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Fresh frozen plasma for reversal of succinylcholine-induced neuromuscular blockade following cesarean delivery under general anesthesia
Abstract Number: FCB-211
Abstract Type: Case Report Case Series
General anesthesia (GA) is used frequently for cesarean delivery (CS) in low-resource countries. We present a case of succinylcholine (sux) induced respiratory depression in undiagnosed psuedocholinesterase (PchE) deficiency.
The parturient was 34-years-old, G6P1, 34 weeks EGA with a triplet pregnancy who presented with preterm labor. Weight was 87 kg, with normal VS and class II airway. PMH was significant for prior vaginal delivery, and 3 laparoscopic procedures for ectopic pregnancy. After a prior procedure, she had a prolonged wake-up, and was advised to have "some laboratory test“ which she "forgot to do“.
On presentation, cervix was 3 cm and all 3 infants were breech. An urgent CS was called. Spinal anesthesia was attempted unsuccessfully before GA was induced, with propofol 2 mg/kg and sux 75mg. Anesthesia was maintained with sevoflurane, rocuronium, and fentanyl. All 3 infants were delivered in good condition.
At the end of surgery, despite lack of sevoflurane, she remained unresponsive and hypotensive with no respiratory effort. No peripheral nerve stimulator (PNS) was available in the facility. Over several minutes, the patient became tachycardic and hypertensive. A diagnosis of PchE deficiency was entertained, and 2 units of fresh frozen plasma (FFP) were administered. Two hours later she recovered sufficiently to be extubated, but respiratory efforts were weak, and 2 more units of FFP were given. Effort improved significantly, and the remainder of her recovery was uneventful. The day after delivery a PchE level returned a value of 2709 u/L (normal, 2879-12,669 u/L).
Discussion: Atypical or decreased PchE is present in about 1:2800 people (1). Pregnancy can further decrease PchE level (2). Deficiency is often undiagnosed prior to surgery. Prevention of complications is with careful monitoring of NM block, both before and after subsequent administration of a non-depolarizing relaxant.
When diagnosed post-op, conservative management includes mechanical ventilation and sedation until spontaneous recovery occurs. FFP has been reported as an effective active treatment (1). FFP retains its PchE level without decrease for at least 7 weeks (1), and can result in recovery of NM function within minutes. The PchE level assayed on the first post-op day likely represents the level of the enzyme present after transfusion of the FFP.
Unfortunately, in some low-resource settings, conservative treatment can be problematic. In this case, a PNS was not available, and the facility lacked the ability to provide prolonged ventilation outside the OR, necessitating ambulance transfer to another facility.
In summary, a case of successful treatment of PchE deficiency with FFP in a post-cesarean patient is presented. Such occurrences provide further impetus to continue to advocate for wider training and utilization of regional anesthetics in the obstetric population.
1) Anaesthesia 2003;58:815-6. 2) BJA Educ 2013;14:69-72