IS CRITICAL CARE MYOPATHY A CONTRAINDICATION FOR SUCCINYLCHOLINE?

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Succinylcholine, a depolarizing muscular blocker, has widespread use for rapid sequence intubation (RSI) in the intensive care unit (ICU), emergency department, and operating room. The advantageous pharmacologic profile includes onset of action (40-60 secs), short duration (6-10 mins), better conditions such as ease laryngoscopy diaphragm inactivation. There are recognized adverse effects including benign manifestations (muscle fasciculations) to life-threatening (acute hyperkalemia malignant hyperthermia). Scenarios with increased risk include dystrophies, rhabdomyolysis, crush/burn injuries, hyperthermia, abdominal infections. We present case after administration setting critical myopathy. CASE PRESENTATION: A 63-year-old woman was admitted acute respiratory distress syndrome from COVID-19 pneumonia. Treatment included steroids, neuromuscular blockade, prone positioning. Due frequent ventilator associated pneumonias difficulty airway hygiene, endotracheal (ET) tube exchange planned on hospital day 34. Succinylcholine utilized given suitable creatinine clearance, normal serum potassium, sinus rhythm. removed ET had dark, thick, adherent secretions. Less than one minute administration, telemetry changed wide QRS complex degenerated into pulseless ventricular fibrillation. no preceding hypoxemia. patient received ACLS defibrillation recurrent fibrillation ROSC. DISCUSSION: binds post-synaptic nicotinic acetylcholine receptor motor endplate causing depolarization. Receptor activation triggers efflux intracellular potassium plasma. upregulation occurs pathologic lower neuron disorders, immobilization, burns, dystrophies. Myopathies have inherent membrane fragility permeability producing release potassium. development illness myopathy, polyneuropathy, polyneuromyopathy ICU an incidence 25-83%. Proposed mechanisms myosin loss, necrosis muscle, muscle dysfunction, denervation nerve ischemia, axonal injury. Activation receptors sustained contraction this state can result devastating hyperkalemia. CONCLUSIONS: paralytic medication RSI patients myopathy should give providers clinical equipoise. is due damaged upregulated receptors. REFERENCE #1: Tran, D. T. T., et al. "Rocuronium vs. succinylcholine intubation: Cochrane systematic review." Anaesthesia 72.6 (2017): 765-777. #2: Martyn, J. A. Jeevendra, Martina Richtsfeld. "Succinylcholine-induced acquired statesetiologic factors molecular mechanisms." Anesthesiology: Journal American Society Anesthesiologists 104.1 (2006): 158-169. #3: Shepherd, Starane, Ayush Batra, David P. Lerner. "Review neuropathy." Neurohospitalist 7.1 41-48. DISCLOSURES: No relevant relationships by Bhupinder Natt, source=Web Response Alan Nyquist,