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Succinylcholine-induced hyperkalemia in a patient with mucositis secondary to chemotherapy
A H Al-Khafaji1, W E Dewhirst, C J Cornell
1Section of Critical Care Medicine, Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
Objective:
To report a case of fatal hyperkalemia owing to succinylcholine administration in a patient with mucositis secondary to chemotherapy.
Design:
Case report.
Setting:
Adult intensive care unit (ICU) at Dartmouth-Hitchcock Medical Center.
Patients:
One patient with mucositis secondary to chemotherapy.
Measurements And Main Results:
A 37-yr-old female with recently diagnosed acute myelogenous leukemia was admitted to the ICU with mental status changes and progressive dyspnea requiring intubation and mechanical ventilation. Before ICU admission, the patient had suffered from painful mucositis causing severe dysphagia and bleeding, which was thought to be the result of chemotherapy. By the 10th ICU day, the patient's respiratory and mental status improved and the patient was successfully extubated. However, 8 hrs after extubation, she gradually developed severe respiratory distress, requiring reintubation and mechanical ventilation. The patient was given 14 mg of etomidate and 100 mg of succinylcholine intravenously. Immediately after the intubation, she suffered cardiac arrest. Her serum potassium level was 13.1 mEq/L and HCO3- was 16 mEq/L. The resuscitation attempt was unsuccessful, and the patient was pronounced dead.
Conclusion:
Oral mucositis is a frequent and potentially severe complication of cancer chemotherapy. We believe that mucositis was a contributing factor to this case of fatal hyperkalemia after administration of succinylcholine, with a mechanism similar to that reported with thermal injury. Only nondepolarizing muscle relaxants should be used in patients who are at risk for mucositis. Mucositis should be added to the list of conditions in which succinylcholine is contraindicated.