1211 - Succinylcholine-Induced Hyperkalemia and Cardiac Arrest in 1 Month Post-Spinal Cord Injury

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

OJ

Oranicha Jumreornvong, MD

Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States

Co-Author(s)

EF

Elisabeth Frankini, MPH

Medical Student
New York Institute of Technology College of Osteopathic Medicine
new york, New York, United States
TB

Thomas Bryce, MD

Medical Director of the Spinal Cord Injury Program
Icahn School of Medicine at Mount Sinai
new york, New York, United States

Case Diagnosis: Succinylcholine-Induced Hyperkalemia and Cardiac Arrest After Spinal Cord Injury

Case Description: A 24-year-old male with history of substance abuse (crystal meth), depression and PTSD was run over by a tractor sand rake. Imaging revealed a T12 fracture dislocation. He underwent emergent T12 decompression and T9-L3 instrumented posterior spinal fusion. His physical exam indicates T12 ASIA B and some right lower extremity volitional motor function. Routine MRI without contrast revealed residual spinal stenosis. He was scheduled for further decompression of the spine approximately one month after his initial injury but arrested due to ventricular fibrillation for five minutes after receiving 100 mg succinylcholine for induction of anesthesia. CPR began and there was return of spontaneous circulation within two cycles. Prior to case potassium was 3.7, intra-op it rose to 6.7. The case was aborted before the operation started with plans to repeat after optimizing his cardiac system.

Discussions: Succinylcholine should be avoided between 3 days and 9 months following spinal cord injury due to the risk of succinylcholine induced hyperkalemia caused by denervation hypersensitivity. Following spinal cord injury, acetylcholine receptors spread from the motor endplate of affected muscle fibers and cover the whole muscle membrane. When a depolarizing muscle relaxant is given, depolarization takes place throughout the muscle and results in ionic flux that leads to vast and potentially fatal increases in serum potassium concentrations. This can result in large increases in serum potassium concentrations and potentially cause serious cardiac disturbances and cardiac arrest.

Conclusions: This case report reveals that interdisciplinary teams caring for patients with denervated muscle due to spinal cord injuries should be aware of succinylcholine-induced hyperkalemia and cardiac arrest. Nondepolarizing muscle relaxants, such as rocuronium, should be used instead of succinylcholine after spinal cord injury. Root cause analysis by quality improvement committee and safety guidelines could prevent future adverse events.