Early Neurophysiological Monitoring of Train of Four Assists in the Detection of Pseudocholinesterase Deficiency

A craniotomy with cortical and subcortical mapping was planned for a 64-year-old male with a large right frontotemporal brain mass. Total intravenous anesthesia was performed, and 200 milligrams of succinylcholine was administered at induction. A train of four prior to head pinning (52 minutes after succinylcholine administration) revealed zero of four twitches in the left hand and foot. The patient did not regain spontaneous breathing despite discontinuation of infusions and the surgeon canceled the case at 108 minutes from induction. The patient was safely extubated at 270 minutes. Pseudocholinesterase deficiency was suspected, and labs revealed that the patient was outside of the normal range for pseudocholinesterase enzyme at 698 units/L with a dibucaine inhibition number of 40. The patient's procedure was rescheduled 2 days later, and neuromuscular blockade was avoided. The procedure went ahead as planned with successful mapping and monitoring. This case highlights the effect of pseudocholinesterase deficiency on neuromonitoring and the importance of running train of four early on to detect neuromuscular junction issues in high-risk procedures. In this case, the surgeon was able to avoid pinning and positioning the patient and rescheduled the procedure so that motor mapping, direct cortical motor evoked potentials, and transcranial motor evoked potentials could be successfully performed.