A 76-year-old woman presents for urgent exploratory laparotomy. She has been receiving several medications for the management of dementia. Which of the following medications is MOST likely to interfere with neuromuscular blockade?

  • □ (A) Citalopram

  • □ (B) Memantine

  • □ (C) Donepezil

As the population ages, more patients are receiving drugs for the treatment of dementia. Many of these drugs have possible interactions with perioperative medications. The indication for some of the commonly used medications is based on a presumed link between loss of cholinergic input and dementia.

Anticholinesterase medications are also frequently used in the treatment of dementia (e.g., donepezil). These medications may prolong paralysis from succinylcholine and impact nondepolarizing muscle relaxants by decreasing or reversing their effects. In order to avoid this interaction, stopping these dementia medications a day before surgery has been suggested. For most medications in this category, the elimination half-life is short enough that this can be considered. Donepezil has a half-life of 70 hours and should ideally be discontinued two to three weeks prior to anesthesia.

If nondepolarizing muscle relaxation is needed, the patient may require higher doses of neuromuscular blockers. If a patient receives anticholinesterase for dementia treatment until the time of surgery, perioperative management would include avoidance of succinylcholine. High-dose rocuronium or vecuronium with sugammadex reversal could be used instead.

Citalopram and memantine are unlikely to interfere with neuromuscular blockade.

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1
Alcorn
S
,
Foo
I
.
Perioperative management of patients with dementia
.
BJA Education
.
2017
;
17
(
3
):
4
98
. doi:10.1093/bjaed/mkw038
2
Cottrell
JE
,
Patel
P
, eds
.
Cottrell and Patel's Neuroanesthesia
. 6th edition.
Philadelphia, PA
:
Elsevier
;
2017
:
402
3
.

Answer: C