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

Abstract

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...

Deficiencia de butirilcolinesterasa identificada después de la administración de succinilcolina. Reporte del caso

“…Se recomienda proteger las vías respiratorias mediante intubación endotraqueal y ventilación de apoyo hasta que el paciente pueda recuperarse espontáneamente (9,16,17). Se aconseja estudiar a los familiares del paciente con deficiencia de la enzima, para determinar si también padecen esta condición patológica (2).…”

Residual Neuromuscular Blockade in Critical Care

“…Careful evaluation of medications before surgery can identify patients who may need decreased doses of NMBAs. 11,24,[36][37][38][39] 24 Donati and Vevan, 36 Kindler et al, 37 Jaramillo et al, 38 and Ramachandran and O'Brien.…”