Journal of clinical anesthesia
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Case Reports
Neostigmine-induced prolonged neuromuscular blockade in a patient with atypical pseudocholinesterase.
A patient with unrecognized atypical pseudocholinesterase was given succinylcholine and then vecuronium before neuromuscular monitoring was instituted. Subsequently, when neostigmine and glycopyrrolate were given to reverse what was thought to be a nondepolarizing block, the patient became further relaxed, and his trachea could not be extubated for more than 10 hours. In this report, we discuss drug interactions, phase II block, and the importance of timely neuromuscular monitoring.
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The prevalence of obesity has increased 15% up to 20% and represents an important challenge for the anesthesiologist in drug-dosing management. The aim of this work is to provide an overview on physiological changes and pharmacokinetic implications of obesity for the anesthesiologist. Obesity increases both fat and lean masses; however, the percentage of fat tissue increases more than does the lean mass, affecting the apparent volume of distribution of anesthetic drugs according to their lipid solubility. ⋯ Inhalation anesthetics with very low lipid solubility, such as sevoflurane and desflurane, allow for quick modification of the anesthetic plan during surgery and rapid emergence at the end of surgery, hence representing very flexible anesthetic drugs for use in this patient population. Drug dosing is generally based on the volume of distribution for the loading dose and on the clearance for maintenance. In the obese patient, the volume of distribution is increased if the drug is distributed both in lean and fat tissues whereas the anesthetic drug clearance is usually normal or increased.