A Case of Succinylcholine-Induced Hyperkalemia
(Authored by Dr. Merrill Tarr, Department of Molecular and Integrative Physiology,
University of Kansas Medical Center)
Case History: The following case history relates to a patient who was treated at Saint
Luke’s Hospital, Kansas City, Missouri and is condensed from the following paper
(Matthews JM. Succinylcholine-Induced Hyperkalemia and Rhabdomyolysis in a Patient
with Necrotizing Pancreatitis. Anesth Analg 2000;91:1552–4.
“A 54-yr-old, 114 kg man presented to the hospital after the abrupt onset of abdominal
pain accompanied by severe nausea and vomiting. A presumptive diagnosis of
pancreatitis was confirmed by increased amylase and lipase. Abdominal computed
tomography showed severe inflammation of the pancreas with probable necrosis. The
pancreatitis was attributed to the presence of gallstones.” .... “On the fifth day of
admission, respiratory failure necessitated orotracheal intubation and mechanical
ventilation. Midazolam infusion provided adequate conditions for ventilatory support,
and nondepolarizing muscle relaxants were not administered. Ventilatory support
continued for 1 wk before it was successfully terminated and the trachea extubated. On
the 35th day of hospitalization, the patient again developed respiratory failure
associated with large bilateral pleural effusions. Anesthesia personnel were summoned
to the intensive care unit (ICU) to perform an endotracheal intubation. Initial assessment
revealed an obese man in obvious respiratory distress. Topical local anesthetic was
applied to the oropharynx, and direct laryngoscopy was attempted. This was
unsuccessful because of the patient’s confusion and inability to cooperate. Midazolam
was titrated IV to a total dose of 8 mg without appreciable sedative effect. Because of
the patient’s vigorous resistance to the procedure, his large body habitus with
associated broad neck, his tolerance to standard sedatives, and the perceived need for
expedient intubation, the decision was made to facilitate laryngoscopy with thiopental
and succinylcholine. After breathing oxygen, thiopental 200 mg and succinylcholine 80
mg were given IV as cricoid pressure was applied. Successful endotracheal intubation
was accomplished within 60 s, and the oxygen saturation increased to 96%.
Approximately 2 min after intubation, the previously normal cardiac rhythm changed to a
wide complex bradycardia. A presumptive diagnosis of hyperkalemia was made, and IV
calcium chloride was given. The electrocardiographic complexes continued to widen to
a sine-wave pattern followed by asystole. Cardiopulmonary resuscitation was
performed. Epinephrine, sodium bicarbonate, and insulin/glucose were administered,
and a blood sample was obtained to determine serum potassium. After 12 min of
cardiopulmonary resuscitation, a narrow complex tachycardia resumed that was
associated with good peripheral pulses. Defibrillation was not performed. Initial
potassium level obtained during cardiopulmonary resuscitation was 9.8 mEq/L.
Approximately 10 min after restoration of cardiac rhythm, the serum potassium had
returned to a normal level of 4.1 mEq/L.” The patient died on the 41st day after
admission due to rhabdomyolysis-induced kidney failure.
