Revise MBBS

Paper I — 2017 August (Supplementary) (2010 Scheme) — Q2

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Paper I
2017 August (Supplementary) (2010 Scheme) · 40 marks · 120 min

Question

Read the clinical problem and answer the following questions:

  • (a) After injection of succinylcholine i.v. to provide muscle relaxation, the patient developed 2 mark(s)
  • (b) What is the probable reason for this. 2 mark(s)
  • (c) Can edrophonium be given as antidote. If yes, why and if not why not. 2 mark(s)
  • (d) What is the line of treatment.
Q26 marksEssays

Answer

(a) What the patient developed

  • Prolonged apnoea/sustained neuromuscular paralysis (“scoline apnoea”) following the standard dose of succinylcholine

(b) Probable reason

  • Succinylcholine is normally rapidly hydrolysed by plasma pseudocholinesterase (butyrylcholinesterase), giving it a very short duration of action
  • Some individuals have a genetically determined atypical or deficient form of plasma pseudocholinesterase (autosomal recessive trait), which hydrolyses succinylcholine very slowly
  • In such patients, the depolarizing neuromuscular block is grossly prolonged, causing sustained paralysis of the respiratory muscles and prolonged apnoea

(c) Can edrophonium be given as an antidote?

  • No. Succinylcholine produces a depolarizing (Phase I) neuromuscular block. Anticholinesterases like edrophonium increase acetylcholine at the neuromuscular junction, which would further prolong/worsen a depolarizing block rather than reverse it (anticholinesterases only reverse non-depolarizing/competitive blockade)

(d) Line of treatment

  • Continue mechanical ventilation/assisted respiration and maintain sedation/anaesthesia until neuromuscular function recovers spontaneously
  • Do NOT give further muscle relaxants or anticholinesterases
  • Confirm diagnosis with a dibucaine number test and counsel the patient/family regarding the genetic trait for future anaesthetic exposures
  • Fresh frozen plasma (source of normal pseudocholinesterase) may be considered in severe/prolonged cases
  1. 1Cholinergic System

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