Abstract Introduction Pseudocholinesterase deficiency is a rare disorder of both genetic and acquired origin which causes prolonged paralysis after administration of agents such as succinylcholine and ester anesthetics. Treatment is supportive and diagnosis is typically not confirmed until dibucaine number and serum pseudocholinesterase levels result days after a patient has already undergone what can be a traumatic experience causing long-term psychological impacts. Case Report We present the case of an 85-year-old woman who presented with ascending cholangitis and underwent endoscopic retrograde cholangiopancreatography under general anesthesia. She received succinylcholine as part of rapid sequence induction. Post-operatively she had no spontaneous movement and zero twitches on train-of-four testing, raising suspicion for pseudocholinesterase deficiency. She remained intubated and was transferred to the intensive care unit. Continuous sedation was initiated with propofol and serial train-of-four monitoring was used to assess for resolution of paralysis. Eleven hours after succinylcholine administration, she had a train-of-four ratio of greater than 0.9 and was successfully extubated. Testing later resulted with pseudocholinesterase concentration of 519 U/L (3,000 – 13,000 U/L) and dibucaine number 32% (70%), confirming the diagnosis of pseudocholinesterase deficiency. Discussion This case highlights the importance of preoperative screening, perioperative management, and prevention of prolonged paralysis in patients with pseudocholinesterase deficiency. Our patient underwent numerous surgeries throughout her life and had documentation of being “slow to wake up” from anesthesia, which could have prompted an opportunity for early detection. Pseudocholinesterase function also declines with age and illness, which may explain her more severe reaction to anesthesia during this hospitalization compared to prior surgeries. Appropriate perioperative management includes supportive care, use of train-of-four testing for early detection and monitoring, and use of adjunctive sedative medications to avoid the psychological impacts of paralysis without sedation. Use of neostigmine as a reversal agent has been linked to a paradoxical prolongation of paralysis. There is theoretical benefit to transfusion of fresh frozen plasma for repletion of pseudocholinesterase, but this is not well studied and is considered second-line therapy. Confirmatory testing with pseudocholinesterase concentration and dibucaine number is typical, however genetic testing has shown some benefit in rapid detection and can be helpful in anesthesia planning for patients and their families. Following diagnosis, alternative induction agents such as rocuronium should be used. This abstract is funded by: None
Rai et al. (Fri,) studied this question.