Uncontrollable head shaking after neostigmine-atropine for postdural puncture headache: Case report

Abstract

Rationale: Postdural puncture headache (PDPH) is a common complication in lactating mothers after cesarean delivery. It was reported that postdural puncture headache was managed through a novel approach by administration of neostigmine-atropine. Neostigmine-atropine is commonly used to reverse residual non-depolarizing neuromuscular blocking agents. The method is simple, well-tolerated, and has fewer side effects compared to epidural blood patch procedure. We report a case of a patient who presented severe side effects following treatment using this method. Patient concerns: A 29-year-old female presented with uncontrollable head shaking (no studies reported) after using neostigmine/atropine. Diagnosis: Based on the clinical, using of neostigmine, the patient was diagnosed with severe side effects of neostigmine. Interventions: Comforted the patient until all symptoms disappeared (self-care). Outcomes: Approximately 10 minutes after administration of neostigmine/atropine, the patient exhibited trembling in the upper limbs, followed by severe head shaking from side to side with large amplitude above 90 degrees. The rate of head shaking was approximately 100 times min−1. The patient complained of stomachache and vomited about 20 mL light yellow liquid. After 20 minutes, the uncontrollable head shaking presented as a slight up-and-down nod. All the symptoms disappeared after approximately 50 minutes. The patient was fully conscious throughout the process and responded normally. Physical examination showed stable vital signs. The patient was discharged after 2 days. The patients were followed up for 1 year and everything was normal. Lessons: There are many side effects observed with neostigmine, such as uncontrollable head shaking. Patients should be informed of all the possible side effects during the consenting process to avoid panicking; dilution of the medications, and the drugs should be administered gradually to minimize side effects.