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ANESTHETIC PHARMACOLOGY

Accidental Epidural Administration of Succinylcholine

Departments of Anaesthesia, General Hospital and Trauma Center of KAT, Athens, Greece

Address correspondence and reprint requests to Chatzieleftheriou Athanasios, MD, Vaiou Kritis 53, Aharnai Athens, 13671, Greece. Address e-mail to uclas00{at}otenet.gr or uclas00{at}hotmail.com.

	Abstract

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We report a case of accidental epidural of succinylcholine injection. A prolonged onset and a longer duration of neuromuscular blockade were observed compared with IV administration. No neurological or cardiovascular side effects or other symptoms of local or systemic toxicity were observed.

	Introduction

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We report a case of accidental epidural administration of succinylcholine 125 mg during an operation for tibial fracture performed under combined spinal and epidural anesthesia.

	Case Report

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A 25-yr-old, 75 kg, 180 cm, ASA physical status I male was admitted for repair of a tibial fracture performed under combined regional anesthesia. The preoperative examination did not reveal any cardiovascular, respiratory, or other problems, and the values of the routine blood tests were normal.

The patient was informed appropriately and consented to receive combined spinal-epidural anesthesia. The epidural space was located at L3-4 interspace, using an 18-gauge Tuohy needle and the loss of resistance technique. The needle-through-needle technique was used to insert a 25-gauge Sprotte needle with magnifying attachment. The position of the spinal needle tip in the subarachnoid space was confirmed by dural puncture (dural click) and backflow of cerebrospinal fluid. Ropivacaine 0.75% 2 mL was injected intrathecally. A 20-gauge epidural catheter was advanced 4 cm into the epidural space and, after negative aspiration, 2 mL of lidocaine 2% was injected as an epidural test dose. Incremental doses of an additional 5 mL of lidocaine 2% were administrated epidurally 5 min later.

Standard monitoring equipment was used. The course of the operation was uncomplicated and the patient’s hemodynamic status was stable, with arterial blood pressure and heart rate within normal limits. After 60 min of operation we planned to epidurally administer 5 mL of lidocaine 2% plus 5 mL normal saline 0.9%, but instead, we accidentally injected succinylcholine 125 mg (5 mL) plus 5 mL normal saline 0.9% through the epidural catheter. The accident was not apparent until after approximately 2 min, when the patient suddenly experienced spasms. The surgeon first observed the spasms at the lower limbs, but after 10 s they were apparent in the rest of the trunk and the patient’s face.

We immediately intubated the trachea with a tracheal tube. The procedure was facilitated by the use of midazolam 1 mg, propofol 150 mg, and 100 µg fentanyl without the use of another muscle relaxant. Anesthesia was maintained with sevoflurane 1% and 50% N₂O in O₂ and controlled ventilation. We administrated 2 mL (8 mg) of dexamethasone in 8 mL 0.9% NaCl through the epidural catheter (1). The 2 syringes of lidocaine 2% and succinylcholine were similar both containing 5 mL.

The duration of the operation after the mistake was 1 h. Examination with a nerve stimulator indicated complete recovery from neuromuscular blockade in 7 min. We extubated the trachea with the patient fully awake with adequate spontaneous ventilation.

The neurological examination from a specialist that followed revealed no signs of sensory or motor blockade or neurotoxicity. The patient was discharged from the postanesthesia care unit at the fourth postoperative hour with no evidence of muscle weakness, back pain, headache, discomfort, fever, or other metabolic, mental or hemodynamic alterations. The patient was discharged home 6 days later. The daily neurological examination showed no complications. Follow-up for clinical signs of neurotoxicity was negative at 1 month (2,3).

	Discussion

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No data have been reported regarding epidural administration of succinylcholine through an epidural catheter in humans. Succinylcholine is the only depolarizing muscle relaxant currently in clinical use and is the only available neuromuscular blocking drug with a rapid onset of effect and an ultra-short duration of action. The commercially available solutions have pH 2–3 and contain stabilizers and buffers (benzyl alcohol, benzoate, and sodium chloride), that may be responsible for some of the side effects. After IV injection, most of the succinylcholine is immediately metabolized by the plasma cholinesterase to succinylmonocholine and choline. A small fraction reaches the neuromuscular junction, providing the depolarizing effect in 20 to 40 s. In patients with genotypically normal plasma cholinesterase activity, recovery after the administration of 1 mg/kg succinylcholine requires maximum 5–10 min (4,5). The rate of absorption of succinylcholine from the epidural space is unknown. In our patient, the duration of onset of succinylcholine was longer (2 min) compared with the clinical onset after IV administration. The muscle fasciculations were observed first at the lower limbs and then at the face, which is the usual initial place of appearance. The duration of the neuromuscular blockade was also longer (10 min) compared with the clinical duration after an IV administration. Our patient’s history of previous surgery with succinylcholine could exclude a prolonged neuromuscular blockade. The protective role of dexamethasone, reducing local edema and inhibiting the hyperacidosis of lipids, is questionable in this case.

In conclusion, the serious side effects of the inadvertent injection of succinylcholine through an epidural catheter must be treated with immediate establishment of airway protection, monitoring of muscle relaxation, avoidance of medications that interfere with neuromuscular blockade or antagonism, and follow-up for signs of neurotoxicity. This case re-emphasizes the important point that during any anesthesia procedure extreme vigilance is imperative and the labeling of the syringes is of major importance.

	Footnotes

 
Accepted for publication November 7, 2005.

	References

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1. Hall ED. The neuroprotective pharmacology of methylprednisolone. J Neurosurg 1992;76:13–22.[Web of Science][Medline]
2. Kostopanagiotou G, Mylona M, Massoura L. Accidental epidural injection of vecuronium. Anesth Analg 2000;91:1550–1.[Abstract/Free Full Text]
3. Vassilakos D, Tsakiliotis S, Veroniki F. Inadvertent epidural administration of cisatracurium. Eur J Anaesthesiol 2004;21:671–2.[Medline]
4. Naguib M, Lien CA, Miller RD. Pharmacology of muscle relaxants and their antagonists. In: Miller RD, ed Anesthesia. 6th ed. Philadelphia: Churchill Livingstone, 2005:481–557.
5. Fink H, Blobner M, Martyn JA. Neuromuscular blocking agents and reversal drugs. In: Evers A, Maze M, ed Anesthetic pharmacology: physiologic principles and clinical practice. Philadelphia: Churchill Livingstone, 2004:573–97.

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This Article Abstract Full Text (PDF) An erratum has been published Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Anta, S. Articles by Kyriaki, V. Search for Related Content PubMed PubMed Citation Articles by Anta, S. Articles by Kyriaki, V. Related Collections Regional Anesthesia Pharmacology