Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942008000600007
Brazilian Journal of Anesthesiology
Clinical Information

Síndrome de Tako-Tsubo em decorrência de bloqueio neuromuscular residual: relato de caso

Tako-Tsubo syndrome secondary to residual neuromuscular blockade. Case report

Marcos Guilherme Cunha Cruvinel; Fabiano Soares Carneiro; Roberto Cardoso Bessa Junior; Yerkes Pereira e Silva; Mirna Bastos Marques

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Resumo

JUSTIFICATIVA E OBJETIVOS: A síndrome de Tako-Tsubo é uma complicação pós-operatória rara, com mortalidade em torno de 5%. O objetivo deste relato é apresentar o bloqueio neuromuscular residual como fator desencadeante da referida síndrome, discutir sobre a mesma e alertar sobre o bloqueio neuromuscular residual. RELATO DO CASO: Paciente do sexo feminino, 61 anos, estado físico ASA I, submetida à anestesia geral associada a bloqueio paravertebral cervical para reparo artroscópico de lesão de manguito rotator. Após extubação foi evidenciado bloqueio neuromuscular residual por meio do exame clínico. Na sala de recuperação pós-anestésica evoluiu com sonolência, taquicardia, hipertensão arterial e acidose respiratória grave. Após a reintubação, evoluiu com parada cardíaca em atividade elétrica sem pulso, revertida com adrenalina e massagem cardíaca externa. Apresentou no pós-operatório elevação de segmento ST, aumento de troponina e acinesia de segmento médio-apical de ventrículo esquerdo com fração de ejeção estimada em 30%. A cineangiocoronariografia mostrou coronárias isentas de ateromatose significativa e grave comprometimento da função sistólica com acinesia inferior e ântero-septo-apical com hipercontratilidade compensatória de suas porções basais. Com o tratamento instituído houve recuperação funcional completa. CONCLUSÕES: O bloqueio neuromuscular residual associado à paralisia diafragmática e possível atelectasia pulmonar levando a insuficiência respiratória, hipercapnia e descarga adrenérgica foram os fatores desencadeantes da síndrome de Tako-Tsubo com sua grave repercussão clínica.

Palavras-chave

COMPLICAÇÕES, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade.
CASE REPORT: A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted.
CONCLUSIONS: Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Keywords

COMPLICATIONS: Residual neuromuscular blockade, Tako-Tsubo syndrome.

References

Morais BS, Castro CHV, Teixeira VC. Bloqueio neuromuscular residual após o uso de rocurônio ou cistracúrio. Rev Bras Anestesiol. 2005;55:623-630.

Baillard C, Gehan G, Reboul-Marty J. Residual curarization in the recovery room after vecuronium. Br J Anesth. 2000;84:394-395.

Berg H, Roed J, Viby-Mogensen J. Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095-1103.

Oliveira AS, Bastos CO, Serafim MM. Avaliação do bloqueio neuromuscular residual na sala de recuperação pós-anestésica. Rev Bras Anestesiol. 1997;47:502-511.

McCaul C, Tobin E, Boylan JF. Atracurium is associated with postoperative residual curarization. Br J Anaesth. 2002;89:766-769.

Kim KS, Lew SH, Cho HY. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656-1660.

Cammu G, Baerdemaeker L, den Blauwen N. Postoperative residual curarization with cisatracurium and rocuronium infusions. Eur J Anaesthesiol. 2002;19:129-134.

Lentsherner C, Vignaux O, Spaulding C. Early postoperative Tako-Tsubo-like left ventricular dysfunction: Transient left ventricular apical ballooning syndrome. Anesth Analg. 2006;105:580-582.

Satoh H, Tateishi H, Uchida T. Tako-Tsubo-type cardiomyopathy due to multivessel spasm: Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo Kagakuhyouronsya. 1990;56-64.

Girod JP, Messerli AW, Zidar F. Tako-Tsubo-like transient left ventricular dysfunction. Circulation. 2003;107:E121.

Tsuchihashi K, Ueshima K, Uchida T. Transient ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001;38:11-18.

Kurisi S, Sato H, Kawagoe T. Tako-Tsubo-like ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimickin acute myocardial infarction. Am Heart J. 2002;143:448-455.

Ueyama T, Kasamatsu K, Hano T. Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenaceptors: a possible animal model of Tako-Tsubo cardiomyopathy. Jpn Circ J. 2002;66:712-713.

Sharkey SW, Lesser JR, Zenovitch AG. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005;11:472-479.

Abe Y, Kondo M. Apical ballooning of the left ventricle: a distinct entity. Heart. 2003;89:974-976.

Cubero JS, Moral RP. Transient apical ballooning syndrome: a transition towards adulthood. Rev Esp Cardiol. 2004;57:194-197.

Cruvinel MGC, Castro CHV, Silva YP. Prevalência de paralisia diafragmática após bloqueio de plexo braquial pela via posterior com ropivacaína a 0,2%. Rev Bras Anestesiol. 2006;56:461-469.

Naguib M, Lien CA. Pharmacology of muscle relaxants and their antagonists. Miller's Anesthesia. 2005:481-572.

Cammu G, Baerdemaeker L, Blauwen ND. Postoperative residual curarization with cisatracurium and rocuronium infusions. Eur J Anaesth. 2002;19:129-134.

Kyo SK, Se HL, Hee YC. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656-60.

Stoelting RK, Hillier SC. Anticholinesterase drugs and cholinergic agonists. Pharmacology & Physiology in Anesthetic Practice. 2006:251-265.

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