Prolonged paralysis following suxamethonium and the use of neostigmine

A case of prolonged neuromuscular block following the administration of suxamethonium is reported. Three hours after administration of suxamethonium, a well defined, recovering phase II block was demonstrated with a T4:T1 ratio of 0.25, and neostigmine was administered. Although the T4:T1 ratio was improved to 0.9, T1 remained at 25% of control, and significant paralysis persisted which responded to administration of cholinesterase. It is concluded that neuromuscular monitoring cannot reliably predict reversibility in such cases and that, even after 3 h, antagonism of prolonged suxamethonium block should commence with cholinesterase, followed by neostigmine if necessary.