Three strikes and you're out: unanticipated hyperkalaemic cardiac arrest following rapid sequence intubation.
The report is unique given the fact that the patient had already two uneventful exposures to this drug in similar doses within 10 days of the catastrophic exposure, with no anticipated risk. Suxamethonium induced hyperkalaemic cardiac arrests have been described in critically ill patients mostly with length of stay more than 17 days (1). The risk has been attributed to immobility, sepsis and critical illness polyneuropathy/myopathy (CIP/CIM). In our opinion the patient was not significantly immobilised to cause a concern. The effect of sepsis and immobility are difficult to delineate. However, we are aware of at least three studies which suggest that sepsis as such is not an independent risk factor (2-4). Of patients admitted to the intensive care unit for at least seven days, 49 to 77% are known to acquire CIP/CIM (5). Although the patient described had unremarkable neurological examination, we cannot exclude subclinical CIP/CIM. A final consideration is the potential influence of repeated exposure to suxamethonium, however we are not aware of any direct action of suxamethonium upon acetylcholine receptor regulation.
As learned from this case, the risks for suxamethonium-associated hyperkalaemia are not only prevalent in intensive care unit population, but more importantly can be difficult to identify, define and quantify. This case report may add weight to the opinion that suxamethonium is an 'obsolete' drug in the intensive care unit (6). However, the authors' experiential belief is that suxamethonium still results in the most rapid onset of optimal conditions for direct laryngoscopy and its place in rapid sequence induction can still be justified. Nonetheless, caution should be exercised in its use in critically ill patients with unresolved sepsis and potentially those with recent prior exposure to the drug.
Bedford Park, South Australia
(1.) Church H, Sinclair S, Oelofse T. Suxamethonium in the intensive care unit: "Fool me once, shame on you; fool me twice, shame on me". Intensive Care Med 2008; 34:208-209.
(2.) Soodan A, Kaul TK, Singh A, Bajwa S. The effect of succinylcholine on serum potassium levels in patients with intra-abdominal infection. Indian J Anaesth 2003; 47:105-110.
(3.) Fink H, Luppa P, Mayer B, Rosenbrock H, Metzger J, Martyn JAJ et al. Systemic inflammation leads to resistance to atracurium without increasing membrane expression of acetylcholine receptors. Anesthesiology 2003; 98:82-88.
(4.) Hinohara H, Morita T, Okano N, Kunimoto F, Goto F. Chronic intraperitoneal endotoxin treatment in rats induces resistance to d-tubocurarine, but does not produce up-regulation of acetylcholine receptors. Acta Anaesthesiol Scand 2003; 47:335-341.
(5.) Coakley JH, Nagendran K, Yarwood GD, Honavar M, Hinds CJ. Patterns of neurophysiological abnormality in prolonged critical illness. Intensive Care Med 1998; 24:801-807.
(6.) Booij LH. Is succinylcholine appropriate or obsolete in the intensive care unit? Crit Care 2001; 5:245-246.
|Printer friendly Cite/link Email Feedback|
|Author:||Prakash, S.; Gallucciu, S.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Letter to the editor|
|Date:||Jan 1, 2012|
|Previous Article:||Target controlled infusion pump failure due to worn drive nut.|
|Next Article:||Modification of Diamedica drawover anaesthetic equipment to facilitate introduction to an Australian teaching hospital.|