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 iv 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 iv 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 rhabdo-myolysis. 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.
Résumé
Cette observation décrit des arythmies potentiellement mortelles survenues chez deux enfants. L’induction de l’anesthésie générale est réalisée avec du thiopentone 5 mg · kg−1 chez le premier et de I’halothane chez le second avec succinylcholine 1,25 et 1,50 mg · kg−1 respectivement. Par la suite, apparaissent des tachyarythmies complexes avec hypotension dans le premier cas et de l’asystolie dans le deuxième malgré un traitement préalable à l’atropine dans les deux cas. Le premier patient est réanimé par intubation trachéale, oxygène à 100%, ventilation manuelle, administration de lidocaïne et de bicarbonate iv. Le second est intubé, ventilé manuellement, reçoit la réanimation cardiopulmonaire pendant 12 minutes et par la voie veineuse, du calcium, de l’épinéphrine et du bicarbonate en plus d’une défibrillation électrique. On n’administre pas de dantrolène aux patients. La récupération immédiate se produit sans incidents ni séquelles. L’investigation subséquente révèle dans les deux cas une dystrophie musculaire insoupçonnée de Duchenne chez le premier patient, et de Becker chez le second. On présume que les arrythmies observées sont causées par l’hyperkaliémie secondaire à la rhabdomyolyse induite par la succinylcholine. Après l’induction avec de la succinylcholine, si des arythmies menaçantes pour le vie des patients pédiatriques surviennent, le clinicien doit inclure dans le diagnostic différentiel une myopathie cachée et entreprendre, en plus des manoeuves de réanimation, un traitement agressif de l’hyperkaliémie.
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References
Rosenberg H, Gronert G. Intractable cardiac arrest in children given succinylcholine (Letter). Anesthesiology 1992; 77: 1054
Miller JD, Lee C. Muscle diseases.In: Katz J, Benumof JL, Kadis LB (Eds.). Anesthesia and Uncommon Diseases, 3rd ed., Philadelphia: WB Saunders 1990; 590–6.
Cobham IG, Davis HS. Anesthesia for muscular dystrophy patients. Anesth Analg 1964; 43: 22–9.
Richards WC. Anaesthesia and serum creatine phosphokinase levels in patients with Duchenne’s pseudohypertrophic muscular dystrophy. Anaesth Intensive Care 1972; 1: 150–3.
Genever EE. Suxamethonium-induced cardiac arrest in unsuspected pseudohypertrophic muscular dystrophy. Br J Anaesth 1971; 43: 984–6.
Walters G, Karpati G, Kaplan B. Post-anaesthetic augmentation of muscle damage as a presenting sign in three patients with Duchenne’s muscular dystrophy. Can J Neurol Sci 1977; 4: 228.
Seay AR, Ziter FA, Thompson JA. Cardiac arrest during induction of anesthesia in Duchenne’s muscular dystrophy. J Pediatr 1978; 93: 88–90.
Smith CL, Bush GH. Anaesthesia and progressive muscular dystrophy. Br J Anaesth 1985; 57: 1113–8.
Kepes ER, Martinez LR, Andrews IC, et al. Anesthetic problems in hereditary muscular abnormalities. N Y State J Med 1972; 72: 1051–3.
Miller Ed Jr.,Saunders DB, Rowlingson JC, Berry FA Jr.,Sussman MD, Epstein RM. Anesthesia-induced rhabdomyolysis in a patient with Duchenne’s muscular dystrophy. Anesthesiology 1978; 48: 146–8.
Linter SPK, Thomas PR, Withington PS, Hall MG. Suxamethonium associated hypertoxicity and cardiac arrest in unsuspected pseudohypertrophic muscular dystrophy. Br J Anaesth 1982; 54: 1331–2.
Marks WA, Bodensteiner JB, Reitz RD. Cardiac arrest during anesthetic induction in a child with Becker type muscular dystrophy (Letter). J Child Neurol 1987; 2: 160–1.
Reiffel JA, Gambino SR, McCarthy DM, Leahey EB Jr. Direct current cardioversion. Effect on creatine kinase, lactic dehydrogenase and myocardial isoenzymes. JAMA 1978; 239: 122–4.
Ehsani A, Ewy GA, Sobel BE. Effects of electrical countershock on serum creatine phosphokinase (CPK) isoenzyme activity. Am J Cardiol 1976; 37: 12–8.
Tetzlaff JE, O’Hara JF Jr., Walsh MT. Potassium and anaesthesia. Can J Anaesth 1993; 40: 227–46.
Lundy EF, Kuhn JE, Kwon JM, Zelenock GB, D’Alecy LG. Infusion of five percent dextrose increases mortality and morbidity following six minutes of cardiac arrest in resuscitated dogs. Journal of Critical Care 1987; 2: 4–14.
Nakakimura K, Fleischer JE, Drummond JC, et al. Glucose administration before cardiac arrest worsens neurologic outcome in cats. Anesthesiology 1990; 72: 1005–11.
Berry FA. Succinylcholine and Duchenne muscular dystrophy (Letter). Anesthesiology 1993; 79: 401.
Allen GC. VIth international workshop on malignant hyperthermia (MH). Can J Anaesth 1993; 40: 284–5.
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Sullivan, M., Thompson, W.K. & Hill, G.D. Succinylcholine-induced cardiac arrest in children with undiagnosed myopathy. Can J Anaesth 41, 497–501 (1994). https://doi.org/10.1007/BF03011544
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DOI: https://doi.org/10.1007/BF03011544