Abstract:

Background: Neostigmine is used to reverse non-depolarizing muscle relaxation in general anesthesia.
We report a cardiac arrest requiring full CPR followed by administration of neostigmine.

Case Report: 82-year-old male patient with DM type2 and 1st degree AV block (PR-interval 210msec) with
ICRBBB on preoperative ECG underwent urgent repair of the incarcerated inguinal hernia. His preoperative
K was 4.5mmol/l, Hb 9.8Gr%, and Glu-6.7mmol/l. Rapid sequence induction was performed, followed by
rocuronium 20 mg. Surgery was uneventful. Shortly (30sec) after the administration of neostigmine 0.04
mg/kg(2.5mg) with atropine 0.15 mg/kg(1mg) (both diluted to 10ml with NS), cardiac arrest was noted on
the monitor that required CPR with chest compressions for about 4 minutes and the use of atropine 1mg,
adrenaline 1mg, and CaCl 1g. On lab tests during CPR K was 9.54mmol/l that gradually returned to normal
(K- 4.47mmol/l) only after CPR. The patient remained hemodynamically unstable after CPR and required
noradrenaline infusion (0.1mcg/kg/min) for few hours. The patient was discharged from the ICU after 1 day
and home on POD7.

Discussion: Neostigmine is a potent anticholinergic agent. Nevertheless, full cardiac arrest with
neostigmine when given with a cholinergic drug like atropine is very rare. Cardiac complications such as
QT interval prolongation or ST-elevation on ECG related to neostigmine were reported in the early
literature1. Additionally, cardiac arrests following neostigmine administration were reported in a case of
combined general and spinal anesthesia, in pediatric or cardiac transplant patients2 and in a patient with
the background of coronary vasospasm3 undergoing noncardiac surgery. To the best of our knowledge
cardiac arrest requiring CPR after administration of neostigmine has not been previously reported in a
patient with preoperative 1st degree AV block.

Learning points: Using neostigmine for reversal of muscle paralysis can be dangerous. Perioperative
neuromuscular monitoring to avoid unnecessary use of neostigmine or the alternative use of sugammadex
can prevent this complication. Elderly patients, especially those with conduction abnormalities on preoperative
ECG or significant coronary disease are at particular risk.

References:
1-J.I. LAWSON, Brit.J. Anaesth.1956, 28, 336
2-Nkemngu NJ. Asystole following neuromuscular blockade reversal in cardiac transplant patients.Ann
Card Anaesth 2017;20:385-6.
3-Jo JY et a-Anesth Pain Med 2014; 9:205-208
Key words: Antagonists, neuromuscular block, Monitoring, neuromuscular function, Complications, cardiac arrest

01 / Cardiac arrest following reversal of muscle relaxation by neostigmine: A Case Report