Inadequate Neuromuscular Blockade Due to Donepezil During General Anaesthesia for Cataract Surgery: A Case Report

Donepezil, an acetylcholinesterase inhibitor used to treat dementia and Alzheimer's disease, can interfere with non-depolarising neuromuscular blockers by increasing synaptic acetylcholine, potentially leading to inadequate neuromuscular blockade. A 57- year-old male with Down syndrome, dementia, and chronic donepezil therapy underwent elective cataract surgery under general anaesthesia. Despite standard dosing of rocuronium, neuromuscular blockade was delayed and incomplete, requiring repeated boluses. Quantitative Train of Four (TOF) monitoring revealed resistance to non-depolarising muscle relaxants, likely due to donepezilinduced acetylcholinesterase inhibition. Rapid recovery occurred despite Chronic Kidney Disease (CKD) Stage 3, and reversal with sugammadex was successful. This case highlights the importance of neuromuscular monitoring and tailored anaesthetic planning in patients on cholinesterase inhibitors.