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1. Sux Apnoea- A Case Study Karenne Nielsen
Clinical Nurse Specialist
West Gippsland Healthcare Group
3. Suxamethonium Sux Dose = 1-2 mgs/kg IVI or IMI
Rapid onset of muscle relaxation
- fasciculation 30-60 seconds
Short duration of 5-10 minutes
- apnoea lasts 5 mins
- paralysis recovery another 5 mins
4. Suxamethonium Sux Metabolised by plasma cholinesterase
- an enzyme produced in the liver & present in the blood
Plasma cholinesterase is usually present in sufficient concentration to give a half-life of approx. 4 mins
No reversal agent
5. Side effects Cardiovascular bradycardia
Hyperkalaemia
Raised intraocular/pressure
Allergic reaction ? Anaphylaxis
Malignant hyperthermia
Muscle pains- calf & chest
Prolonged muscle paralysis
6. Sux apnoea Rare condition in 4-6% population
Patients with abnormal plasma cholinesterase are incapable of metabolising suxamethonium resulting in prolonged muscle paralysis and apnoea.
Inherited - often normal levels but abnormal plasma cholinesterase (up to 8hrs or more)
Acquired lower levels of normal plasma cholinesterase
7. Case study 55 year old Female
No significant medical/family history
Nil current medications
Non smoker
Surgical & Anaesthetic history
- Varicose Vein Ligation 2002
- GA no muscle relaxants
8. Pre-Anaesthetic Assessment Weight: 77.5 kgs / Height: 156cm
Reflux lying flat in bed
High risk of gastric reflux
Undershot jaw Airway Grade III
? Difficult intubation
ASA score 2
Anxious patient ++
9. Anaesthetic drugs Midazolam 2mgs IVI
Fentanyl 100gs IVI
Propofol 200mgs IVI
Suxamethonium 100mgs IVI @ 1355
Nitrous/Oxygen 2:2
Sevoflurane 2%
Cephazolin 1gm IVI
10. Anaesthetic/Operation Ventral Hernia Repair with Mesh
- surgery straightforward = 1hr
No muscle movement noted throughout the operation end time 1hr & 10 mins after suxgiven
Sux apnoea or another diagnosis ?
Assumption of Sux apnoea confirmed by nerve stimulation
11. Management Anaesthesia maintained
- important to be patient
- keep asleep and unaware
Continuous monitoring
Entropy monitoring
Fluid and electrolyte balance
Temperature
BSL
12. Management Urinary catheter
Pressure area care
Calf stimulation
Eye care
Wound/drain care
Nerve stimulator
Plan for emergency surgery
13. Management Relatives kept informed & to visit
- truthful explanation of condition
- reassure safe & waiting to wake
- ? Fresh Frozen Plasma
Started to swallow @ 6hrs
Extubated 30 mins later
Total time = 7 hours
14. Recovery Drowsy
Co-operative and talking
No recollection
Required narcotic analgesia
Very dry mouth
Puffy eyes
Husband to visit
15. Post-op period Hypokalaemia post op day 1& 2
- Potassium replaced IVI & orally
Febrile post op day 2
- CXR ? pneumonia
- oral antibiotics
Erythema of wound day 3
Discharged post op day 5
16. Follow up for Sux Apnoea Review 1 month post-op
Debriefing with family present
- Sux Apnoea episode
- Importance of alerting staff with future anaesthetics -
Pseudocholinesterase typing &
Phenotype differentiation
Patient and family tested
17. Follow up testing Normal Dibucaine = over 70%
Homozygous normal = (6.0-15.6)
K Dibucaine Inhibition = 15% confirming susceptibility to Sux
Genotype testing unavailable but length of apnoea suggests rare clinical variant
Children 4/6 tested all normal levels
18. The end!!
Thankyou very much for your attention.