Rev. Bras. Anestesiol. vol.67 número4

RevBrasAnestesiol.2017;67(4):411---414

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Inadvertent

injection

of

succinylcholine

as

an

epidural

test

dose

Chryssa

Pourzitaki

_,

_Georgia

_Tsaousi,

_Helena

_Logotheti,

_Ekaterini

_Amaniti

AristotleUniversityofThessaloniki,AHEPAUniversityHospital,ClinicofAnesthesiologyandIntensiveCare,Salonica,Greece

Received25September2014;accepted28October2014 Availableonline12May2015

KEYWORDS Succinylcholine; Epidural administration; Accidental; Neuromuscular blockingagents; Fasciculations; Diazepam

Abstract

Backgroundandobjectives: Epidural action of neuromuscular blocking agents could be explained underthe lightoftheirphysicochemical characteristicsandepiduralspace prop-erties. In the literature there are few cases of accidental neuromuscular agent’s epidural administration,manifestingmainlywithneuromuscularblockadeinstitutionorfasciculations.

Casereport: Wereportacaseofaccidentalsuccinylcholineadministrationasanepiduraltest dose,inafemalepatientundergoingscheduledlaparotomy,undercombinedgeneraland epidu-ralanesthesia.Approximately2minafterthesuccinylcholineinjectionthepatientcomplained for shortnessofbreath,whilemildfasciculationsappeared inhertrunk andface,managed by immediategeneralanesthesiainstitution.Withtheexceptionofarelativelylonger dura-tionofneuromuscularblockadecomparedwithintravenousadministration,noneurologicalor cardiovascularsequelaeorothersymptomsoflocalorsystemictoxicitywereobserved.

Conclusions: Oraladministrationofdiazepamseemstolessentheadverseeffectsfrom acci-dentalepiduraladministrationofsuccinylcholine.Themeticulousanddiscriminativelabeling ofsyringes,aswellaskeepingpersistentcautionsduringallanesthesiaproceduresremainsof crucialimportance.

©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE Succinilcolina; Administrac¸ão epidural; Acidental;

Injec¸ãoinadvertidadesuccinilcolinacomoumadosetesteepidural

Resumo

Justificativaeobjetivos: Aac¸ãoepiduraldeagentesbloqueadoresneuromuscularespodeser explicadasàluzdesuascaracterísticasfísico-químicasepropriedadesdoespac¸oepidural.Na

∗_{Correspondingauthor.}

E-mail:[email protected](C.Pourzitaki). http://dx.doi.org/10.1016/j.bjane.2014.10.007

412 C.Pourzitakietal.

Agentesbloqueadores

neuromusculares; Fasciculac¸ões; Diazepam

literaturaexistempoucoscasossobreaadministrac¸ãoacidentalemespac¸oepiduraldeagente neuromuscular,manifestando-seprincipalmentecomainstituic¸ãodebloqueioneuromuscular oufasciculac¸ões.

Relatodecaso:Relatamosumcasodeadministrac¸ãoacidentaldesuccinylcholinecomouma dosetesteepiduralemumapacientesubmetidaàlaparotomiaprogramada,sobanestesia com-binadageraleperidural.Aproximadamentedoisminutosapósainjec¸ãodesuccinylcholine,a pacientequeixou-se defaltadear, enquantofasciculac¸õeslevesapareceramemseutronco erosto, tratadascomainstituic¸ãoimediatade anestesiageral.Excetopela durac¸ão relati-vamentelongadobloqueioneuromuscularemcomparac¸ãocomaadministrac¸ãointravenosa, sequelasneurológicasoucardiovascularesououtrossintomasdetoxicidadelocalousistémica nãoforamobservados.

Conclusões:A administrac¸ão oral de diazepam parece diminuir os efeitos adversos da administrac¸ãoepiduralacidentaldesuccinilcolina.Ameticulosidadeediscriminac¸ãodos rótu-losdasseringas,bemcomooscuidadospersistentesmantidosdurantetodososprocedimentos deanestesiacontinuamsendodeimportânciacrucial.

©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background

and

objectives

Inthehistory ofregionalanesthesiatechniques, avariety

ofanesthetic drugs andother substanceshave been

acci-dentally injected into epidural space, withconsequences

ranging from no clinical symptoms to irreversible

neuro-logicaldeficit.1---4_{Intheliteraturetherearefewreportsof} accidentalepiduraladministrationofdifferenttypesof non-depolarizingneuromuscularblocking(NMB)agents,treated properlyandthusthepatientshadanuneventfulcourse.5---8 In the unique case of accidental epidural administra-tion of succinylcholine, 125mg of the depolarizing NMB agent have been injected during a combined spinal and epiduralanesthesia.This wasimplicated withthe appear-anceof spasms, whichwereinitially locatedat thelower limbs and thereafter were expanded in the rest of the trunk,uptothepatient’sface.9_{Wereportacaseof} acci-dental epidural administration of succinylcholine, which hasobscurepharmacokineticsandpharmacodynamicsafter epiduraladministration,aswellasforhighorlow acciden-tallyadministereddoses.

Case

report

A63-yrs-old,64kg,ASAphysicalstatusI,femalepatientwas scheduledtoundergoelectivetotalabdominalhysterectomy duetouterinefibroids. Theanesthesiaplaninvolved com-binedgeneralandepiduralanesthesia.Patientwasinformed appropriatelyandhadgivenconsenttoreceivethespecific modelofanesthesia.Shereceivedorally5mgofdiazepam thenightbeforeoperationandwaspremedicatedwith10mg (peros)ofthesameagent1hbeforebeingtransportedtothe operationroom.

Followingtheapplicationofstandardmonitoring equip-ment, the patient was placed in the lateral decubitus position. Then the epidural space was located at L3-4

interspaceusingan18gaugeTuohyneedleandthe‘‘lossof resistancetoair’’techniqueand a20gaugecatheterwas insertedintoit.Afterstabilizingthecatheter,the adminis-trationofatestdoseof3mLlidocaine2%wasplanned,but accidentally3mLofsuccinylcholine(75mg)wereinjected, as the depolarizing NMB agent availability is a standard practicein ourdepartment. Succinylcholineandlidocaine 2%solutionswerealike,bothpreparedin5mLsyringes.

Approximately 2min after thesuccinylcholine adminis-trationthepatientcomplainedforshortnessofbreathand feeling of discomfort, while mild fasciculations appeared in hertrunk and face.At this point themistake was per-ceptibleandassistedventilationwasinstantlyinitiatedvia facemaskwith100%oxygen.Inordertoassessthedepthof thepossible neuromuscularblockadea train-of-four(TOF) ulnar nerve stimulation was applied, which showed 40% reduction in TOF response. Thereafter, we proceeded to inductiontogeneralanesthesia,achievedby200␮gfentanyl and140mgpropofoladministration,withoutanyadditional NMBagent. Maintenance ofanesthesia wasachievedby 1 MAC of sevoflurane. Up to this point, the patient’s vital signs remained stable. To accelerate systemic absorption of succinylcholine, 2mL (8mg) of dexamethasone in 8mL 0.9% NaCl were injected through the epidural catheter.10 Afterepiduralsuccinylcholineinjection,completerecovery oftheTOFresponseoccurredat5min.Assoonasthe mis-takewasapparentthesurgeonsandthepatient’srelatives wereinformedand itwasdecidedtocontinue the opera-tion.Consequently12mgofintravenouscisatracuriumwere administered in order to conduct the operation. Epidural anesthesia plan was discarded and substituted by intra-venousopioidadministration.

Inadvertentepiduralinjectionofsuccinylcholine 413

Neurologicalassessmentafterrecoveryfromaspecialist revealednosignsofevensensoryormotorblockadeand neu-rotoxicity.Thepatientstayedinthepostanesthesiacareunit for4h;shewasfullyawakeandoriented,withnoclinical evidence of muscle weakness and pain, headache, dis-comfort,abnormalbodytemperature,orother metabolic, mental,orhemodynamicalterations.

The daily neurological examination was free of complications and showed no biochemical or electrolytic alterations.Thepatientwasdischargedhome7dayslater, after she was officially informed about the incident, as well as a complete hospital incident report wasfilled in. Follow-upexaminationat2weeksand1and3monthsafter surgery didnotreveal anyneurological, cardiovascularor othercomplications.

Conclusions

Drugs after epidural administration redistribute by the diffusion from spinal cordmeninges, due to special char-acteristicsofepiduralspace.Duraandarachnoidmeninges represent the main and primary permeability fragment in epidural drug administrationand drugs epidural action dependsontheircoefficientoflipidsolubility.11 _Therefore, hydrophilic drugscontrarilyto lipophilicones have better action in epidural than in intrathecal infusion. Moreover, dura mater due to its increased number of vessels is an importantplacefordrugmetabolism,asitcontainsmultiple enzymicsystems.11

NMB agents can induce excitement and seizures when they are injected into the central nervous system,12---14 while their acute intrathecal administration cause dose-dependentincreaseinintracellularcalciumconcentrations andactivation of nicotinic acetylcholinereceptors or glu-tamate receptors in the rat brain12 _{The reports about} non-depolarizingNMB administration, like pancuroniumin a dose of 4mg, vecuronium in a dose of 10mg and cisatracuriuminadoseof8mg,5---7_{intotheepiduralspace,} are restricted either before induction or during general anesthesia,soitisgenerallyconsideredthatsomeclinical manifestationswerepossiblynotsufficientlyobserved.Ina singlecaseofaccidentalepiduralinfusionof40mg rocuro-nium,shortnessofbreathandareductioninTOFresponse of25%,occurred.8

Succinylcholine is the only depolarizing muscle relax-ant in clinical use today andas all neuromuscularagents is watersoluble. It acts through stimulation of nicotinic receptorsinparasympatheticandsympatheticganglia.9_Its popularity is attributed to its rapid onset, low lipid sol-ubility and short duration of action. According to Mazze et al.,15 _{the time to apnea for patients receiving} intra-muscularsuccinylcholinewasapproximately3.5min,5-fold higherthanintravenousand3foldhigherthanintralingual time. Notably, apnea was less distinct with intramuscu-lar administration of succinylcholine than with the other two routes. However, the time needed for complete recovery after intralingual, intravenous and intramuscu-lar succinylcholine administration was 7, 5 and 9min, respectively.15 _{Since there is no indication for epidural} administration of succinylcholine, the evidence for the exacttimeofitsonsetanddurationislacking.However,it

seemsthatitmimicsthepharmacokineticsofintramuscular administration.15

Interestingly,therearetworeportssuggestingthe inten-tional epidural injection of a small (30---40mg) dose of succinylcholine,witha viewto identify a possible epidu-ral catheter misplacement. According to them, when an epiduralcatheteris placed properly, asmall dose of suc-cinylcholine results only in minor deterioration of tidal volume,whileinanintravenouslyplacedepiduralcatheter thesamedosecausesapnea.16,17

To the authors’ knowledge, it is the first time that a moderatedose of succinylcholineepiduraladministration, without any other previous concomitant anesthetic inter-ventions,isreported.9_{Itisassumedthat,thetimeelapsed} from accidental epidural injection to general anesthesia inductionwassufficientenoughforsuccinylcholinetoreveal itsclinicalsigns,whiletheoperationlastedlongenoughto detectanyprolongationinneuromuscularblockade.

Inthesinglereportedcaseofaccidentalepidural admin-istrationof125mgsuccinylcholine,thepatientexperienced intense fasciculations and spasms, which were initially locatedatthelowerlimbsandthereafterwereexpandedin therestofthetrunk,uptothepatient’sface.9_Thesubtle clinicalpresentationinourcase,involvingonlymild fascic-ulationsinthetrunkandfaceandshortnessofbreath,could possiblybeattributedtorelativelylowerdoseof succinyl-cholineinjectedepidurally.

Another possible reason could be the premedication with diazepam. There are data showing that, 10mg of diazepam administered orally 90min before intravenous succinylcholine administration can reduce the intensity of fasciculations.18 _{Nevertheless, there is no reference} regardingtheimpactof concomitantintravenous orperos administeredbenzodiazepinesincasesofepiduralinjection ofNMBagents.Beyondtheireffectonclinicalpresentation, thecombinationofthesetwofactorsalsodeterredfromany permanentneurologicalcomplications,whichinaccordance withthepreviousreports.

In orderto dilute the concentration of succinylcholine andlimit the inflammatory response,dexamethasone and normalsalinewereflushedintotheepiduralspace.10_Albeit, thispracticeiscommonlyreportedincasesofinadvertent epiduralinjection of drugs, its rescue utility underthese circumstancesisquestionable.6

Finally,it is apparentthat themeticulousand discrim-inative labelingof syringes, as well askeeping persistent cautionsduringallanesthesiaproceduresremainsofcrucial importance.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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