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Anticholinergic syndrome: case report A 66-year-old woman developed anticholinergic syndrome during treatment with scopolamine, fentanyl and midazolam [durations of treatments to reactions onset not stated; not all routes and dosages stated]. The woman with suspected rectal malignancy was scheduled to undergo a robotic low anterior resection, and bilateral salpingooophorectomy with hysterectomy. For the procedure, she was placed on enhanced recovery after surgery protocol by her physician, which included an order set comprising the application of a preoperative transdermal scopolamine patch placed before, she moved to the operating room. During surgery, she was administered fentanyl 300µg in divided doses with the last dose administered 45 minutes prior to extubation and midazolam 2mg administered at the beginning. Additionally, she received various concomitant medications. The procedure was uneventful. In the post-anesthesia care unit (PACU), it was observed that she was unresponsive to verbal and tactile stimuli; however, removed from painful stimuli in all four extremities. Physical examination showed dilated, sluggishly reactive pupils bilaterally. She also had mydriasis, delirium and tachycardia. During further examination, the scopolamine patch was observed close to an area of skin breakdown, which was removed immediately. Based on these clinical presentation, findings and after excluding the other conditions, she was diagnosed with anticholinergic syndrome associated with scopolamine, fentanyl and midazolam. The woman was treated with glycopyrrolate and physostigmine. Soon after the treatment, she started moving all extremities on command and responding to questions appropriately. Approximately 2 hours after PACU stay, she was discharged from the PACU to an inpatient unit. Several hours following discharge, she developed an episode of acute agitation. Subsequently, she was shifted to ICU. The head CT scan revealed no acute intracranial pathology. On the postoperative day 2 morning, the delirium had resolved, and she was shifted out of the ICU. On day 4 of hospitalisation, she was discharged. Knuf KM, et al. Scopolamine Toxicity in an Elderly Patient. Military Medicine 184: 937-938, No. 11-12, Nov-Dec 2019. Available from: URL: http://doi.org/10.1093/milmed/ 803500293 usz086

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Reactions 12 Sep 2020 No. 1821