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Succinylcholine-induced cardiac arrest in children with undiagnosed myopathy
M Sullivan1, W K Thompson, G D Hill
1Department of Anaesthesia, York County Hospital, Newmarket, Ontario.
Insights
Sudden, severe arrhythmias in children during anesthesia induction, linked to succinylcholine, may signal underlying muscular dystrophy. Prompt recognition and aggressive hyperkalemia management are crucial for patient survival.
Area of Science:
- Pediatric Anesthesiology
- Neuromuscular Disorders
- Cardiology
Background:
- Succinylcholine is commonly used for rapid sequence induction in pediatric anesthesia.
- Life-threatening arrhythmias are rare but serious complications during anesthesia induction.
- Undiagnosed neuromuscular disorders can predispose patients to adverse events.
Observation:
- Two pediatric patients developed severe arrhythmias (tachyarrhythmia with hypotension, asystole) after succinylcholine administration.
- Arrhythmias occurred despite pre-treatment with atropine.
- Both patients were successfully resuscitated with advanced life support measures.
Findings:
- Subsequent investigations revealed undiagnosed muscular dystrophies (Duchenne and Becker) in both patients.
- The arrhythmias were attributed to hyperkalemia secondary to succinylcholine-induced rhabdomyolysis.
- Neither patient received dantrolene, and both recovered without neurological deficits.
Implications:
- Occult myopathy should be considered in the differential diagnosis for pediatric patients experiencing sudden, life-threatening arrhythmias post-succinylcholine.
- Aggressive management of hyperkalemia is essential in these cases, alongside standard resuscitation.
- This highlights the importance of considering neuromuscular disease in unexplained perioperative cardiac events.
Abstract:
Two paediatric cases are reported in which unexpected, life-threatening arrhythmias occurred. Routine induction of general anaesthesia with thiopentone, 5 mg.kg-1, in one and with halothane in the other, and succinylcholine 1.25-1.5 mg.kg-1 i.v. was followed by the development of wide complex tachyarrhythmia with hypotension in the first case and asystole in the second case despite pre-treatment with atropine in both cases. The first patient was resuscitated with tracheal intubation, 100% oxygen, manual ventilation and intravenous lidocaine and bicarbonate. The second patient required intubation, manual ventilation, 12 min of CPR and i.v. calcium, epinephrine and bicarbonate, as well as DC counter shock. Neither patient received dantrolene. Early recovery in both patients was uneventful with no neurological sequelae. Subsequent investigations revealed the presence of a dystrophin-deficient muscular dystrophy, Duchenne muscular dystrophy and Becker muscular dystrophy respectively, previously unsuspected, in both patients. The aetiology of the observed arrhythmias was presumably hyperkalaemia, secondary to succinylcholine-induced rhabdomyolysis. It is suggested that when faced with sudden, life-threatening arrhythmias following succinylcholine at induction of anaesthesia for paediatric patients, clinicians should include occult myopathy in the differential diagnosis, and thus consider the aggressive management of hyperkalaemia in addition to basic resuscitative efforts.