Suxx and Asystole

[chocomorsel]

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Think it happened to me today. 65y/o came in for a closed hip reduction. Rheumatoid and obesity are her only health issues. Wasn't gonna tube at first but surgeon had such a difficult time popping in that we then gave 60mg suxx and continued with mask then tubed when we had to transfer from stretcher to OR bed. Anyway tubed successfully without issues. Went out to check on CRNA in next room.

Came back about 5 minutes after initial dose of suxx and CRNA asks, "can someone check for a pulse"? I do and nothing. No pulse ox, no ETCO2, asystole. I start chest compressions and call a code. Patient came back within a few seconds. Maybe fifteen. She'd received a second dose of 40 mg.

Could it have been the suxx? Manipulation of abdomen causing a vagal response? Both? Anyway did fine, kept overnight in tele, but that was scary. I have done this many times before, never had this issue cuz it's so rare. What dose does it become an issue? She got about 1.1mg/kg total at least 5 minutes apart.

Choco

 

[Doctor4Life1769]

Why was a second dose administered? Curious.

Found this article:

http://www.anesthesia-analgesia.org/content/57/1/135.full.pdf

Suggests arrhythmia and bradycardia may occur after repeat dose of sux. Potential for brief/transient asystole following repeat dose.

Perhaps combination of sux vagotonic effect, fentanyl (if administered), trauma in an elderly pt all played a role?

Again, not sure why repeat sux dose was given rather than a non-depolarizing agent.

 

[G0S2]

Tube in. Move pt and tube tickles carina causing vagal response. Seen it with deep suctioning ICU pts.

 

[chocomorsel]

Why was a second dose administered? Curious.

Found this article:

http://www.anesthesia-analgesia.org/content/57/1/135.full.pdf

Suggests arrhythmia and bradycardia may occur after repeat dose of sux. Potential for brief/transient asystole following repeat dose.

Perhaps combination of sux vagotonic effect, fentanyl (if administered), trauma in an elderly pt all played a role?

Again, not sure why repeat sux dose was given rather than a non-depolarizing agent.

Short case. Avoid having to possibly wait and reverse the patient. Will be giving atropine next time or roc if needed. Yeah, found that article earlier too.

 

[dhb]

Brady on the second dose of sux imho

 

[stonemd]

2nd dose sux classic cause if a systole, but I have seen it with a single dose. Defasiculating dose of curare or NDMR can decrease incidence of arrythmias from sux, and anticholinergic will prevent bradycardias.

 

[soonerfrog]

Had a similar event years ago. Very benign pt, maybe some controlled HTN with low ACEI. Anywho, standard induction (with SCh), reach back for laryngoscope, I can hear the monitor Peter out in about 4 beats. I do an "extra generous DL" with MAC 3, pulse ox and ECG come back to life, all proceeds without incident or sequelae. Good times.

 

[sevoflurane]

Had a similar event years ago. Very benign pt, maybe some controlled HTN with low ACEI. Anywho, standard induction (with SCh), reach back for laryngoscope, I can hear the monitor Peter out in about 4 beats. I do an "extra generous DL" with MAC 3, pulse ox and ECG come back to life, all proceeds without incident or sequelae. Good times.

Had a partner go through the same thing a couple years ago. She got .4mg of atropine.

 

[Idiopathic]

Theres a reason why its in the literature and still dogmatically taught 🙄 in residency, this study is old though

Miller Chapter 33

The most common causes of anesthesia- related cardiac arrest were inadequate ventilation (27 patients), asystole after succinylcholine (23 patients), and postinduction hypotension (14 patients). The incidence of cardiac arrest increased with increasing severity of comorbid disease, as assessed by the ASA physical status classification. In evaluating the inci- dence of intraoperative cardiac arrest over time, there was a con- siderable decline between 1967 and 1984, coincident with the increased number of anesthesia specialists employed at the clinic.

 

[Planktonmd]

I do all these closed reductions with Propofol+ Sux and mask with almost 100% success.
If the "surgeon" can't do it then we go to plan B: Tube + Rocuronium.

 

[jwk]

Came back about 5 minutes after initial dose of suxx and CRNA asks, "can someone check for a pulse"? I do and nothing. No pulse ox, no ETCO2, asystole. I start chest compressions and call a code. Patient came back within a few seconds. Maybe fifteen. She'd received a second dose of 40 mg.

Brady/asystole after 2nd dose of sux is well recognized even though pretty rare. Brady/asystole after the first dose of sux is the primary reason it's generally contraindicated in pediatric patients.

On another note - I assume when you say "no pulse ox" you mean there was no pulsatile waveform, "no EtCO2" means there was no exhaled CO2 showing on the monitor, and "asystole" was actually the rhythm showing on the EKG. Did this happen as you entered the room, or had it already happened before you got back in the room and "someone" is trying to figure out what is going on?

 

[sevoflurane]

Although some of the younger pedi/neo kids can be big vagal nerves waiting to fire off, I still don't practice as if sux is contraindicated in the pedi population and use it if it's necessary (big abdominal distentions/NEC, etc).

Man, I've seen some sick looking <1 y/o's with big ass bellies coming to the OR for an ex-lap. Sux's IM indications carry a significant weight in the little ones when things get a little tense with no working IV and a rapidly desaturating kid.

I don't fear it and pick it up when the circumstances call for it.

 

[chocomorsel]

Brady/asystole after 2nd dose of sux is well recognized even though pretty rare. Brady/asystole after the first dose of sux is the primary reason it's generally contraindicated in pediatric patients.

On another note - I assume when you say "no pulse ox" you mean there was no pulsatile waveform, "no EtCO2" means there was no exhaled CO2 showing on the monitor, and "asystole" was actually the rhythm showing on the EKG. Did this happen as you entered the room, or had it already happened before you got back in the room and "someone" is trying to figure out what is going on?

Yup. That's what I mean. Just so happens that this happened right as I walked into the room and up to the head of the bed. Talk about timing.

 

[btbam]

Give atropine before sux in neonates and you don't have to worry about it.

 

[BLADEMDA]

Brady on the second dose of sux imho

I've seen this before in my career. Never give a second dose of Sux without worrying about severe bradycardia followed by asystole. I've seen it and it can happen to you.

 

[BLADEMDA]

However, severe bradycardia is common after a second dose of succinylcholine, regardless of the patient's age.

http://www.anesthesiologyrounds.ca/crus/anesthe_06[047]0702.pdf


http://books.google.com/books?id=39...inylcholine and bradycardia or arrest&f=false

 

[BLADEMDA]

The autonomic mechanism involved in sinus bradycardia is stimulation of cardiac muscarinic receptors in the sinus node, which is particularly problematic in individuals with predominantly vagal tone, such as children who have not received atropine.[95] [96] Sinus bradycardia has also been noted in adults and appears more commonly when a second dose of the drug is given approximately 5 minutes after the first.[97] The bradycardia may be prevented by thiopental,[98] [99] atropine,[98] ganglion-blocking drugs, and nondepolarizing neuromuscular blockers.[98] [100] The implication from this information is that direct myocardial effects, increased muscarinic stimulation, and ganglionic stimulation may all be involved in the bradycardiac response. The higher incidence of bradycardia after a second dose of succinylcholine[100] suggests that the hydrolysis products of succinylcholine (succinylmonocholine and choline) may sensitize the heart to a subsequent dose.

 

[Idiopathic]

Brady/asystole after 2nd dose of sux is well recognized even though pretty rare. Brady/asystole after the first dose of sux is the primary reason it's generally contraindicated in pediatric patients.

On another note - I assume when you say "no pulse ox" you mean there was no pulsatile waveform, "no EtCO2" means there was no exhaled CO2 showing on the monitor, and "asystole" was actually the rhythm showing on the EKG. Did this happen as you entered the room, or had it already happened before you got back in the room and "someone" is trying to figure out what is going on?

what? my understanding is this: there were unexpected mortalities in the OR in children when anesthetized with halothane and sux, most of these children were found/suspected to have muscular dystrophy after the fact. since there are subclinical variants that may not be clinically obvious, it is recommended that no one use sux in young children (not sure the age when it is considered "okay"). this and the bradycardia leading to asystole effect are completely unrelated.

 

[BLADEMDA]

Recent concerns about the elective use of succinylcholine in pediatric patients have focused on the occasional reports of hyperkalemic cardiac arrest, particularly in children with undiagnosed Duchenne muscular dystrophy. The incidence of Duchenne muscular dystrophy is only 1 in 3000 to 8000 male children. The revised labeling continues to permit the use of succinylcholine for emergency control of the airway and treatment of laryngospasm

 

[BLADEMDA]

WARNING
RISK OF CARDIAC ARREST FROM HYPERKALEMIC RHABDOMYOLYSIS
There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death after the administration of succinylcholine to apparently healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy.
This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or have also been reports in adolescents.
Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine not felt to be due to inadequate ventilation, oxygenation, or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. This should include administration of intravenous calcium, bicarbonate, and glucose with insulin, with hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. In addition, in the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.
Since there may be no signs or symptoms to alert the practitioner to which patients are at risk, it is recommended that the use of succinylcholine in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible (see PRECAUTIONS: Pediatric Use and DOSAGE AND ADMINISTRATION).

 

[Oggg]

How about giving glycopyrolate (or atropine) prophylactically before any redose of succinylcholine? Roc is tough to use for cases less than 30min

 

[Idiopathic]

How about giving glycopyrolate (or atropine) prophylactically before any redose of succinylcholine? Roc is tough to use for cases less than 30min

that is supposed to work, the problem is if you are redosing sux you could easily forget about it or not have it drawn up since you may be doing it in a difficult airwar scenario

 

[BLADEMDA]

that is supposed to work, the problem is if you are redosing sux you could easily forget about it or not have it drawn up since you may be doing it in a difficult airwar scenario

I agree that if you foget to give the Robinul you could be looking at doing CPR

 

[Planktonmd]

Although some of the younger pedi/neo kids can be big vagal nerves waiting to fire off, I still don't practice as if sux is contraindicated in the pedi population and use it if it's necessary (big abdominal distentions/NEC, etc).

Man, I've seen some sick looking <1 y/o's with big ass bellies coming to the OR for an ex-lap. Sux's IM indications carry a significant weight in the little ones when things get a little tense with no working IV and a rapidly desaturating kid.

I don't fear it and pick it up when the circumstances call for it.

👍

 

[Sonny Crocket]

I've done a lot of these with a single shot interscalene block with lidocaine. Anyone else do this?

 

[Sonny Crocket]

Sorry, thought we were talking about a shoulder. Never mind

 

[Arch Guillotti]

that is supposed to work, the problem is if you are redosing sux you could easily forget about it or not have it drawn up since you may be doing it in a difficult airwar scenario

I have redosed sux twice, once as a resident and once as an attending. Don't think we gave atropine but I clearly remember thinking about during the airway drill. Of course when I was a resident it was the peds attending who raised the possibility of atropine (although it was an adult patient).

 

[Arch Guillotti]

I love it. The nurse can't even figure out if the patient is dead or not!

I don't really get why the patient was tubed though?

Think it happened to me today. 65y/o came in for a closed hip reduction. Rheumatoid and obesity are her only health issues. Wasn't gonna tube at first but surgeon had such a difficult time popping in that we then gave 60mg suxx and continued with mask then tubed when we had to transfer from stretcher to OR bed. Anyway tubed successfully without issues. Went out to check on CRNA in next room.

Came back about 5 minutes after initial dose of suxx and CRNA asks, "can someone check for a pulse"? I do and nothing. No pulse ox, no ETCO2, asystole. I start chest compressions and call a code. Patient came back within a few seconds. Maybe fifteen. She'd received a second dose of 40 mg.

Could it have been the suxx? Manipulation of abdomen causing a vagal response? Both? Anyway did fine, kept overnight in tele, but that was scary. I have done this many times before, never had this issue cuz it's so rare. What dose does it become an issue? She got about 1.1mg/kg total at least 5 minutes apart.

Choco

 

[Dejavu]

I've seen this before in my career. Never give a second dose of Sux without worrying about severe bradycardia followed by asystole. I've seen it and it can happen to you.

Definitely can happen from second bolus.

To dig up the old days, I never saw this with Succs drips. Gosh, I miss that technique.

 

[JonnyG]

had one of our crnas redose the other day here...........they were shocked it could happen. Thank god it was transient

 

[deleted59964]

Definitely can happen from second bolus.

To dig up the old days, I never saw this with Succs drips. Gosh, I miss that technique.

how did you do you Succs drips?
can't imagine I'll ever need to -- but out of interest

 

[Arch Guillotti]

how did you do you Succs drips?
can't imagine I'll ever need to -- but out of interest

Sux drips are great. Take out 70 ml from a 250 bag. Inject 2 bottles in there so the concentration is 2 mg/ml. Put it on a microdripper and let it fly. Very useful for certain cases.

 

[pgg]

I've seen people add some methylene blue or indigo carmine to the succ bag so they'd have a visual cue that paralytic was dripping in.

 

[Idiopathic]

how did you do you Succs drips?
can't imagine I'll ever need to -- but out of interest

can work well for quick cases as long as you avoid phase 2 block, ive previously used it for quick ENT cases, just leave the twitcher on, remember you will have twitches just decreased amplitude. when they go away you turn the drip down or off. its not perfect but its cheaper than extra time in the OR waiting for reversal and/or a vial of remi

 

[sevoflurane]

Everyone should do at least 5 sux drips in residency. It used to be used a lot, and you never know when your supplier might run out of reversal agents. (We wen't through a short dry spell of neostigmine this year- although we had a good stash of Enlon +).

 

[chocomorsel]

Well, learned my lesson. Never doing that again. Did it three or four time prior without any problems. Only takes one.

 

[btbam]

Everyone should do at least 5 sux drips in residency. It used to be used a lot, and you never know when your supplier might run out of reversal agents. (We wen't through a short dry spell of neostigmine this year- although we had a good stash of Enlon +).

Enlon+ is the shizz.