A 17 year old male with a history of
bronchial asthma was admitted to the intensive care unit in severe respiratory distress. During a two week period of intensive respiratory care he received large doses of
aminophylline and
corticosteroids. In addition,
pancuronium was given to facilitate ventilation and to reduce airway pressure. Large doses of
pancuronium, as much as 5 mg/hr, were required to stop spontaneous respiratory efforts and
restlessness. The total
pancuronium dose given during the two week period was 800 mg. One hour after
pancuronium was discontinued the patient could open his eyes and move his lips. Peripheral nerve stimulation indicated partial
paralysis which improved promptly following a test dose of
edrophonium. The authors speculate the
aminophylline, which is a known inhibitor of the
enzyme phosphodiesterase, raised the level of c-
AMP and, in turn, the level of
acetylcholine at the neuromuscular junction and thus antagonized the blocking effect of
pancuronium. In addition, the large doses of
corticosteroids that the patient had received may have enhanced the release of
acetylcholine and further facilitated neuromuscular transmission.