Authors: Chamma AG, et al.
Cureus 17(9): e91738, September 6, 2025. doi:10.7759/cureus.91738
This case report describes a 40-year-old healthy woman who developed ventricular fibrillation (VF) and stress-induced cardiomyopathy (Takotsubo syndrome) immediately after routine reversal of neuromuscular blockade with neostigmine (0.04 mg/kg) plus atropine (0.02 mg/kg) at the end of an elective laparoscopic cholecystectomy. VF occurred within 50 seconds of drug administration and required two shocks and epinephrine, with return of spontaneous circulation in four minutes. Post-resuscitation imaging showed apical ballooning and severe mid-apical hypokinesis, while coronary angiography was normal—consistent with Takotsubo. The authors propose that autonomic imbalance from acetylcholinesterase inhibition and antimuscarinic effects precipitated malignant arrhythmia during emergence. They suggest selective relaxant binding with sugammadex as a safer alternative when available, especially when spontaneous recovery is already near complete (TOFR ~0.9).
What You Should Know:
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Standard-dose neostigmine–atropine can, rarely, trigger life-threatening arrhythmias and Takotsubo even in low-risk patients.
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Rapid onset after administration supports a drug-triggered autonomic mechanism during emergence.
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Consider whether reversal is necessary when quantitative monitoring shows near-complete recovery, and consider sugammadex when reversing rocuronium.
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Close cardiac monitoring around reversal is prudent, and teams should be prepared for immediate resuscitation.
Clinical Relevance:
For anesthesiologists, this report is a reminder to individualize reversal strategy: use quantitative neuromuscular monitoring, avoid routine neostigmine when recovery is sufficient, and preferentially use sugammadex when appropriate. If using neostigmine, pair with vigilant hemodynamic/ECG monitoring during emergence and ensure readiness for rapid defibrillation and advanced life support.
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