Butyrylcholinesterase deficiency or “I remember intubation”

Czech version

Authors: D. Novotný ^1,3; J. Závada ²; M. Novotná ³; A. Bočková ³; T. Vymazal ⁴
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny 1. lékařské fakulty Univerzity Karlovy a Ústřední vojenské nemocnice Praha ¹; Klinika anesteziologie, resuscitace a intenzivní medicíny 1. lékařské fakulty Univerzity Karlovy a Všeobecné fakultní nemocnice Praha ²; VUAB Pharma, a. s., Roztoky ³; Klinika anesteziologie, resuscitace a intenzivní medicíny 2. lékařské fakulty Univerzity Karlovy a Fakultní nemocnice Motol Praha ⁴
Published in: Anest. intenziv. Med., 33, 2022, č. 1, s. 51-54
Category: Case Reports

Overview

This case report describes a patient with a personal history of muscle paralysis after emergence from a short general anaesthesia with the use of suxamethonium. She has a partial recall of subsequent intubation. After a few hours of mechanical ventilation and sedation, she was extubated without complication in the ICU. During the preanesthesia evaluation, we suspected a deficiency of butyrylcholinesterase, an enzyme metabolizing mivacurium and suxamethonium. Due to that, general anaesthesia with muscle relaxation using rocuronium was performed for a planned hemithyreoidectomy. There were no complications during the surgery and subsequent genetic examinations revealed a combined mutation of the butyrylcholinesterase gene. Butyrylcholinesterase deficits increase the risk of perioperative respiratory complications. Testing of family members of patients with a confirmed mutation or preventive preoperative examination in high-risk surgery prevent such complications.

Keywords:

Apnea – Inborn errors of metabolism – suxamethonium – mivacurium – butyrylcholinesterase deficiency – neuromuscular monitoring

Sources

1. Soliday FK, Conley YP, Henker R. Pseudocholinesterase deficiency: a comprehensive review of genetic, acquired, and drug influences. AANA J. 2010;78(4):313-320.

2. Andersson ML, Møller AM, Wildgaard K. Butyrylcholinesterase deficiency and its clinical importance in anaesthesia: a systematic review. Anaesthesia. 2019;74(4):518-528. doi: 10.1111/anae.14545.

3. Thomsen JL, Nielsen CV, Palmqvist DF, Gätke MR. Premature awakening and underuse of neuromuscular monitoring in a registry of patients with butyrylcholinesterase deficiency. Br J Anaesth. 2015 Jul;115 Suppl 1:i89–i94. doi: 10.1093/bja/aev103.

4. Vickers MD. The mismanagement of suxamethonium apnoea. Br J Anaesth. 1963;35: 260-268. doi: 10.1093/bja/35. 4. 260.

5. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015 Oct 29;2015(10): CD002788. doi: 10.1002/14651858.CD002788.pub3.

6. Vymazal T, Krecmerova M, Bicek V, Lischke R. Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patiens undergoing surgery – the serie of 117 cases. Ther Clin Risk Manag. 2015 Oct 15;11:1593-1596. doi: 10.2147/TCRM.S93009.

7. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al.; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-848. doi: 10.1093/bja/aev371.

8. Adamus M, Cvachovec K, Černý V, Herold I, Horáček M, Mach D, et al. Doporučený postup ČSARIM: Zásady bezpečné anesteziologické péče, Anest Intenziv Med. 2018;29:107-110.

9. Klein AA, Meek T, Allcock E, Cook TM, Mincher N, Morris C, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia. 2021 Sep;76(9):1212-1223. doi: 10.1111/anae.15501.

10. Schmartz D, Chénard L, Baumann C, Fuchs‑‑Buder T. A modified train‑of‑four ratio to assess recovery from depolarizing neuromuscular blockade after succinylcholine, a prospective observational study. J Clin Monit Comput. 2021 Oct;35(5):1133-1138. doi: 10.1007/s10877-020-00560-5.