Interesting case

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narcusprince

narcusprince

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34 y/o female shows up for t/a with ent.
Pmhx smoking/ mild obesity bmi 31 200lbs. No known allergies. Greater then 4 mets activity level. Airway exam normal. Proceeds with case. Induction drugs 100 succ, 200 prop/ 100 fentanyl/ 10 decadron/ 1 gram ofirimev. Surgeon has some extra bleeding and throws stitch to control bleeding. 1.5 hrs at the end of the case 0 twitches on twitch monitor??? Management?? differential?
 
narcusprince said:
34 y/o female shows up for t/a with ent.
Pmhx smoking/ mild obesity bmi 31 200lbs. No known allergies. Greater then 4 mets activity level. Airway exam normal. Proceeds with case. Induction drugs 100 succ, 200 prop/ 100 fentanyl/ 10 decadron/ 1 gram ofirimev. Surgeon has some extra bleeding and throws stitch to control bleeding. 1.5 hrs at the end of the case 0 twitches on twitch monitor??? Management?? differential?
Click to expand...
Put new batteries in your nerve stimulator 🙂
 
Be sure twitch monitor works. I put it on myself to be sure.
Drug error possibly but unlikely unless you used pancuronium by mistake
Pseudochlinesterase def is the next thing I think of.
If you are at an ambulatory center then you probably should start working on transferring to hospital for vent support. This could last a few hours or more depending on the genetic allele (am I saying that right?) homozygous or heterozygous.
 
Monty Python said:
Any similar hx in a blood relative? Any pt hx of same thing?
Click to expand...
Pt reports no family history of any problems with anesthesia( in my practice environment people may be motivated not to fully disclose medical history). Good direction I will elaborate on this later. Lets hear from some residents. This is her first general anesthetic. I like the differential of drug error. This came to my mind. We dont carry panc and Roc comes in 5ml vials. My syringe with succ was drawn up by myself in a 10ml syringe.
 
Don't forget about LES or myasthenia gravis. May be a little lower on the initial differential, but if everything else checks out, gotta start looking for the unicorns.
 
I agree with all the above.
Pseudocholinesterase deficiency until proven otherwise. I'd start getting her ready to transfer to hospital/ICU if at ambualtory facility.
While waiting I'd check blood sugar, temperature and electrolytes.
Also, when I'm wondering if the twitch monitor is working, I always look at the patient-is she trying to breath, diaphragm moving, etc. Kind of obvious, but thought I'd mention it.
 
Agree pseudocholinesterase deficient at top of diff. Sedation and mech vent with Tx to hospital if necessary. Not much else you can do right now.

Monty Python said:
PS. What's the status of Sugammadex in the US? Haven't seen any yet.
Click to expand...

Never heard of Sugammadex reversing sux. 😵 But maybe that's not what you meant.
 
wje3 said:
I agree with all the above.
Pseudocholinesterase deficiency until proven otherwise. I'd start getting her ready to transfer to hospital/ICU if at ambualtory facility.
While waiting I'd check blood sugar, temperature and electrolytes.
Also, when I'm wondering if the twitch monitor is working, I always look at the patient-is she trying to breath, diaphragm moving, etc. Kind of obvious, but thought I'd mention it.
Click to expand...

Patient breathing/not breathing has a laundry-list sized differential which is not related at all to the twitch monitor working. If you really need to know if the twitch monitor is working, put the twitch monitor on the lowest current setting and just stimulate your own ulnar nerve. Doesn't hurt, and you have reliable information.
 
SaltyDog said:
Agree pseudocholinesterase deficient at top of diff. Sedation and mech vent with Tx to hospital if necessary. Not much else you can do right now.



Never heard of Sugammadex reversing sux. 😵 But maybe that's not what you meant.
Click to expand...

True; please pardon my sloppy/lazy paragraph construction. I was just wondering about sugammadex tangentially, while thinking it's too bad there's not a reversal agent for sux in cases like this.
 
Interesting case! Agree with the above (pseudocholinesterase deficiency, undiagnosed neuromuscular pathology). I'd like to know what happened post-operatively (her course, additional testing, etc.)

As far as Sugammadex, expect the FDA to shoot it down AGAIN on December 19th, lol. Nah, I hope it gets approval. Better invest in Merck now! 😉
 
Random Resident said:
Is she postpartum? Something to think about if choosing sux for short cases.
Click to expand...

OK, maybe I'm suffering a brain fart, or maybe I skipped that paragraph in the text books, or more likely just slept through that lecture in residency, but what is the problem with sux in the post-partum pt?
 
twoliter said:
Decreased pseudocholinesterase, but not clinically significant

http://www.ncbi.nlm.nih.gov/m/pubmed/3946807/
Click to expand...

Maybe it was a heterozygote or maybe it was just PP status, but had one PP tubal not have twitch return for ~30 min. No family Hx, sisters had pp tubals too with no problem, unsure if sux used for them. Chalked it up to PP decrease vs unknown heterozygote.
 
SaltyDog said:
OK, maybe I'm suffering a brain fart, or maybe I skipped that paragraph in the text books, or more likely just slept through that lecture in residency, but what is the problem with sux in the post-partum pt?
Click to expand...
Plasma cholinesterase levels decrease by about 1/3 intrapartum and immediately postpartum. I can't imagine it's clinically relevant to this case though.


Something else to think about. Healthy 32 year olds with good airways don't necessarily need any muscle relaxant for intubation. Succinylcholine myalgias are miserable. I try to never use the drug unless I have a solid indication like RSI ... or laryngospasm.
 
Urzuz said:
Patient breathing/not breathing has a laundry-list sized differential which is not related at all to the twitch monitor working. If you really need to know if the twitch monitor is working, put the twitch monitor on the lowest current setting and just stimulate your own ulnar nerve. Doesn't hurt, and you have reliable information.
Click to expand...
My point in mentioning her breathing status is to never forget to actually look at the patient.
People can develop tunnel vision/monitor obsession and forget to look at the patient.
That's all.
 
Agree with above and Ill add:

Put the BIS on and run her really light like 0.2 mac. IF the bis is high, I would think more of residual neuromuscular blockade. If the bis low I would think about narcan or some injury to her CNS. Id also advance and retract the tube while she is light, if she has any muscle strength that irritate ANYONE into moving. Then if she jerks to tube movement you know she has some muscle strength, and maybe she is just really comfy. Id want confirmation by some other means than the nerve stimulator that she truly is paralyzed.
 
Patient not breathing at all. No inspiratory effort. Twitch monitor was working as soon as I confirmed the twitch monitor was working. I turned up the vapor, gave versed, called icu sent bmp glucose. Surgeon called next of kin. First words out of surgeons mouth sister carries a med alert bracelet for you guessed it psuedocholinesterase deficiency, her brother went into cardiac arrest after his first anesthetic( which begs to wonder undiagnosed myopathy?). Four hours later patient extubated in ICU, listed succinycholine allergy referred for genetic testing. I wonder being in our condition PGG was their motive to not disclose.....
 
narcusprince said:
Patient not breathing at all. No inspiratory effort. Twitch monitor was working as soon as I confirmed the twitch monitor was working. I turned up the vapor, gave versed, called icu sent bmp glucose. Surgeon called next of kin. First words out of surgeons mouth sister carries a med alert bracelet for you guessed it psuedocholinesterase deficiency, her brother went into cardiac arrest after his first anesthetic( which begs to wonder undiagnosed myopathy?). Four hours later patient extubated in ICU, listed succinycholine allergy referred for genetic testing. I wonder being in our condition PGG was their motive to not disclose.....
Click to expand...

Same scenario happened to one of my old partners about 2 years ago.
 
We give sux all the time for stat c-section under GA. I know the levels decrease but seems very unlikely that it is clinically relevant. If it's not the sux or medicine error then you gotta start looking for zebras! Maybe she developed guillen-barre 🙂
 
One of my former partners "discovered" her pt had pseudocholinesterase deficiency on ECT Tx #1. She had fun with that one over in the psych ward.

The pt got low dose Roc for all his subsequent ECT's which worked out way better than I would have guessed.
 
narcusprince said:
Patient not breathing at all. No inspiratory effort. Twitch monitor was working as soon as I confirmed the twitch monitor was working. I turned up the vapor, gave versed, called icu sent bmp glucose. Surgeon called next of kin. First words out of surgeons mouth sister carries a med alert bracelet for you guessed it psuedocholinesterase deficiency, her brother went into cardiac arrest after his first anesthetic( which begs to wonder undiagnosed myopathy?). Four hours later patient extubated in ICU, listed succinycholine allergy referred for genetic testing. I wonder being in our condition PGG was their motive to not disclose.....
Click to expand...

Hell yes, there was motive to not disclose. Was the patient active duty? I believe pseudocholinesterase deficiency leads to MEB.
 
Random Resident said:
Maybe it was a heterozygote or maybe it was just PP status, but had one PP tubal not have twitch return for ~30 min. No family Hx, sisters had pp tubals too with no problem, unsure if sux used for them. Chalked it up to PP decrease vs unknown heterozygote.
Click to expand...
I have seen increased duration of action of Sux many times in post-partum patients, because at my previous job we did almost all PP tubal ligations under GA.
It is definitely clinically significant!
 
chocomorsel said:
Narcusprince, what is it about your "environment" that makes people not want to disclose health information?
Click to expand...

Active duty military. Some conditions (like MH) warrant medical boarding out of the military. The service member then may or may not be able to get VA disability for that condition. Therefore, it is not uncommon for active duty patients with hereditary diseases to conceal them to remain on active duty. I have seen it several times.
 
Ok. Thanks. Although how does a female remain on active duty weighing in at 200lbs with a BMI of 31?. Do they not make people exercise and meet weight standards anymore?
 
chocomorsel said:
Ok. Thanks. Although how does a female remain on active duty weighing in at 200lbs with a BMI of 31?. Do they not make people exercise and meet weight standards anymore?
Click to expand...
Short version ... twice per year the military has a fitness test and weigh-in. One failure of either part doesn't get anyone kicked out. People with injury, illness, or pregnancy get a pass for a while. It takes multiple consecutive failures to reach that point, and sometimes people won't ever get booted. Mostly it just holds up promotions ... and often those people get tired of not getting promoted and choose to get out and the problem solves itself. It is a long uncertain process to kick out an overweight person who doesn't want to get out.
 
Pseudocholinesterase trivia for you youngsters.
What other drug or drugs should you avoid in this pt?
 
Another point that I didn't realize until about 5 years ago. We had a case like this and everyone said we should draw a Dibucaine number in the RR. Actually, you need to wait.
According to ARUP labs(a reference lab my wife uses):

"Pseudocholinesterase, Dibucaine Inhibition
0020159

Ordering Recommendation
Order to detect increased sensitivity in individuals who experience prolonged paralysis following succinylcholine or mivacurium administration.
Mnemonic
PCHE PHENO
Methodology
Quantitative Enzymatic
Performed
Mon-Fri
Reported
1-5 days
New York DOH Approval Status
This test is New York DOH approved.
Submit With Order


Disease Topics
PGx
Specimen Required
Patient Preparation
Specimen must be drawn prior to surgery or more than two days following surgery. Do not draw in recovery room.
Collect
Serum separator tube, green (sodium or lithium heparin), lavender (EDTA), or pink (K2EDTA).
Specimen Preparation
Allow specimen to clot completely at room temperature. Separate serum or plasma from cells ASAP or within 2 hours of collection. Transport 1 mL serum or plasma. (Min: 0.25 mL)
Storage/Transport Temperature
Refrigerated.
Unacceptable Conditions
Lt. blue (sodium citrate) or gray (oxalate/fluoride). Whole blood.
Remarks
Stability
Ambient: 4 hours; Refrigerated: 1 week; Frozen: 3 months

Underline and Bold are mine. source arup.com
 
Noyac said:
Pseudocholinesterase trivia for you youngsters.
What other drug or drugs should you avoid in this pt?
Click to expand...

Old ITE question (k type):

A patient with a dibucaine number of 20 would have

(1) increased risk of toxicity from intranasally administered cocaine
(2) increased risk of toxicity from subarachnoid administration of tetracaine
(3) prolonged paralysis after intravenous administration of succinylcholine
(4) decreased duration of local anesthesia with chloroprocaine


We were actually just talking about this at our weekly board review.
 
wje3 said:
Another point that I didn't realize until about 5 years ago. We had a case like this and everyone said we should draw a Dibucaine number in the RR. Actually, you need to wait.
According to ARUP labs(a reference lab my wife uses):

"Pseudocholinesterase, Dibucaine Inhibition
0020159

Ordering Recommendation
Order to detect increased sensitivity in individuals who experience prolonged paralysis following succinylcholine or mivacurium administration.
Mnemonic
PCHE PHENO
Methodology
Quantitative Enzymatic
Performed
Mon-Fri
Reported
1-5 days
New York DOH Approval Status
This test is New York DOH approved.
Submit With Order


Disease Topics
PGx
Specimen Required
Patient Preparation
Specimen must be drawn prior to surgery or more than two days following surgery. Do not draw in recovery room.
Collect
Serum separator tube, green (sodium or lithium heparin), lavender (EDTA), or pink (K2EDTA).
Specimen Preparation
Allow specimen to clot completely at room temperature. Separate serum or plasma from cells ASAP or within 2 hours of collection. Transport 1 mL serum or plasma. (Min: 0.25 mL)
Storage/Transport Temperature
Refrigerated.
Unacceptable Conditions
Lt. blue (sodium citrate) or gray (oxalate/fluoride). Whole blood.
Remarks
Stability
Ambient: 4 hours; Refrigerated: 1 week; Frozen: 3 months

Underline and Bold are mine. source arup.com
Click to expand...


Interesting. Any idea why that is?
 
Planktonmd said:
I don't think they make it anymore
Click to expand...

The story I always heard was there was one factory that made Miva and it burned down. The manufacturer didn't bother to set up shop anywhere else.
 
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