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      Neostigmine induced coronary artery spasm: A case report and literature review

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          Abstract

          Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery spasm, after the administration of repeated doses of neostigmine. Ours is the first case to demonstrate such a longstanding coronary artery vasospasm that lasted several hours in response to neostigmine, resulting in myocardial damage and left ventricular dysfunction. We would like to draw the attention of the anesthesiologists to this rare effect that may lead to perioperative cardiac complications.

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          Paradoxical vasoconstriction induced by acetylcholine in atherosclerotic coronary arteries.

          P. L. Ludmer, A P Selwyn, T Shook … (1986)
          Acetylcholine is believed to dilate normal blood vessels by promoting the release of a vasorelaxant substance from the endothelium (endothelium-derived relaxing factor). By contrast, if the endothelium is removed experimentally, acetylcholine constricts blood vessels. We tested the hypothesis that muscarinic cholinergic vasodilation is impaired in coronary atherosclerosis. Graded concentrations of acetylcholine and, for comparison, the nonendothelial-dependent vasodilator nitroglycerin were infused into the left anterior descending artery of eight patients with advanced coronary stenoses (greater than 50 percent narrowing), four subjects with angiographically normal coronary arteries, and six patients with mild coronary atherosclerosis (less than 20 percent narrowing). Vascular responses were evaluated by quantitative angiography. In several segments each of four normal coronary arteries, acetylcholine caused a dose-dependent dilation from a control diameter of 1.94 +/- 0.16 mm to 2.16 +/- 0.15 mm with the maximal acetylcholine dose (P less than 0.01). In contrast, all eight of the arteries with advanced stenoses showed dose-dependent constriction, from 1.05 +/- 0.05 to 0.32 +/- 0.16 mm at the highest concentration of acetylcholine (P less than 0.01), with temporary occlusion in five. Five of six vessels with minimal disease also constricted in response to acetylcholine. All vessels dilated in response to nitroglycerin, however. We conclude that paradoxical vasoconstriction induced by acetylcholine occurs early as well as late in the course of coronary atherosclerosis. Our preliminary findings suggest that the abnormal vascular response to acetylcholine may represent a defect in endothelial vasodilator function, and may be important in the pathogenesis of coronary vasospasm.
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            Sugammadex as a reversal agent for neuromuscular block: an evidence-based review

            Stefan Schaller, Heidrun Fink (2013)
            Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the “gold standard” muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
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              Reversal of rocuronium induced neuromuscular block with sugammadex or neostigmine: a large observational study.

              G Della Rocca, L Pompei, C Pagan DE Paganis … (2013)
              This 'real-life' study aimed to analyze the time from the start of neostigmine or sugammadex administration to recovery to a train of four ratio (TOFr) of 0.9 in a real-life in patients receiving rocuronium. The secondary aims were to assess the proportion of patients: presenting TOFr < 0.9 after 5, 10, and 20 min from reversal agent administration, receiving opioids for intraoperative analgesia and extubated in the post-anesthesia care unit (PACU).
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Anaesthesiol Clin Pharmacol
                Journal ID (iso-abbrev): J Anaesthesiol Clin Pharmacol
                Journal ID (publisher-id): JOACP
                Title: Journal of Anaesthesiology, Clinical Pharmacology
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0970-9185
                ISSN (Electronic): 2231-2730
                Publication date (Print): Jul-Sep 2017
                Volume: 33
                Issue: 3
                Pages: 402-405
                Affiliations
                [1]Department of Cardiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
                [1 ]Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
                Author notes
                Address for correspondence: Dr. Alexander Ioscovich, Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, POB 3235, Jerusalem 91031, Israel. E-mail: aioscovich@ 123456gmail.com
                Article
                Publisher ID: JOACP-33-402
                DOI: 10.4103/0970-9185.173337
                PMC ID: 5672522
                SO-VID: f819db91-d9ed-40a5-9fe2-439176ca33c3
                Copyright © Copyright: © 2017 Journal of Anaesthesiology Clinical Pharmacology
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                History
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: anesthesia,cardiology,complication,muscle relaxants,postoperative care
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: anesthesia, cardiology, complication, muscle relaxants, postoperative care

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