Prolonged paralysis following an infusion of alcuronium in a patient with renal dysfunction

The case is described of a patient who underwent artificial ventilation in an intensive therapy unit and received an infusion of alcuronium 10 mg/hour for more than 4 days, in the presence of significant renal (and later, some degree of hepatic) impairment. Prolonged and profound neuromuscular block persisted despite haemodialysis (5 hours on each of 3 days) followed by 72 hours of continuous haemofiltration; it appeared to resolve only after plasma exchange (4 litres). The total of persistent block, for 9 days after the infusion had been stopped, is thought to be the longest period ever reported after administration of alcuronium. Neuromuscular block was monitored throughout this period using the train-of-four twitch technique. The potentiating effects of concurrent aminoglycoside therapy and hepatic dysfunction on the degree of paralysis are discussed.