Prolonged neuromuscular blockade as a result of malnutrition-induced pseudocholinesterase deficiency

Niazi, Ahtsham U.; Leonard, Irene; O'Kelly, Breda

doi:10.1016/j.jclinane.2003.02.010

Cited by 22 publications

(18 citation statements)

References 14 publications

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“…However, if prolonged paralysis does occur, the patient is usually admitted to the ICU for extended intubation and mechanical ventilation. [1][2][3][4][5][6] Succinylcholine and mivacurium are NMBAs of choice when only a very short period of paralysis is needed. Recovery from succinylcholine paralysis starts within 2 to 3 minutes, and recovery from mivacurium paralysis begins within approximately 5 to 10 minutes.…”

Section: Discussionmentioning

confidence: 99%

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Prolonged Paralysis and Apnea After Receiving a Neuromuscular Blocking Agent: What Nurses Should Know

Jaramillo

Scruth

Cheng

2009

American Journal of Critical Care

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After receiving mivacurium, a short-acting neuromuscular blocking agent used for intubation before surgery, a patient experienced prolonged paralysis and prolonged apnea that required ventilator support. Although this complication is rare, all critical care nurses should be aware of it so they can be competent in managing and providing holistic and comprehensive nursing care to the patient and the patient's family. Although this complication has been documented in the anesthesia literature, it has received little mention in critical care nursing journals. (American Journal of Critical Care. 2009;18:592,588-591) T his case report describes a patient who had prolonged paralysis and apnea after receiving mivacurium, a neuromuscular blocking agent (NMBA), for endotracheal intubation before surgery. This rare perioperative complication occurs in patients with plasma cholinesterase (pseudocholinesterase) deficiency. Most reported cases of prolonged paralysis are in patients receiving succinylcholine. In this case report, we discuss the use of both depolarizing and nondepolarizing muscle relaxants that undergo metabolism by plasma cholinesterase and the following critical care nursing issues: providing competent care for patients receiving NMBAs, management of acute prolonged paralysis and apnea, management of suspected plasma cholinesterase deficiency, strategies for prevention and patient safety, and future objectives for research. Case ReportA 56-year-old woman with a below-the-knee amputation of the right lower extremity was readmitted to the hospital for treatment of a 1-week-old stump that was dehisced and infected due to injury. Her medical history included chronic kidney disease treated with peritoneal dialysis, congestive heart failure, hypertension, neuropathy, peripheral vascular disease, diabetes, and malnourishment. The plan Continued on page 588Cases of Note features peer-reviewed case reports and case series that document clinically relevant findings from critical and high acuity care environments. Cases that illuminate a clinical diagnosis or a management issue in the treatment of critically and acutely ill patients and include discussion of the patient's experience with the illness or intervention are encouraged. Proposals for future Cases of Note articles may be e-mailed to ajcc@aacn.org. After induction and the start of maintenance anesthesia, the train of four (TOF) delivered by the peripheral nerve stimulator was 0 out of 4 twitches, indicating complete paralysis or 100% blockage of the acetylcholine receptors at the motor end plate. Because the patient's TOF did not return as expected and neuromuscular blockade could not be reversed, the surgical procedure was deferred and the patient was transferred to the intensive care unit (ICU) still intubated and mechanically ventilated for recovery from anesthesia. The prolonged paralysis was assumed to be due to plasma cholinesterase deficiency that resulted in extremely slow metabolism of mivacurium. By day 3, the patient's paralysis had compl...

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Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9]18 Nurses should recognize and report an abnormal dibucaine inhibition number and plasma cholinesterase levels. Additionally, nurses should not hesitate to discuss referral for genetic consultation when the dibucaine inhibition number is less than 80%.…”

Section: Nursing Skill Rationalementioning

confidence: 99%

Prolonged Paralysis and Apnea After Receiving a Neuromuscular Blocking Agent: What Nurses Should Know

Jaramillo

Scruth

Cheng

2009

American Journal of Critical Care

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“…[23] A study was performed on 22 men and women of Arya Vysya community belonging to Coimbatore, Tamil Nadu state of India showed that 9 of them had pseudocholinesterase deficiency; [24] The gene mutations responsible for absence of pseudocholinesterase activity were identified [25] and it was associated with 58 different mutations, including frame shift mutations, deletions, substitutions, insertions of alu repeats, and mutations affecting intron/exon splicing. The silent phenotype of human pseudocholinesterase has a frequency of 1 in100,000 in European and American populations, but an extremely high frequency of 1 in24 in the Vysya community of India [24] ; Literature review revealed a total of 40 pseudocholinesterase deficiency cases were being reported in USA from 1956 to 2011; [10] A very recent studies in 2016 reveals that malnutrition-induced pseudocholinesterase deficiency is also a possible etiology; [26,27] A 36-year-old correctional officer with pseudocholinesterase deficiency when exposed to organophosphate toxicity he immediately developed abdominal cramps, diarrhea, sweating, excessive salivation, frequent urination, and increased bronchial secretions; [28] A 19 year old girl underwent her first experience of general anesthesia for 30 minute dentoalveolar procedure and unexpectedly met extubation requirement for 5 hours due to pseudocholinesterase deficiency; [29] The four patients in the Mostas Private Health Hospital, Turkey was identified with positive pseudocholinesterase deficiency. In all four of the patients, the prolonged blocks are deteriorated due to mivacurium use; [9] A 72-year-old male underwent neck dissection and parotidectomy with facial nerve preservation.…”

Section: Case Reports Of Affected Hindu Arya Vysya Communitymentioning

confidence: 99%

Pseudocholinesterase Deficiency in an Indian Community

Maddi¹,

Prudhivi²

2017

JPPCM

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Back ground: India, the seventh largest country, 3rd largest standing army and one of the oldest civilizations in the world, with a literacy rate of 74.04%. Indian population was a mixture of 46,73,034 categories of different castes and sub-caste each related to a specific occupation. Arya Vysya is a Hindu Indian caste with a total population of 22,952,000. Methods:Pseudocholinesterase is a glycoprotein enzyme with complex molecular structure synthesized in the liver and specifically hydrolyzes certain exogenous cholinesters. Pseudocholinesterase deficiency is a genetic enzyme abnormality or acquired alteration in the metabolism of choline esters in this patient may experience a paralysis of the respiratory muscles, to overcome this, required more time mechanically-assisted breathing. The presence of the genetic defect is not realized until one is exposed to succinylcholine or mivacurium. Results: Arya Vysya community people of India having deficiency of pseudocholinesterase is the most affected people than any other with homozygous mutation incidence rate of 2-4%. Very recent studies in 2016 reveal that malnutrition-induced pseudocholinesterase deficiency is also a possible etiology. Conclusion: It was suggested that the Arya Vysya Community people with a history of pseudocholinesterase deficiency should tell his or her doctor if when they undergo anesthesia for surgery to avoid potentially serious unwanted adverse effects.

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“…Renal and liver disease can also affect metabolism and excretion of muscle relaxants and some neuromuscular diseases can change sensitivity to muscle relaxants. [1][2][3][4] Suspected Diagnosis:…”

Section: Possible Causes Of Prolonged Neuromuscular Blockadementioning

confidence: 99%

“…The number of twitches corresponds to the level of paralysis: four indicates 75% blockade, three indicates 80%, two indicates 85%, one indicates 90%, and no twitch indicates 100% blockade. [1][2][3][4] The patient was reassessed after the injection of succinylcholine with the PNS, and the TOF revealed no twitch. The surgeon was notified, the patient was continued on mechanical ventilation, and anesthesia was maintained.…”

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confidence: 99%

A Case of Pseudocholinesterase Deficiency in the PACU

Leadingham¹

2007

Journal of PeriAnesthesia Nursing

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Prolonged neuromuscular blockade as a result of malnutrition-induced pseudocholinesterase deficiency

Cited by 22 publications

References 14 publications

Prolonged Paralysis and Apnea After Receiving a Neuromuscular Blocking Agent: What Nurses Should Know

Prolonged Paralysis and Apnea After Receiving a Neuromuscular Blocking Agent: What Nurses Should Know

Pseudocholinesterase Deficiency in an Indian Community

A Case of Pseudocholinesterase Deficiency in the PACU

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