Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 6, 2020; 8(21): 5341-5346
Published online Nov 6, 2020. doi: 10.12998/wjcc.v8.i21.5341
Donepezil-related inadequate neuromuscular blockade during laparoscopic surgery: A case report
Eun-A Jang, Tae-Young Kim, Eu-Gene Jung, Seongtae Jeong, Hong-Beom Bae, Seongheon Lee
Eun-A Jang, Tae-Young Kim, Eu-Gene Jung, Seongtae Jeong, Hong-Beom Bae, Seongheon Lee, Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
Author contributions: Jang EA and Lee S wrote the manuscript; Kim TY and Jung EG performed literature analysis; Jeong S was the anesthesiologist in charge of the patient; Bae HB revised the manuscript for important intellectual content; all authors approved the final version of the manuscript to be submitted.
Informed consent statement: Written informed consent was obtained from the patient for the publication of this case.
Conflict-of-interest statement: The authors have no funding and conflicts of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Seongheon Lee, MD, PhD, Assistant Professor, Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, 160, Baekseo-ro, Dong-gu, Gwangju 61469, South Korea. aneshead@gmail.com
Received: May 12, 2020
Peer-review started: May 12, 2020
First decision: September 14, 2020
Revised: September 27, 2020
Accepted: October 12, 2020
Article in press: October 12, 2020
Published online: November 6, 2020
Processing time: 178 Days and 5.1 Hours
Abstract
BACKGROUND

Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels. This drug may potentially interact with neuromuscular blocking agents (NMBAs) that act on muscular acetylcholine receptors during general anesthesia. Herein, we present a case of inadequate neuromuscular blockade with rocuronium, a nondepolarizing NMBA, in a dementia patient who had taken donepezil.

CASE SUMMARY

A 71-year-old man was scheduled for laparoscopic gastrectomy. He had been taking donepezil 5 mg for dementia. General anesthesia was induced with propofol and remifentanil. The depth of neuromuscular blockade was monitored by train-of-four (TOF) stimulation. After the administration of rocuronium, the TOF ratio decreased at an unusually slow rate, and a TOF count of 0 was detected 7 min later. After intubation, a TOF count of 1 was detected within 1 min, and a TOF ratio of 12% was detected within 2 min. The TOF count remained at 4 even with an additional bolus and continuous infusion of rocuronium, suggesting resistance to this NMBA. Instead of propofol, an inhalation anesthetic was administered alongside another NMBA (cisatracurium). Then, the quality of neuromuscular blockade improved, and the TOF count remained at 0-1 for the next 70 min. No further problems were encountered with respect to surgery or anesthesia.

CONCLUSION

Donepezil may be responsible for inadequate neuromuscular blockade during anesthesia, especially when total intravenous anesthesia is used.

Keywords: Donepezil; Dementia; General anesthesia; Rocuronium; Neuromuscular blocking agents; Case report

Core Tip: In the present case of a 71-year-old patient taking donepezil for dementia, we collected peripheral nerve stimulation data that showed objective evidence of inadequate neuromuscular blockade during total intravenous anesthesia. The goal of this case report is to draw attention to the need to carefully review potential drug interactions between donepezil and neuromuscular blocking agents during general anesthesia. As the number of elderly patients with dementia is increasing and total intravenous anesthesia has become more popular, there is a possibility that this drug interaction may be observed more frequently in the future.