Abstract

Background: Neostigmine methyl sulfate, a quaternary ammonium compound with anticholinesterase activity, is routinely employed for the reversal of non depolarising neuromuscular blockade. Despite its favourable safety profile, cardiovascular complications, including bradycardia, atrioventricular block, and, in rare instances, ventricular arrhythmias, have been documented.

Case description: We describe the case of a 58-year-old female with diabetes mellitus, hypertension, bronchial asthma, and post-thyroidectomy status on thyroxine, who underwent Functional Endoscopic Sinus Surgery under general anaesthesia. Neuromuscular blockade with vecuronium was reversed postoperatively using neostigmine and glycopyrrolate; however, the patient subsequently developed stable monomorphic ventricular tachycardia. Pharmacologic intervention with lidocaine and amiodarone restored sinus rhythm.

Literature review Although neostigmine is more frequently associated with bradyarrhythmias, isolated cases of ventricular tachyarrhythmias have been reported. Beta-agonist and thyroxine use may upregulate myocardial β-receptors, thereby enhancing susceptibility to cholinergic-induced arrhythmogenesis, particularly in the perioperative setting.

Clinical relevance: This case highlights the importance of anticipating arrhythmic complications in patients receiving chronically administered sympathomimetic and thyroid replacement therapies. Perioperative vigilance and readiness to manage such adverse events are essential when reversing neuromuscular blockade with anticholinesterase agents

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Funding