery from a rocuronium-induced neuromuscular block: a case report

“…It is most likely that the reported decrease of TOF ratio by Ninomiya et al was due to epinephrine [ 2 ], because a following investigation showed no impact of lidocaine on rocuronium-induced block [ 14 ]. Another report by Arndt et al of postoperative reparalysis following nebulized epinephrine also highlights the assumed interaction [ 3 ]. Considering our data, previous clinical reports, and experimental findings all this indicates that epinephrine caused the documented prolongation of the recovery period in our patient.…”

“…Although the effects of different catecholamines on haemodynamic variables are well documented [ 1 ] few reports are available on potential adrenergic effects at the neuromuscular junction in humans. An intensification of a rocuronium-induced neuromuscular block (NMB) by epinephrine was reported twice, once in association with co-administration of lidocaine [ 2 ] and once by the use of nebulized epinephrine [ 3 ].…”