A 25 year old overweight female was given fentanyl-pancuronium anesthesia for surgery. After surgery and extubation she was observed to have limited movement of the upper body and chest wall in the recovery room. She was conscious and ale but voluntary respiratory effo was limited. Her blood pressure and hea rate were normal. The likely diagnosis is:
Patient with limited movement of the upper body and chest wall and limited respiratory effo after receiving a long acting muscle relaxant pancuronium is showing features of incomplete reversal from the effects of muscle relaxant drug. Factors affecting rate of recovery of neuromuscular activity after reversal depend upon: 1. Intensity of block - greater the intensity of block at the time or reversal longer the recovery of neuromuscular activity. 2. Dose. 3. Choice of neuromuscular blocking agent - Overall recovery of intermediate acting agents (atracuium, vecuronium, mivacurium, rocuronium) following same dose of anticholinesterase is more rapid and more complete than after pancuronium. 4. Age - recovery occur more rapidly with smaller doses of anticholinesterases in infants and children than adults. 5. Drug interactions 6. Renal failure. Ref: Neonatal Formulary : Drug Use in Pregnancy and the First Year of Life By Edmund Hey, Nohern Neonatal Network, Page 102; Clinical Anesthesia By Paul G. Barash, Page 465; Textbook of Pediatric Emergency Procedures By Christopher King, Page 422 ; Clinical Anesthesia By Paul G. Barash, Page 524; Respiratory Disorders for Lawyers By Norman John, Page 114
Incomplete reversal of pancuronium
Pulmonary embolism
Fentanyl induced chest wall rigidity
Respiratory depression