Possible Pseudocholinesterase Deficiency in an Acutely Ill Patient with Prolonged Neuromuscular Blockade

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Butyrylcholinesterase (BChE), also known as pseudocholinesterase, is a liver-derived plasma enzyme that rapidly metabolizes succinylcholine (SCh). SCh, a short-acting neuromuscular blocker used for rapid sequence intubation, typically induces paralysis within 45 seconds and lasts 10-15 minutes at standard doses (1-1.5 mg/kg). BChE deficiency, inherited or acquired, reduces enzyme activity and prolongs SCh action, increasing the risk of extended paralysis. Inherited forms result from gene variants; homozygous types markedly prolong paralysis, while heterozygous types cause milder effects. Acquired deficiency has multiple causes. Although neither heterozygous variants nor acquired deficiency alone significantly lower BChE, their coexistence can produce clinically significant reduction. This case describes complications in a patient with possible combined BChE and acquired deficiencies.

The patient is a 59-year-old male with chronic pancreatitis complicated by pseudocyst formation and chronic alcohol use who presented with abdominal pain radiating to the back. Imaging raised concern for pancreatic malignancy with hepatic and adrenal metastases, prompting transfer to a tertiary care center. During hospitalization, he underwent multiple gastroduodenal artery embolizations, two exploratory laparotomies, and esophagogastroduodenoscopy (EGD), requiring MICU and SICU care. An acute decline in hemoglobin from 9.8 to 7.6 g/dL raised concern for GI bleeding, and repeat EGD was planned. Pre-procedure laboratory values included creatinine 1.7, AST 34, ALT 36, ALP 105, and albumin 2.1. Liver biopsy showed no malignancy but revealed extensive necrosis. Pre-anesthesia evaluation demonstrated a hemodynamically stable patient. Given his significant comorbidities, he was classified as ASA physical status IV. He had no prior anesthetic complications, including previous exposure to SCh.

Prolonged neuromuscular blockade with agents such as succinylcholine should prompt anesthesia providers to consider BChE deficiency, even after prior uneventful anesthetic encounters. This assessment should include the potential synergistic effects of inherited variants and critical illness on BChE activity, which may result in clinically significant prolonged paralysis. Neuromuscular monitoring, including train-of-four stimulation, enhances vigilance and reduces risk. Clear documentation and communication further mitigate risk during future anesthetic care.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 1976

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