Pseudo Cholinesterase

Blood

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Enzyme activity test.

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Pseudo Cholinesterase (Butyrylcholinesterase) Test Guide

Why is it done?
- Test Purpose: Pseudo cholinesterase (also called butyrylcholinesterase or plasma cholinesterase) is an enzyme found primarily in the blood plasma and liver that metabolizes certain medications and substances. This test measures the levels and activity of this enzyme.
- Primary Indications: Assessment of medication sensitivity, particularly to succinylcholine (a muscle relaxant used during anesthesia) and mivacurium; evaluation of liver function and disease; detection of genetic variants affecting drug metabolism; assessment of organophosphate or carbamate pesticide exposure; preoperative screening before anesthesia.
- Clinical Circumstances: Before surgical procedures requiring anesthesia; patients with personal or family history of prolonged paralysis after anesthesia; evaluation of unexplained liver dysfunction; suspected organophosphate poisoning; monitoring patients on certain medications; genetic screening for enzyme deficiency variants.
Normal Range
- Reference Ranges: Normal pseudo cholinesterase levels typically range from 200-550 units per liter (U/L) or 2.0-5.5 units per milliliter (U/mL), though normal ranges may vary by laboratory. Some laboratories report results as: Normal = 200-550 U/L; Borderline = 150-200 U/L; Low = <150 U/L.
- Units of Measurement: Units per liter (U/L), units per milliliter (U/mL), or nanomoles per minute per milliliter (nmol/min/mL). Results may also be reported as activity percentages (% activity) relative to normal.
- Interpretation Categories: Normal (200-550 U/L): Adequate enzyme levels for normal drug metabolism; low risk of medication sensitivity complications. Borderline Low (150-200 U/L): Reduced enzyme activity; increased sensitivity to certain medications; may require dose adjustments. Low (<150 U/L): Significantly reduced enzyme function; high risk of prolonged drug effects; requires careful medication management and anesthetic precautions. Genetic variants may show atypical patterns that correlate with specific enzyme deficiencies.
Interpretation
- High Results (>550 U/L): Indicates increased enzyme activity; generally not clinically significant; may be seen in pregnancy, obesity, or certain medications; suggests normal drug metabolism capacity; low risk for medication-related complications.
- Normal Results (200-550 U/L): Enzyme levels are adequate for normal metabolism of succinylcholine and other substrates; standard anesthetic protocols can be used safely; low risk of abnormal drug responses; suggests normal liver function.
- Low Results (<150 U/L): Indicates deficiency in pseudo cholinesterase enzyme activity; increased risk of prolonged paralysis from succinylcholine or mivacurium; may indicate liver disease, malnutrition, pregnancy, or genetic enzyme deficiency; requires modified anesthetic approach; contraindication for standard doses of muscle relaxants.
- Genetic Variants and Phenotype Testing: Dibucaine number test identifies genetic variants (atypical/silent variants) of the enzyme; results categorized as normal (dibucaine number 70-80%), heterozygous (dibucaine number 40-60%), or homozygous (dibucaine number 15-30%); determines whether patient has genetic resistance to succinylcholine metabolism.
- Factors Affecting Results: Liver disease decreases enzyme production; pregnancy and estrogen use lower levels; malnutrition and kidney disease reduce values; certain medications (oral contraceptives, corticosteroids) may decrease levels; organophosphate exposure can deplete enzyme activity; acute illness may temporarily lower results; genetic variants significantly alter enzyme function and drug metabolism capacity.
- Clinical Significance: Critical for anesthetic safety; identifies patients at risk of adverse reactions to specific muscle relaxants; aids in diagnosis of liver dysfunction; important for occupational health assessment; genetic information helps in family screening; results guide medication dosing and drug selection.
Associated Organs
- Primary Organs Involved: Liver (primary site of pseudo cholinesterase production and metabolism); plasma/blood (where enzyme circulates and functions); kidney (affects clearance and metabolism of enzyme substrates).
- Associated Medical Conditions: Cirrhosis and chronic liver disease; acute hepatitis; liver failure; nephrotic syndrome and kidney disease; severe malnutrition and cachexia; pregnancy complications; organophosphate or carbamate pesticide poisoning; genetic enzyme deficiency disorders; chronic kidney disease; myocardial infarction; certain cancers with liver involvement.
- Diseases Diagnosed or Monitored: Hereditary pseudo cholinesterase deficiency (atypical enzyme); acquired pseudo cholinesterase deficiency; acute organophosphate poisoning; liver cirrhosis; hepatic encephalopathy; end-stage renal disease; occupational pesticide exposure; acute myocardial infarction.
- Potential Complications from Abnormal Results: Prolonged apnea after succinylcholine administration requiring mechanical ventilation support; anaphylactic reactions if muscle relaxants not adjusted; respiratory failure due to inability to reverse paralysis; aspiration risk during prolonged paralysis; rhabdomyolysis complications; malignant hyperthermia in susceptible individuals; organophosphate poisoning leading to cholinergic crisis; progression of underlying liver disease.
Follow-up Tests
- Recommended Follow-up Tests: Dibucaine number test (genetic phenotype determination); DNA sequencing for BCHE gene mutations; liver function tests (AST, ALT, bilirubin, albumin); hepatitis panel if liver disease suspected; kidney function tests (creatinine, BUN); prothrombin time (PT/INR); albumin levels; prealbumin; viral hepatitis serology.
- Further Investigations Based on Results: If low levels: ultrasound or CT imaging of liver; hepatology consultation; consideration of liver biopsy; genetic counseling for inherited deficiency; occupational history and pesticide exposure assessment. If abnormal results before surgery: genetic testing confirmation; anesthesiology consultation; modified anesthetic plan; family screening for genetic variants.
- Monitoring Frequency: One-time genetic testing if hereditary deficiency suspected; repeat testing if liver disease is being treated (every 3-6 months during acute illness); periodic monitoring in chronic liver disease (every 6-12 months); pre-operative testing within 2 weeks of planned surgery; occupational monitoring annually for pesticide-exposed workers.
- Complementary Tests: Acetylcholinesterase (RBC cholinesterase) for organophosphate exposure; complete metabolic panel; coagulation studies; complete blood count; serum electrolytes; glucose levels; toxicology screening if poison exposure; tissue transaminase levels; alkaline phosphatase; gamma-glutamyl transferase (GGT).
Fasting Required?
- Fasting Status: No, fasting is NOT required for pseudo cholinesterase testing. The test can be performed in both fasting and non-fasting states without affecting result accuracy or interpretation.
- Patient Preparation Instructions: Patient can eat and drink normally before the test; no special dietary restrictions; continue regular meal schedule; stay adequately hydrated; wear loose-fitting clothing to facilitate blood draw; arrive at least 10-15 minutes early for appointment; bring insurance card and identification.
- Medications to Avoid: No medications need to be stopped or avoided specifically for this test; however, inform healthcare provider of all current medications as some may affect enzyme levels: oral contraceptives; corticosteroids; certain antibiotics; anticholinesterase medications (physostigmine, neostigmine); cholinergic agents; pesticide exposures. Continue all essential medications unless otherwise instructed by physician.
- Other Preparation Requirements: No vigorous exercise immediately before test; avoid significant stress if possible; report any recent illnesses or infections to phlebotomist; disclose recent surgeries or transfusions; inform technician of pregnancy or suspected pregnancy; provide occupational history if pesticide exposure possible; blood sample requires standard venipuncture collection into appropriate tube (usually SST or plasma tube); no special tube handling required; sample can be processed at room temperature.

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