Pseudocholinesterase Deficiency

[ZachNear]

Hey all,
I had an interesting case on Monday, coiling of a non-ruptured cerebral aneurysm. Patient was ~80kg, no past medical history, no renal/liver Dz. attending gave propofol/fentanyl and 120mg of SUX at induction at 1230h. Rocuronium was given 10 minutes later and once more during the case. A total of 70mg rocuronium was administered over a period of 3.5 hours. As the case was finishing, patient had TOF: 2/4 and was given reversal (0.8mg glyco, 5mg neostigmine). Within a few minutes, 4 twitches were observed. Patient spontaneously ventilating but with VT of only ~50mL. Patient would open eyes and blink at me, but arms were weak/flaccid. An additional 0.3 glyco and 3mg neostig were given. No further improvement in muscle weakness or ventilatory effort. Residual rocuronium floating around or pseudocholinesterase deficiency? My main question is, if a patient has pseudocholinesterase deficiency, would they have any twitches on a TOF?
Your thoughts are appreciated.
Thanks.
Zach

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[ZachNear]

also, we went to CT just to make sure the neuroradiologists did not make any grave errors during the case (as they did the previous week, oops). Scan was normal. ok, discuss. thanks.

 

[LongSnow]

where were and how were the twitches checked?

Sometimes newbies will mistake direct muscle stimulation for true twitches; this will of course bypass the nerve and give a underappreciation of the density of the neuromuscular block. This especially can occur with orbicularis oculi testing and the facial nerve if you stimulate to close to the orbit.

Was the twitch response observed in an area of prior upper motor denervation? this will also cause an underestimation of block density.

thirdly - sometimes rocuronium just doesn't reverse well, despite seemingly adequate twitches - it is notorious in this regard.

There is a whole long laundry list of things that make NMB hard to reverse: antibiotics, drugs, disease processes, length of time since last dose, etc. Any of these could come into play.

My vote would be the roc, not pseudo cholinesterase inhib at first. But, as already said, if you didn't test before administering the roc, you don't know for sure.

 

[jwk]

Is it just me, or would anyone else think twice before giving sux on this type of case in the first place?

 

[LongSnow]

Is it just me, or would anyone else think twice before giving sux on this type of case in the first place?

Certainly would not be my first choice, just would have intubated with roc (unless a compelling reason to use sux)and and make sure patient nice and very deep prior to DL- for a normal size dude like 250 mg propofol guaruntee deepness, a probobly like 25 mcg sufenta. Probobly use an LTA as well.

 

[Noyac]

Is it just me, or would anyone else think twice before giving sux on this type of case in the first place?

Ditto, no reason to use it.

 

[Idiopathic]

i dont see the problem with sux its a perfectly fine drug, whats your concern?

 

[amyl]

never push roc after you intubate w sux w/o checking twitches first.

 

[Noyac]

i dont see the problem with sux its a perfectly fine drug, whats your concern?

No great concern, it's just not necessary and if it's not necessary then why use it.