Case study

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• Case study
• -Muscle Relaxant

Intern ???
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Case Presentation

• A twenty year old lady undergoes a laparotomy
  for a ruptured ectopic pregnancy under general
  anesthesia
• Mass 60kg
• No abnormalities found in the preoperative
  history and examination
• It is, however , her first anesthetic

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• She receives
• Propofol 120 mg
• Suxamethonium (Succinylcholine) 60 mg
• Cisatracurium 8 mg
• Fentanyl 100 µg
• O2/air/sevoflurane
• Atropine 0.4mg
• Neostigmine 2.5mg

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• Hemodynamically stable throughout the procedure
• She remains apneic, is sweating, blushing and
  hypertensive after reversal of the
  nondepolarizing muscle relaxant

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Discussion

• Postoperative apnea
• Sweating
• Blushing
• Hypertensive

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• Postoperative apnea
• Residual anesthetic agent
• I. Propofol
• II. Sevoflurane
• III. Fentanyl
• Residual muscle relaxant
• I. Suxamethonium(Succinylcholine)
• II. Cisatracurium

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• Intraoperative hyperventilation
• Electrolyte acid-base imbalance
• Underline disease (ex stroke, liver disease)

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Residual anesthetic agent

• Propofol
• bradycardia
• Myoclonus
• Apnea
• Hypotension (especially with narcotics less with
  infusion)
• Phlebitis (rare)
• Reported to cause tissue necrosis on subcutaneous
  extravasations in small children

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• Sevoflurane
• mild negative inotrope
• little or no tarchycardia
• may prolong the QT interval
• depresses respiration
• bronchodilator
• slightly increases ICP

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• Fentanyl
• Abdominal pain, dry mouth, diarrhea,
  constipation, indigestion, nausea
• anxiety, confusion, depression,dizziness,
  fatigue, hallucinations, headache, insomnia,
  sleepiness,
• impaired or interrupted breathing, shortness of
  breath
• itching, sweating
• urinary retention

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Residual muscle relaxant

• Suxamethonium (Succinylcholine)
• Depolarizing muscle relaxant
• Stimulates all cholinergic autonomic receptors
• Cardiac dysrrhythmia
• Hyperkalemia
• Myalgia
• Malignant hyperthermia
• Increase intragastric pressure, intraocular
  pressure, and intracranial pressure
• esp. low pseudocholinesterase activity,
  atypical pseudocholinesterase activity

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low pseudocholinesterase activity

• liver disease, advanced age, malnutrition,
  pregnancy, burns, oral contraceptives, monoamine
  oxidase inhibitors, echothiophate, cytotoxic
  drugs, neoplastic disease, anticholinesterase
  drugs(neostigmine) , tetrahydroaminacrine,
  hexafluorenium, and metoclopramide.

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atypical pseudocholinesterase activity

• Succinylcholine-induced neuromuscular blockade
  can be significantly prolonged if the patient has
  an abnormal genetic variant pseudocholinesterase
• Dibucaine number Assess the presence of
  homozygous or heterozygous atypical
  cholinesterase variant, in patients who have low
  result of serum or plasma cholinesterase assay,
  and may be at risk of apnea when given
  succinylcholine muscle relaxant

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• Cisatracurium
• Non-depolarizing muscle relaxant, competitive
• Hofmann elimination
• Unlike atracurium, dose not cause histamine
  release
• Bradycardia, hypotension, flushing, Bronchospasm,
  Rash

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• Laudanosine
• Metabolite of Cisatracurium
• No neuromuscular blocking activity
• Contribution to seizures in ICU patients remained
  undetermined

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• Sweating
• sympathetic nerve stimulate
• increased secretion
• increased Ach
• I. cocaine and amphetamine
• II. Organophosphates
• III. physostigmine, pyridostigmine, neostigmine,
  and edrophonium.

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• Blushing
• sympathetic nerve stimulate
• histamine release
• I. Atropine and atropine-like agents
• II. Neuromuscular blocker
• Hypertensive
• ? sympathetic nerve stimulate

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management

• Residual anesthetic agent
• ?Discontinue anesthetic
• ?naloxone
• Residual muscle relaxant
• ?prolonged paralysis from succinylcholine
• caused by abnormal pseudocholinesterase
  should be treated with continued mechanical
  ventilation until muscle function returns to
  normal
• ?anticholinesterases drug( ex neostigmine,
  edrophonium, and pyridostigmine)

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• Intraoperative hyperventilation
• ? ABGhypocarbia
• ? adjust ventilation,
• ? postoprative hypoventilation
• Electrolyte , acid-base imbalance