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Larsen MH, Rosenkrantz O, Rasmussen BS, Nielsen MKK, Linnet K, Rasmussen LS, Isbye D. Detection of cocaine 24 h after administration before nasotracheal intubation. Acta Anaesthesiol Scand 2024. [PMID: 38932490 DOI: 10.1111/aas.14475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/13/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Cocaine may be applied to decongest the nasal mucosa before nasotracheal intubation, but patients risk a criminal offence if cocaine is detected when patients drive a car shortly after surgery. We aimed to evaluate whether benzoylecgonine levels in saliva exceeded the cut-off point 24 h after administration in patients undergoing nasotracheal intubation and whether cocaine would be detectable above the Danish legal fixed limit in blood samples 1 and 24 h after surgery. METHODS We conducted a prospective study following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. We included patients scheduled for surgery under general anaesthesia with nasotracheal intubation. They received 80 mg cocaine as a nasal spray 5 min before induction and nasotracheal intubation. The primary outcome was a dichotomous assessment of benzoylecgonine levels in saliva samples measured 24 h after administration of nasal cocaine with a cut-off limit of 200 ng/mL. Secondary outcomes were dichotomous assessments of cocaine in whole blood samples measured 1 and 24 h after administration of nasal cocaine with a cut-off limit of 0.01 mg/kg. RESULTS Overall, 70 patients had valid saliva samples and 75 had valid blood samples 24 h after cocaine administration. Benzoylecgonine in saliva was traceable above the cut-off in 9/70 patients (13%; CI95%: 6% to 23%), and cocaine in blood was detected above the cut-off in 2/75 patients (3%; CI95%: 0.3% to 9%). CONCLUSION We found benzoylecgonine traceable in saliva in 13% of patients and cocaine traceable in blood in 3% of patients 24 h after administration of 80 mg nasal cocaine. Patients should be informed when receiving cocaine and advised not to drive for at least 24 h.
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Affiliation(s)
- Mo H Larsen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Oscar Rosenkrantz
- Department of Clinical Epidemiology, Aarhus University & Aarhus University Hospital, Aarhus, Denmark
| | - Brian S Rasmussen
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie K K Nielsen
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristian Linnet
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Dan Isbye
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Robles A, Michael M, McCallum R. Pseudocholinesterase Deficiency: What the Proceduralist Needs to Know. Am J Med Sci 2019; 357:263-267. [DOI: 10.1016/j.amjms.2018.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
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3
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Molloy LS, Ledowski T. Mivacurium: a Review. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tropical medicine and anaesthesia 1. BJA Educ 2018; 18:35-40. [DOI: 10.1016/j.bjae.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 11/23/2022] Open
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LaRocca CJ, Beilman GJ, Birch M. A Case of Pseudocholinesterase Deficiency Resulting From Malnutrition. ACTA ACUST UNITED AC 2016; 7:112-4. [PMID: 27467903 DOI: 10.1213/xaa.0000000000000362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pseudocholinesterase deficiencies occur because of both genetic and acquired factors. We present the case of a patient with a history of bariatric surgery and severe malnutrition who subsequently developed prolonged neuromuscular blockade after succinylcholine administration. She had markedly decreased pseudocholinesterase levels at the time of the incident, but her motor function returned to normal with supportive care. After aggressive nutritional support over multiple weeks, her pseudocholinesterase levels drastically improved. For those patients in a poor nutritional state who experience an unexpected episode of apnea or prolonged neuromuscular blockade, practitioners must always consider malnutrition-induced pseudocholinesterase deficiency as a possible etiology.
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Affiliation(s)
- Christopher J LaRocca
- From the Departments of *Surgery and †Anesthesiology, University of Minnesota, Minneapolis, Minnesota
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Abdullayev R, Küçükebe ÖB, Kaya R, Çelik B, Kuşderci H, Duran M, Uludağ Ö, Öterkuş M, Buyrukcan A, Sabuncu Ü, Arpacı A. Pseudocholinesterase Enzyme Deficiency in Adıyaman City Area. Turk J Anaesthesiol Reanim 2016; 43:381-6. [PMID: 27366534 DOI: 10.5152/tjar.2015.32848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 04/06/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Pseudocholinesterase (PChE) is an enzyme responsible for the hydrolysis of succinylcholine. In case of its deficiency, the effect of succinylcholine that is approximately 5-10 min is prolonged up to few hours. The use of succinylcholine has been declined recently. However, it is still actively used in some special conditions and in developing countries. In this study, incidence of PChE enzyme deficiency around Adiyaman city was investigated and presented with the literature review. METHODS After obtaining an approval from the investigational board of our hospital (Adiyaman University Medical School, Biomedical Research Ethics Board, 30.12.2012, Nr: B.30.2.ADY.0.20.00-600/51), patients undergoing any elective operation under general anaesthesia in the Adiyaman University Medical School Hospital between March and December 2013 were recruited for the study. After obtaining the patients' written consents, blood PChE, alanine aminotransferase (ALT), aspartate aminotransferase (AST), urea, creatinine, international normalisation ratio (INR) and activated partial thromboplastin time (aPTT) values of the patients were analysed. Possible association of the PChE deficiency with other values was also investigated. The normal value of PChE was taken as 4260-11250 for females aged 16-40 years and 5320-12920 U L(-1) for other patients. RESULTS The study was completed with 964 patients, 702 (72.8%) of whom were females. PChE enzyme levels were under the normal in 7.2% of the patients. There were no correlation between patient group, ALT, INR, aPTT and creatinine elevation with PChE deficiency (p>0.05), whereas AST and urea level elevation was significantly associated with PChE deficiency (p<0.05). The risk of PChE deficiency was 4.5 and 9 times higher in the patients with the elevation of AST and urea levels, respectively. CONCLUSION Pathological elevations of AST and urea that are a part of normal pre-operative biochemical analysis of blood will indicate the possible deficiency of PChE enzyme.
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Affiliation(s)
- Ruslan Abdullayev
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Ömer Burak Küçükebe
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Recai Kaya
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Bülent Çelik
- Department of Biostatistics, Gazi University Faculty of Science, Ankara, Turkey
| | - Hatice Kuşderci
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Mehmet Duran
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Öznur Uludağ
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Mesut Öterkuş
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Aysel Buyrukcan
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Ülkü Sabuncu
- Clinic of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Abdullah Arpacı
- Clinic of Biochemistry, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
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Nagpal N, Chowdhary S, Bhattacharyya R, Banerjee D. A color-reaction-based rapid screening for null activity of butyrylcholinesterase: A step toward point-of-care screening for succinylcholine apnea. Biotechnol Appl Biochem 2015; 62:154-63. [DOI: 10.1002/bab.1252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/21/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Nitish Nagpal
- Department of Experimental Medicine and Biotechnology; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Sheemona Chowdhary
- Department of Experimental Medicine and Biotechnology; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Rajasri Bhattacharyya
- Department of Biotechnology; Maharishi Markandeshwar University, Mullana; Ambala Haryana India
| | - Dibyajyoti Banerjee
- Department of Experimental Medicine and Biotechnology; Postgraduate Institute of Medical Education and Research; Chandigarh India
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Pollach G, Mndolo S. Teaching corner: A new method of measuring mid upper arm circumference at Queen Elizabeth Central hospital, Blantyre, Malawi. Malawi Med J 2014; 23:20-1. [PMID: 23638252 DOI: 10.4314/mmj.v23i1.67678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- G Pollach
- Department of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre
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Geyer BC, Larrimore KE, Kilbourne J, Kannan L, Mor TS. Reversal of succinylcholine induced apnea with an organophosphate scavenging recombinant butyrylcholinesterase. PLoS One 2013; 8:e59159. [PMID: 23536865 PMCID: PMC3594170 DOI: 10.1371/journal.pone.0059159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 02/12/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Concerns about the safety of paralytics such as succinylcholine to facilitate endotracheal intubation limit their use in prehospital and emergency department settings. The ability to rapidly reverse paralysis and restore respiratory drive would increase the safety margin of an agent, thus permitting the pursuit of alternative intubation strategies. In particular, patients who carry genetic or acquired deficiency of butyrylcholinesterase, the serum enzyme responsible for succinylcholine hydrolysis, are susceptible to succinylcholine-induced apnea, which manifests as paralysis, lasting hours beyond the normally brief half-life of succinylcholine. We hypothesized that intravenous administration of plant-derived recombinant BChE, which also prevents mortality in nerve agent poisoning, would rapidly reverse the effects of succinylcholine. METHODS Recombinant butyrylcholinesterase was produced in transgenic plants and purified. Further analysis involved murine and guinea pig models of succinylcholine toxicity. Animals were treated with lethal and sublethal doses of succinylcholine followed by administration of butyrylcholinesterase or vehicle. In both animal models vital signs and overall survival at specified intervals post succinylcholine administration were assessed. RESULTS Purified plant-derived recombinant human butyrylcholinesterase can hydrolyze succinylcholine in vitro. Challenge of mice with an LD100 of succinylcholine followed by BChE administration resulted in complete prevention of respiratory inhibition and concomitant mortality. Furthermore, experiments in symptomatic guinea pigs demonstrated extremely rapid succinylcholine detoxification with complete amelioration of symptoms and no apparent complications. CONCLUSIONS Recombinant plant-derived butyrylcholinesterase was capable of counteracting and reversing apnea in two complementary models of lethal succinylcholine toxicity, completely preventing mortality. This study of a protein antidote validates the feasibility of protection and treatment of overdose from succinylcholine as well as other biologically active butyrylcholinesterase substrates.
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Affiliation(s)
- Brian C. Geyer
- School of Life Sciences and The Biodesign Institute, Arizona State University, Tempe, Arizona, United States of America
| | - Katherine E. Larrimore
- School of Life Sciences and The Biodesign Institute, Arizona State University, Tempe, Arizona, United States of America
| | - Jacquelyn Kilbourne
- School of Life Sciences and The Biodesign Institute, Arizona State University, Tempe, Arizona, United States of America
| | - Latha Kannan
- School of Life Sciences and The Biodesign Institute, Arizona State University, Tempe, Arizona, United States of America
| | - Tsafrir S. Mor
- School of Life Sciences and The Biodesign Institute, Arizona State University, Tempe, Arizona, United States of America
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Han TH, Martyn JAJ. Neuromuscular pharmacodynamics of mivacurium in adults with major burns. Br J Anaesth 2011; 106:675-9. [PMID: 21354998 DOI: 10.1093/bja/aer023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Mivacurium is metabolized by plasma pseudocholinesterase (PChE) enzyme, which is decreased in burns. We tested whether the decreased metabolism of mivacurium due to decreased PChE activity can overcome the pharmacodynamic resistance to non-depolarizing relaxants previously seen in major burns. METHODS Thirty adults with 35 (13)% [mean (sd)] burn were studied at 5-91 post-burn days and 31 non-burns matched controls. Mivacurium 0.2 mg kg(-1) was administered as a single bolus. Neuromuscular block was monitored with single-twitch response using TOF-Watch™. Onset time (drug administration to maximal twitch suppression) and spontaneous recovery were measured. RESULTS Onset time was significantly prolonged in burns when compared with non-burns (115 vs 90 s; P<0.001). The PChE levels were lower in burns [1432 (916) vs 2866 (731) IU litre(-1); P<0.001] and the neuromuscular recovery to 50% of baseline twitch height was prolonged in burns (41 vs 26 min; P<0.001). There was a significant correlation between PChE and time to 50% recovery for the whole group together (r=-0.6; P<0.001). The dibucaine numbers were not different. CONCLUSIONS The prolonged onset time suggests resistance to neuromuscular effects, whereas the prolonged recovery suggests increased sensitivity. This divergent response can be explained by qualitative and quantitative changes in acetylcholine receptor expression causing resistance and decreased PChE activity causing sensitivity. Despite using a relatively large dose of mivacurium (0.2 mg kg(-1)) in the presence of decreased PChE levels, this did not overcome the resistance resulting from up-regulated receptors.
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Affiliation(s)
- T-H Han
- Department of Anesthesia #6505-3 JCP, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Jaramillo KS, Scruth E, Cheng E. Prolonged paralysis and apnea after receiving a neuromuscular blocking agent: what nurses should know. Am J Crit Care 2009; 18:592, 588-91. [PMID: 19880962 DOI: 10.4037/ajcc2009572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
After receiving mivacurium, a short-acting neuromuscular blocking agent used for intubation before surgery, a patient experienced prolonged paralysis and prolonged apnea that required ventilator support. Although this complication is rare, all critical care nurses should be aware of it so they can be competent in managing and providing holistic and comprehensive nursing care to the patient and the patient's family. Although this complication has been documented in the anesthesia literature, it has received little mention in critical care nursing journals.
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Affiliation(s)
- Kathryn S. Jaramillo
- Kathryn S. Jaramillo is a graduate student in the cardiovascular genomics clinical nurse specialist program in the School of Nursing, University of California, San Francisco. Elizabeth Scruth is a critical care clinical nurse specialist in the Department of Educational Services and Eugene Cheng is chief of intensivists in the Department of Anesthesia at Kaiser Permanente Medical Center, San Jose, California
| | - Elizabeth Scruth
- Kathryn S. Jaramillo is a graduate student in the cardiovascular genomics clinical nurse specialist program in the School of Nursing, University of California, San Francisco. Elizabeth Scruth is a critical care clinical nurse specialist in the Department of Educational Services and Eugene Cheng is chief of intensivists in the Department of Anesthesia at Kaiser Permanente Medical Center, San Jose, California
| | - Eugene Cheng
- Kathryn S. Jaramillo is a graduate student in the cardiovascular genomics clinical nurse specialist program in the School of Nursing, University of California, San Francisco. Elizabeth Scruth is a critical care clinical nurse specialist in the Department of Educational Services and Eugene Cheng is chief of intensivists in the Department of Anesthesia at Kaiser Permanente Medical Center, San Jose, California
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Abstract
A 39-year-old patient with unrecognized atypical pseudocholinesterase was given succinylcholine during the rapid-sequence induction process and subsequently had a prolonged neuromuscular blockade. The patient was reassured, sedated, and ventilated in the postanesthesia care unit (PACU). The primary nursing interventions included airway clearance, communication, comfort, and patient education. Several important learning experiences occurred for the nurses in the PACU related to identifying possible causes, ordering the pseudocholinesterase and dibucaine inhibition test, interpreting the results, and developing and delivering patient education. This article will provide the perianesthesia nurse with the fundamental understanding of the physiology, laboratory diagnostic interpretation, and nursing interventions needed to deliver evidence-based, high-quality care to patients diagnosed with pseudocholinesterase deficiency.
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Whyte AJ, Wang HE. Prehospital Airway Management Complicated by Reported Pseudocholinesterase Deficiency. PREHOSP EMERG CARE 2007; 11:343-5. [PMID: 17613911 DOI: 10.1080/10903120701347984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with pseudocholinesterase deficiency can experience prolonged neuromuscular blockade if given succinylcholine or certain other drugs. We describe the case of a patient with a reported pseudocholinesterase deficiency requiring emergent prehospital airway management. Knowledge of the reported condition influenced airway management decisions.
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Affiliation(s)
- Allyson J Whyte
- Department of Emergency Medicine, University of Pittsburgh, Pennsylvania 15213, USA
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Bensaid A, Miloudi Y, El Harrar N. [Prolonged neuromuscular block induced by mivacurium]. ACTA ACUST UNITED AC 2005; 25:462-3. [PMID: 16377125 DOI: 10.1016/j.annfar.2005.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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