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CASE REPORTS

Accidental Epidural Injection of Vecuronium

Department of Anesthesiology, Aretaieion Hospital, Medical School, University of Athens, Athens, Greece

Address correspondence and reprint requests to Georgia Kostopanagiotou, MD, PhD, 2 Florinis Str, Vrilissia, Athens, GR-15 235, Greece. Address e-mail to narkado{at}otenet.gr

	Abstract

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Implications: We report a case of accidental epidural injection of vecuronium in a female patient who underwent hemorrhoidectomy using epidural anesthesia. Because epidural injection of muscle relaxants may have serious side effects, immediate establishment of airway protection, monitoring of muscle relaxation, and follow-up for clinical signs of neurotoxicity are recommended.

	Introduction

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We report a case of accidental epidural vecuronium injection; from this site of injection, a longer duration of action of vecuronium was noted compared with IV administration. No neurological or cardiovascular side effects or other symptoms of local or systemic toxicity were observed.

	Case Report

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A 40-yr-old, 65-kg woman, ASA physical status I, was admitted for hemorrhoidectomy using epidural anesthesia. The epidural space was located at the L2-3 interspace, using an 18-gauge Tuohy needle and the "loss of resistance to air technique." A 20-gauge epidural catheter was advanced 4 cm into the epidural space, and after negative aspiration, 3 mL of lidocaine 2% was injected as an epidural test dose; 5 min later, incremental doses of an additional 5 mL of lidocaine 2% and fentanyl (1 µg/kg) were administered epidurally.

Because of the patient’s psychological intolerance to the operative environment we proceeded to general anesthesia, although epidural anesthesia had been successfully initiated. Anesthesia was induced with propofol (1.5 mg/kg), thiopental (3.5 mg/kg), and maintained with 66% nitrous oxide in oxygen. Succinylcholine (1.5 mg/kg) was administered for neuromuscular blockade, and the airway was secured with a size 4 laryngeal mask. The patient had had an uneventful previous surgery using succinylcholine. Standard monitoring equipment was used. Five minutes after the induction of anesthesia, 10 mL of vecuronium was mistaken for ropivacaine and was accidentally injected as a slow bolus through the epidural catheter. Neuromuscular blockade was monitored by train-of-four (TOF) ulnar nerve stimulation. No volatile anesthetics were used. To accelerate systemic absorption of vecuronium, 10 mL of NS 0.9% solution was injected from the epidural catheter. When the accident was recorded, the maximum neuromuscular blockade was 100%. After epidural vecuronium injection, recovery of the TOF response to a ratio of 10%, 25%, 50%, and 70% occurred at 80, 90, 100, and 105 min, respectively. When TOF response reached 70%, the residual neuromuscular blockade was reversed with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine IV. Five minutes after the reversal, the patient was able to sustain head lift > 3 s, had adequate spontaneous ventilation, demonstrated adequate coordinated respiratory effort, and was fully awake, oriented, and able to follow commands appropriately. Within 2 h from the time of the vecuronium injection, the patient had no evidence of muscle weakness, back pain, headache, discomfort, fever, or other metabolic, mental, or hemodynamic alterations. A thorough examination and a specialist neurological assessment revealed no sign of even sensory or motor blockade.

The patient was discharged from the postanesthesia care unit on the sixth postoperative hour and from the hospital on the second postoperative day. Follow-up for clinical signs of neurotoxicity was negative at 2 mo.

	Discussion

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No data about accidental injection of vecuronium through an epidural catheter in humans have been documented in the literature. In our patient, the duration of action of vecuronium administered epidurally was longer, compared with clinical duration after IV administration (105 vs 45–90 min) (1,2). Her history of previous surgery with succinylcholine could exclude a prolonged succinylcholine-induced neuromuscular blockade. The rate of absorption of vecuronium from the epidural space is unknown, and its principal metabolite, 3-desacetylvecuronium, is a potent (80% of vecuronium) neuromuscular blocking drug, with lower plasma clearance and longer duration of action than vecuronium (1,2).

Few data exist regarding the time course of IM or sites other than IV administered relaxants. After rocuronium is administered into the deltoid muscle, plasma concentrations peak at 13 min, and approximately 80% of the drug is absorbed systemically (3,4).

Neuromuscular blocking drugs cause excitement and seizures when introduced into the central nervous system (5–7). Acute intrathecal administration of these drugs leads to dose-dependent central nervous system effects in the rat (5). Comparisons of intraventricular seizure threshold doses revealed that pancuronium and atracurium are approximately 12 and 28 times, respectively, more potent than vecuronium in eliciting seizures. At 1/100 of seizure dose, decreased locomotor activity and piloerection occurred. At 1/10 to 1/5 of seizure dose, agitation, shivering, splayed limbs, and whole-body shaking resulted (5). These effects may be the result of accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels (6,8,9). At present, we have no information on the kinetics of disposition of the neuromuscular blocking drugs after their intraventricular administration. Data that would permit a comparison of the relative sensitivity of the rodent brain to neuromuscular relaxants with that of the human brain are not available.

Because no clinical or experimental data exist about interactions between vecuronium and other drugs injected epidurally, no other drugs should be given at this site. Although we injected saline into the epidural space to accelerate systemic absorption of vecuronium ("volume effect"), there is not sufficient evidence in the literature that this maneuver is effective (10). Volatile anesthetics may interfere with vecuronium-induced neuromuscular blockade; however, there is no convincing argument to avoid vapor-based anesthesia in the presence of vecuronium (11–13).

In conclusion, to prevent the serious side effects of accidental injection of vecuronium through an epidural catheter, immediate care should include establishment of airway protection, monitoring of muscle relaxation, avoidance of medications that may interfere with neuromuscular blockade or antagonism, and follow-up for clinical signs of neurotoxicity.

	References

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1. Caldwell JE, Szenohradszky J, Segredo V, et al. The pharmacodynamics and pharmacokinetics of the metabolite 3-desacetylvecuronium (ORG 7268) and its parent compound, vecuronium, in human volunteers. J Pharmacol Exp Ther 1994; 270: 1216–22.[Abstract/Free Full Text]
2. Savarese JJ, Caldwell JE, Lien CA, Miller RD. Pharmacology of muscle relaxants and their antagonists. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2000: 412–90.
3. Reynolds LM, Lau M, Brown R, et al. Bioavailability of intramuscular rocuronium in infants and children. Anesthesiology 1997; 87: 1096–105.[ISI][Medline]
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5. Szenohradszky J, Trevor AJ, Bickler P, et al. Central nervous system effects of intrathecal muscle relaxants in rats. Anesth Analg 1993; 76: 1304–9.[Abstract]
6. Cardone C, Szenohradszky J, Yost S, Bickler PE. Activation of brain acetylcholine receptors by neuromuscular blocking drugs: a possible mechanism of neurotoxicity. Anesthesiology 1994; 80: 1155–61.[ISI][Medline]
7. Scheepestra GL, Vree TB, Crul JF, et al. Convulsive effects and pharmacokinetics of laudanosine in the rat. Eur J Anaesthesiol 1986; 3: 371–83.[ISI][Medline]
8. Engle J Jr. Functional explorations of the human epileptic brain and their therapeutic implications. Electroencephalogr Clin Neurophysiol 1990; 76: 296–316.[ISI][Medline]
9. McDonald JW, Garofalo EA, Hood T, et al. Altered excitatory and inhibitory amino acid receptor binding in hippocampus of patients with temporal lobe epilepsy. Ann Neurol 1991; 29: 529–41.[ISI][Medline]
10. Okutomi T, Hoke S. Epidural saline solution prior to local anaesthetic produces differential nerve block. Can J Anaesth 1998; 45: 1091–3.[Abstract/Free Full Text]
11. Morita T, Tsukagoshi H, Sugaya T, et al. Inadequate antagonism of vecuronium-induced neuromuscular block by neostigmine during sevoflurane or isoflurane anesthesia. Anesth Analg 1995; 80: 1175–80.[Abstract]
12. Morita T, Kurosaki D, Tsukagoshi H, et al. Factors affecting neostigmine reversal of vecuronium block during sevoflurane anaesthesia. Anaesthesia 1997; 52: 538–43.[ISI][Medline]
13. Dernovoi B, Agoston S, Barvais L, et al. Neostigmine antagonism of vecuronium paralysis during fentanyl, halothane, isoflurane, and enflurane anesthesia. Anesthesiology 1987; 66: 698–701.[ISI][Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Kostopanagiotou, G. Articles by Siafaka, I. Search for Related Content PubMed PubMed Citation Articles by Kostopanagiotou, G. Articles by Siafaka, I.

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999