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It happened again: How safe is neostigmine and glycopyrrolate during nonobstetric surgery?
Abstract Number: S-31
Abstract Type: Case Report/Case Series
“It happened again: How safe is neostigmine and glycopyrrolate during nonobstetric surgery?”
Introduction: There is limited and controversial data concerning the use of neuromuscular blockade reversal agents in parturients undergoing non obstetric surgery.1 Due to their large quaternary ammonium structure, neostigmine and glycopyrrolate are thought to have limited placental transfer.2 However, Clark and Brown, et al. previously reported a case of mild, transient fetal bradycardia after neostigmine and glycopyrrolate administration in a parturient under general anesthesia. The authors attributed this bradycardia to neostigmine placental transfer and the inability of glycopyrrolate to cross the placenta relative to neostigmine. On a repeat surgery in the same patient a few days later, the authors used neostigmine and atropine without complication.2 Due to the lack of conclusive evidence of harm, many providers still use the combination of neostigmine and glycopyrrolate for reveral of neuromuscular blockade in parturients undergoing nonobstetric surgery.
Case: We present a case of a G4P2 parturient at 27+6 weeks gestational age undergoing general anesthesia for placement of bilateral nephrostomy tubes for nephrolithiasis. Prior to induction of anesthesia, fetal heart rate was reassuring and within normal limits. Induction, intubation and maintenance of general anesthesia were uncomplicated with continued reassuring fetal heart tones throughout the case. At conclusion of procedure, neuromuscular blockade was reversed with neostigmine and glycopyrrolate, which was followed by immediate prolonged and persistent fetal bradycardia. The patient had not received any other medications and was hemodynamically stable at the time of fetal deceleration. Intrauterine resuscitation was performed with left uterine displacement, 100% oxygen and intravenous fluids. Although no uterine contractions were noted, the fetal bradycardia persisted necessitating emergent cesarean delivery.
Discussion: This case highlights that the combination of neostigmine and glycopyrrolate for the reversal of neuromuscular blockade during nonobstetric surgeries may present unrecognized risk to the fetus. Providers should be aware of this potential for harm and may choose to administer these agents incrementally with special attention to fetal status. Although unproven, this case supports the recommendation for consideration of a prior injection of an anticholingeric agent followed by a slow titration of an anticholinesterase inhibitor 3
1. Murad, et al. Atropine and Glycopyrrolate: Anesthesia and Analgesia 1981;60:710-4
2. Clark, et al. Anesthesiology 1996; 84: 450-2
3. Hellman, et al. Am J Obstet Gynecol 1961; 82:1055-64