DrR B Sharath Chandra KumarPost Graduate

MD AnaesthesiologyCHALMEDA ANAND RAO INSTITUTE OF MEDICAL SCIENCES

Karimnagar, INDIAGuide : DR B Syama Sundara Rao, Prof

INTRODUCTION Also known as scoline apnoea or post anaesthetic

apnoea

Abnormal prolongation of action of succinyl choline, due to failure of the body to metabolise it; leading to sustained paralysis

Succinylcholine Depolarizing muscle relaxant

Rapid action, 30-60 sec

Quick metabolism, 3-5 min

Metabolized by plasma cholinesterase, also known as pseudocholinesterase or butyryl cholinesterase or BuChE

Causes of Succinyl-choline apnea1. Low or atypical Plasma Cholinesterase Level

2. Altered Response of the End-Plate to Depolarizing Relaxants; myasthenia gravis

3. Accumulation of Succinylmonocholine after a dose of 5-7 mg/kg body weight, which is slowly metabolized than succinylcholine

4. Central Depression From Succinylcholine

5. Failure of Redistribution of Succinylcholine from the End-Plate

6. Hepatic failure, pregnancy

Atypical pseudo cholineterase Naturally occurring mutation Leu307Pro of human

butyrylcholinesterase

Produces Atypical pseudo cholineterase

Wont metabolize succinylcholine

Succinylcholine apnoea

Atypical pseudo cholineterase and vysyas Incidence of Atypical pseudo cholineterase was found

more in arya vysya community

Arya vaishya or arya vysya is an orthodox telugu/ kannada speaking indians

Found in Andhra Pradesh, Karnataka, Tamil Nadu, Maharashtra and Orissa

Notable people from arya vysya

MAHATMA GANDHI – our father of nation

POTTI SREERAMULU – sacrifised life for formation of our state andhra pradesh

KONIJETI ROSAIAH – ex CM of AP & present governor of tamilnadu

How to identify pre operatively?1. Simple blood test using ACHOLEST Test Paper :

- When a drop of the patient's plasma is applied to the substrate-impregnated test paper, a colorimetric reaction occurs. The time it takes the exposed Acholest Test Paper to turn from green to yellow is inversely proportional to the pseudocholinesteraseenzyme activity in the plasma sample

ACHOLEST TEST PAPER INFERENCE

Reaction time in minutes Pseudocholinesterase activity

< 5 above normal

5 - 20 normal

20 - 30 borderline low

> 30 below normal

2. Dibucaine number :

- an amide local anaesthetic

- inhibits normal pseudocholinesrerase by 80 % & atypical one with only approx 20 %

- Dibucaine number 80 indicates normal enzyme, homozygous atypical variant has Dibucainenumber 20

Prevention Good history regarding vysya status & previous

prolongation

Estimation of pseudocholinesterase Qualitatively & Quantatively

Rule out other systemic diseases like hepatic dysfunction

Avoid repeated & large doses of succinylcholine

Treatment 1. Fresh Plasma transfusion from non deficient person

2. Continue controlled ventilation till full recovery

3. Recombinant pseudocholinesterase administrarion

4. Not much role of anti cholinesterases

My experiences1. A 20 year old engineering student posted for an ENT

surgery.

- PAC done. ASA grade 1, VYSYA, MPG 2

- on the day of surgery, junior resident failed to inform that he is a vysya

- as usual we gave propofol & succinylcholine

- patient did’nt recover even after 15 min

- to our horror, we came to know that he was a vysya

- that patient recovered 6 hours after elective ventilation

- a great relief to whole of our department

2. a 35 year male patient posted for upper limb orthosurgery

- PAC done on the day before

- ASA 1, MPG 1, VYSYA

- brachial plexus block was given through inter scalene approach using winnie technique

- surgery started & patient was in discomfort due to sparing

- immediately converted to GA using propofol & scoline

- again same horror

- but to our goodness he recovered in 45 min. all of us had a sigh….

Bibilography1. Bush, G. H., Prolonged apnea due to suxamethonium.

Brit..1. Anae8th. 33,454(1961).

2. Harris, H., Whittaker, M., Lehmann, H., and Silk, E., The pseudocholinesterase variants. Esterase levels and dibucaine numbers in families selected through suxamethonium sensitive individuals. Acta Genet. Statist. Med. 10, 1 (1960).

3. Stoelting physio pharma

4. Millers