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Canadian Journal of Anesthesia 48:102 (2001)
© Canadian Anesthesiologists' Society, 2001

Correspondence

Pancuronium added to intravenous regional anesthesia: systemic weakness after prolonged tourniquet inflation time

Mona G. Sarkiss, MD PhD, M. Denise Daley, MD MSC FRCPC DABA, Peter H. Norman, MD FRCPC DABA and Lewis A. Coveler, MD FACA DABA

Houston, Texas, Usa

To the Editor:

Neuromuscular blockers (NMBs) may be added to intravenous regional anesthesia (IVRA) to enhance both the motor and sensory blockade.1,2 Most reports indicated lack of systemic effects with these agents but we encountered a case of weakness upon tourniquet deflation with the use of pancuronium despite a tourniquet inflation time of 89 min.

A healthy 41-yr-old, 81 kg man presented for repair of a lacerated right extensor pollicis longus tendon and IVRA was performed with 40 lidocaine ml 0.7% plus 2 mg pancuronium. This quantity of pancuronium was inadvertently administered instead of the 1 mg dose typically used at our institution. The block was performed in the standard manner, with exsanguination of the arm and inflation of a double-cuffed tourniquet to 300 mmHg. The tourniquet was deflated after 89 min. Three minutes later the patient experienced diplopia and was unable to lift his head. Intravenous administration of 2.5 mg neostigmine (with 0.5 mg glycopyrrolate) terminated the diplopia and allowed a sustained head lift for > 5 sec.

The apparent systemic release of a substantial quantity of NMB in this case is in contrast to that of local anesthetics, in which one would expect no systemic effects after deflation of a tourniquet which had been inflated for 89 min. The differences probably relate to the lesser extremity tissue binding with NMBs due to their greater ionization and lower lipid solubility. Clinicians who add NMBs to IVRA should be aware of the potential for systemic weakness, even after prolonged tourniquet inflation.

References

1 McGlone R, Heyes F, Harris P. The use of a muscle relaxant to supplement local anaesthetics for Bier's blocks. Arch Emerg Med 1988; 5: 79–85.[Medline]

2 Elhakim M, Sadek RA. Addition of atracurium to lidocaine for intravenous regional anaesthesia. Acta Anaesthesiol Scand 1994; 38: 542–4.[Medline]





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