Sux Apnoea - A Case Study Karenne Nielsen Clinical Nurse

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Sux Apnoea- A Case Study

• Karenne Nielsen
• Clinical Nurse Specialist
• West Gippsland Healthcare Group

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Suxamethonium Chloride Sux Scoline

• Short acting muscle relaxant
• Allows rapid intubation of trachea
• provides short periods of neuromuscular
• blockade
• Main uses - difficult intubation
• - emergency conditions
• - brief procedures

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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

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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

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Side effects

• Cardiovascular bradycardia
• Hyperkalaemia
• Raised intraocular/pressure
• Allergic reaction ? Anaphylaxis
• Malignant hyperthermia
• Muscle pains- calf chest
• Prolonged muscle paralysis

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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

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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

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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

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Anaesthetic drugs

• Midazolam 2mgs IVI
• Fentanyl 100µgs IVI
• Propofol 200mgs IVI
• Suxamethonium 100mgs IVI _at_ 1355
• Nitrous/Oxygen 22
• Sevoflurane 2
• Cephazolin 1gm IVI

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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

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Management

• Anaesthesia maintained
• - important to be patient
• - keep asleep and unaware
• Continuous monitoring
• Entropy monitoring
• Fluid and electrolyte balance
• Temperature
• BSL

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Management

• Urinary catheter
• Pressure area care
• Calf stimulation
• Eye care
• Wound/drain care
• Nerve stimulator
• Plan for emergency surgery

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Management

• Relatives kept informed to visit
• - truthful explanation of condition
• - reassure safe waiting to wake
• - ? Fresh Frozen Plasma
• Started to swallow _at_ 6½hrs
• Extubated 30 mins later
• Total time 7 hours

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Recovery

• Drowsy
• Co-operative and talking
• No recollection
• Required narcotic analgesia
• Very dry mouth
• Puffy eyes
• Husband to visit

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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

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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

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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

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The end!!

• Thankyou very much for your attention.