Sux Apnoea

- A Case Study
Karenne Nielsen
Clinical Nurse Specialist
West Gippsland Healthcare Group
 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
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
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
Side effects

 Cardiovascular – bradycardia
 Hyperkalaemia

 Raised intraocular/pressure

 Allergic reaction → Anaphylaxis

 Malignant hyperthermia

 Muscle pains- calf & chest

 Prolonged muscle paralysis

“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
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
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 ++
Anaesthetic drugs
 Midazolam 2mgs IVI
 Fentanyl 100µgs IVI
 Propofol 200mgs IVI
 Suxamethonium 100mgs IVI @ 1355
 Nitrous/Oxygen 2:2
 Sevoflurane 2%
 Cephazolin 1gm IVI
Anaesthetic/Operation
 Ventral Hernia Repair with Mesh
- surgery straightforward = 1hr
 No muscle movement noted
throughout the operation – end
time 1hr & 10 mins after “sux”given
 Sux apnoea or another diagnosis ?
 Assumption of Sux apnoea confirmed
by nerve stimulation
Management
 Anaesthesia maintained
- important to be patient
- keep asleep and unaware
 Continuous monitoring
 Entropy monitoring
 Fluid and electrolyte balance
 Temperature
 BSL
Management

 Urinary catheter
 Pressure area care

 Calf stimulation

 Eye care

 Wound/drain care

 Nerve stimulator

Plan for emergency surgery

Management

 Relatives kept informed & to visit

- truthful explanation of condition
- reassure safe & waiting to wake
- ? Fresh Frozen Plasma
 Started to swallow @ 6½hrs

 Extubated 30 mins later

 Total time = 7 hours

Recovery

 Drowsy
 Co-operative and talking

 No recollection

 Required narcotic analgesia

 Very dry mouth

 Puffy eyes

 Husband to visit
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

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
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
The end!!

Thankyou very much

for your attention.