Prolonged neuromuscular blockade; after emergency cesarean section

ABSTRACT

We are presenting a case of prolonged neuromuscular blockade after emergency cesarean section. A 34 years old, young lady with no previous history of any systemic illness including neuromuscular disorder reported in the operation theatre for cesarean section. She was offered standard protocol for general anaesthesia using thiopentone sodium i/v for induction, suxamethonium i/v for intubation, and pancuronium bromide i/v for intra-operative relaxation. Intra-operative analgesia was obtained with nalbuphine i/v [after delivery of child]. Ampicillin and gentamicin i/v were used as prophylactic antibiotics, The patient failed to regain spontaneous breathing effort after a lapse of two hours since the last dose of pancuronium bromide. Laboratory investigations including complete blood picture, urea, creatinine, electrolytes [calcium, sodium, potassium] revealed anemia and severe hypocalcemia. She was given fresh whole blood and calcium gluconate intravenously, in addition to other supportive measures like ven tilatory support using SIMV mode of ventilation with 40% 02. Patient started regaining breathing effort after about 12 hours and was extubated after about 15 hours of artificial ventilation with little residual neuromuscular blocking effect. She was kept in the ICU for the next 24 hours for observation and was discharged from ICU the next day with full recovery. Conclusion Patient probably suffered from the interaction between gentamicin and pancuronium bromide, that was further potentiated by hypocalcemia and anaemia. She was given supportive care along with replacement of calcium, and anaemia was corrected by fresh whole blood transfusion. Patient recovered uneventfully and was discharged from ICU the next day