Heterozygous Atypical Cholinesterase: Management During ECT

Area of Science:

• Anesthesiology
• Pharmacology
• Neurology

Background:

• Electroconvulsive therapy (ECT) is a medical treatment most often used for patients with severe major depression or bipolar disorder that has not responded to other treatments.
• Succinylcholine is a common muscle relaxant used during ECT to facilitate intubation and reduce the force of muscle contractions during the seizure.
• Prolonged apnea, or cessation of breathing, can occur if a patient has an atypical form of cholinesterase, an enzyme that metabolizes succinylcholine.

Purpose of the Study:

• To report a case of prolonged apnea during electroconvulsive therapy (ECT) in a patient with suspected atypical cholinesterase.
• To describe the successful management of subsequent ECT sessions with a modified drug dosage.

Main Methods:

• A 70-year-old female patient undergoing ECT experienced prolonged apnea after administration of succinylcholine.
• Cholinesterase deficiency was suspected based on the duration of apnea.
• Subsequent ECT sessions were performed using a reduced dose of succinylcholine.

Main Results:

• The patient developed prolonged apnea following the initial ECT administration with standard succinylcholine dosage.
• The suspected diagnosis of heterozygous atypical cholinesterase was supported by the prolonged apnea.
• No recurrence of prolonged apnea was observed during subsequent ECT sessions with the reduced succinylcholine dose.

Conclusions:

• Patients undergoing ECT with succinylcholine may have atypical cholinesterase, leading to prolonged apnea.
• Careful dose adjustment of succinylcholine is crucial for patients with suspected or confirmed atypical cholinesterase to ensure safe ECT administration.
• This case highlights the importance of recognizing and managing pseudocholinesterase deficiency in the context of ECT.