Interrupted (self -)medication with pancuronium(bromide) and fatal outcome

Area of Science:

• Neurology
• Pharmacology
• Toxicology

Background:

• Generalized dystonia is a severe neurological movement disorder often resistant to conventional treatments.
• Pancuronium bromide is a neuromuscular blocker used to relax striated muscles, typically requiring artificial respiration.
• Patient-controlled analgesia (PCA) pumps can deliver continuous medication, potentially improving quality of life for chronic conditions.

Observation:

• A 52-year-old woman with therapy-resistant generalized dystonia used a PCA pump for continuous pancuronium infusion for over a decade, maintaining autonomy.
• The patient was found deceased; autopsy revealed a blocked pancuronium infusion line and non-specific findings, except for opioid tablets.
• Toxicology showed low pancuronium levels (72 ng/ml), below the typical therapeutic range (80-2,000 ng/ml).

Findings:

• The blocked infusion led to recurrent dystonia symptoms, including respiratory muscle spasms and respiratory arrest.
• The low pancuronium level, not the presence of oxycodone, is believed to have precipitated the fatal event.
• Previous suicide attempts were noted during the investigation.

Implications:

• This case underscores the importance of uninterrupted neuromuscular blockade in managing severe, chronic dystonia.
• Innovative drug delivery systems like PCA pumps can enhance patient autonomy but require vigilant monitoring.
• The findings highlight the potential for fatal outcomes due to mechanical failure in continuous infusion therapies.