Tanaka H, Murata K, Sera A, Horibe M, Izumi H, Tsuchiya T
Department of Anesthesia, Akane Foundation, Tsuchiya General Hospital, Hiroshima.
Masui. 1991 Apr;40(4):616-21.
A case of intraoperative conversion to 2nd degree from 1st degree AV block by the reversal of neuromuscular blockade was reported. A 78 year old male, who originally suffered from 1st degree AV block, underwent choledocholithotomy and T-tube drainage for choledocholithiasis. He was administered 4 mg of pancuronium at the time of intubation. The operation lasted for 160 minutes under epidural anesthesia, NLA and nitrous oxide-oxygen. The patient started spontaneous breathing and the recovery was confirmed after the operation which finished without any problem. Neuromuscular blockade was reversed with atropine 0.5 mg and neostigmine 1.0 mg that were administered simultaneously taking 3 minutes. Then he was extubated without any troublesome stimulation. Suddenly, however, he suffered from the worse condition of bradycardia with the 2nd degree AV block. It took about 45 minutes until he recovered to the original 1st degree AV block despite atropine treatment. We believe that this accident was induced by a vasovagal reflex which was triggered by extubation under the effect of neostigmine which acts longer than that of atropine. We should be careful in reversing the effect of the non-depolarizing neuromuscular blockade. A short acting neuromuscular blockade, i.e. vecuronium, is preferable so as to avoid neostigmine reversal, and extubation should be performed when the effect of neuromuscular blockade is confirmed to be exhausted.
报告了一例因神经肌肉阻滞逆转导致术中一度房室传导阻滞转变为二度房室传导阻滞的病例。一名78岁男性，原本患有一度房室传导阻滞，因胆总管结石接受了胆总管切开取石术和T管引流术。插管时给予4毫克潘库溴铵。手术在硬膜外麻醉、神经安定镇痛麻醉和氧化亚氮-氧气混合麻醉下持续了160分钟。术后患者开始自主呼吸且恢复顺利，手术过程无任何问题。同时给予0.5毫克阿托品和1.0毫克新斯的明以逆转神经肌肉阻滞，给药过程持续3分钟。随后在无任何不良刺激的情况下进行了拔管。然而，突然他出现了更严重的心动过缓并伴有二度房室传导阻滞。尽管使用了阿托品治疗，但他恢复到原来的一度房室传导阻滞仍花费了约45分钟。我们认为这一意外是由新斯的明作用时间长于阿托品导致的拔管触发的迷走神经反射引起的。在逆转非去极化神经肌肉阻滞作用时我们应谨慎。为避免新斯的明逆转，使用短效神经肌肉阻滞剂，即维库溴铵更为可取，并且应在确认神经肌肉阻滞作用消失后再进行拔管。
