A nurse administered the neuromuscular blocking agent succinylcholine (SUX) to at least one patient and gave first aid in the therapy of unexpected respiratory depression. SUX is regarded as an undetectable and thus perfect poison due to its short half-life and degradation to the endogenous compounds choline and succinic acid. However, SUX and especially its metabolite succinylmonocholine (SMC) were found in plasma and urine a few hours after administration by means of high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Compared to clinical studies, the window of detection was sufficient to gain definite proof; in other cases no samples were collected. The nurse enjoyed high reputation with the doctors. According to the court she wanted to present herself spectacularly as the first and decisive rescuer to demonstrate her special abilities and capacities, perhaps to receive a better job in the hospital. Considering the actual case, the hero syndrome is not limited to fire-fighters. Copyright © 2013 John Wiley & Sons, Ltd.

This report addresses the dilemma of continuing lithium prophylaxis and antidepressant therapy in view of cardiovascular adverse effects under electroconvulsive therapy (ECT) in patients with a long history of recurrent affective disorders. A severely depressed 48-year-old woman who had been treated with lithium for 18 years developed a ventricular tachycardia during ECT. Possible interaction with succinylcholine was taken into account, and rocuronium was used as an alternative muscle relaxant. Electroconvulsive therapy was continued without adverse effects after reduction of lithium and withdrawal from duloxetine. Systemic studies on cardiac adverse effects of serotonin and norepinephrine reuptake inhibitors and serotonin and norepinephrine reuptake inhibitor-lithium combinations during ECT are needed.

A patient presenting with paramyotonia congenita (Eulenburg's paramyotonia) was seen at the preanaesthetic visit during pregnancy. The underlying disease was known for years. Analysis of the literature and advice taken from specialists emphasized the safe use of regional anaesthesia and analgesia which was indeed used for labour and delivery without any complication. By contrast, the limited information available on the use of general anaesthesia suggests the risks associated with the use of succinylcholine and possibly with halogenated agents. Additional and useful factors that may limit the occurrence of myotonic crises such as maintenance of normal temperature and plasma potassium concentration, should be undertaken simultaneously.

Spinal muscle atrophy (SMA) is autosomal recessive and one of the most common inherited lethal diseases in childhood. The spectrum of symptoms of SMA is continuous and varies from neonatal death to progressive symmetrical muscle weakness first appearing in adulthood. The disease is produced by degeneration of spinal motor neurons and can be described in three or more categories: SMA I with onset of symptoms before 6 months of age; SMAII with onset between 6 and 18 months and SMA III, which presents later in childhood. Genetics: The disease is in more than 95% of cases caused by a homozygous deletion in survival motor neuron gene 1 (SMN1). Pathophysiology: The loss of full-length functioning SMN protein leads to a degeneration of anterior spinal motor neurons which causes muscle weakness. Anesthetic risks: Airway: Tracheal intubation can be difficult. Respiration: Infants with SMA I almost always need postoperative respiratory support. Patients with SMA II sometimes need support, while SMA III patients seldom need support. Circulation: Circulatory problems during anesthesia are rare. Anesthetic drugs: Neuromuscular blockers: Patients with SMA may display increased sensitivity to and prolonged effect of nondepolarizing neuromuscular blockers. Intubation without muscle relaxation should be considered. Succinylcholine should be avoided. Opioids: These should be titrated carefully. Anesthetic techniques: All types of anesthetic technique have been used. Although none is absolutely contraindicated, none is perfect: anesthesia must be individualized.

Conclusion:

The perioperative risks can be considerable and are mainly related to the respiratory system, from respiratory failure to difficult/impossible intubation.

Huntington's chorea is a rare hereditary disorder of the nervous system. It is inherited as an autosomal dominant disorder and is characterized by progressive chorea, dementia and psychiatric disturbances. The best anesthetic technique is yet to be established for these patients with increased risk of aspiration due to involvement of pharyngeal muscles and an exaggerated response to sodium thiopental and succinylcholine. The primary goal in general anesthesia for these patients is to provide airway protection and a rapid and safe recovery. We report the anesthetic management of a 51-year-old patient with Huntington's chorea admitted for an emergency operation.

Rapid sequence induction (RSI) is indicated in various situations. Succinylcholine has been the muscle relaxant of choice for RSI, and rocuronium has become an alternative medicine for patients who cannot be administered succinylcholine for various reasons. Although rocuronium has the most rapid onset time among non-depolarizing muscle relaxants, the standard dose of rocuronium (0.6 mg/kg) takes 60 seconds to achieve appropriate muscle relaxation. We evaluated intubating conditions using the "modified timing principle" with rocuronium and succinylcholine.In this prospective controlled blinded study, all patients received 1.5 µg/kg fentanyl intravenously with preoxygenation for 2 minutes and were randomized to receive 0.6 mg/kg rocuronium followed by 1.5 mg/kg propofol or 1.5 mg/kg propofol and 1.5 mg/kg succinylcholine. The rocuronium group was intubated just after confirming loss of consciousness, and the succinylcholine group was intubated 1 minute after injecting succinylcholine. Intubation condition, timing of events, and complications were recorded.All patients were successfully intubated in both groups. Apnea time of the rocuronium group (38.5 seconds) was significantly shorter than that in the succinylcholine group (100.7 seconds). No significant differences were observed in loss of consciousness time or intubation time. The succinylcholine group tended to show better intubation conditions, but no significant difference was observed. None of the patients complained awareness of the intubation procedure or had respiratory difficulty during a postoperative interview.The modified RSI with rocuronium showed shorter intubation sequence, acceptable intubation conditions, and a similar level of complications compared to those of conventional RSI with succinylcholine.

To determine the effects of dexmedetomidine on the incidence of fasciculation and myalgia, and to evaluate changes in creatine kinase levels due to succinylcholine administration.Sixty patients undergoing direct laryngoscopy were enrolled in this study carried out in the Department of Anesthesiology and Reanimation, Hacettepe University, Ankara, Turkey between January and March 2010. Patients were allocated blindly to 3 anesthesiologists. In the dexmedetomidine group (group D) (n=30), dexmedetomidine 1ug/kg was administered intravenously over 10 minutes before the intubation. In the control group (group C) (n=30), the same volume of normal saline was administered. Laryngoscopy was performed one minute after administration of succinylcholine. Dexmedetomidine infusion was continued until the end of surgery. Fasciculation and myalgia at the postoperative thirtieth minute, and creatine kinase levels before the induction of anesthesia and at the postoperative 24th hour, and adequacy of relaxation for intubation were recorded.The severity and incidence of fasciculation were better in group D than group C (p=0.025). Intubating conditions were better in the dexmedetomidine group (p=0.011). At the thirtieth minute, the incidence and severity of myalgia were significantly higher in group C (p=0.014). Postoperative creatine kinase levels increased significantly compared with their base-line levels in both groups (p=0.022 in group D and p=0.017 in group C). Creatine kinase level elevation was higher in group C (p=0.03).Dexmedetomidine infusion before and after succinylcholine administration may be useful in diminishing the incidence of succinylcholine-induced myalgia in the early postoperative period. Routine use of dexmedetomidine cannot be recommended, but further research is needed with a larger number of patients.

We describe tracheobronchial injury (TBI) in a 17-year-old teenager following blunt trauma resulting from a road traffic accident. The patient presented to a peripheral hospital with swelling over the neck and face associated with bilateral pneumothorax for which bilateral intercostal drains were inserted and the patient was transferred to our institute. Fiber-optic videobronchoscopy (FOB) was performed, the trachea and bronchi were visualized, and the site and extent of injury was assessed. Spontaneous respiration was maintained till assessment of the airway. Then the patient was anesthetized with propofol and paralyzed using succinylcholine and a double-lumen endobronchial tube was inserted; thereafter, the adequacy of controlled manual ventilation and air-leak through intercostal drains was assessed and the patient was transferred to operating room (OR) for repair of the airway injury. The OR was kept ready during FOB to manage any catastrophe. This case describes the need for proper preparation and communication between health care team members to manage all possible scenarios of traumatic TBI.

Concerns about the safety of paralytics such as succinylcholine to facilitate endotracheal intubation limit their use in prehospital and emergency department settings. The ability to rapidly reverse paralysis and restore respiratory drive would increase the safety margin of an agent, thus permitting the pursuit of alternative intubation strategies. In particular, patients who carry genetic or acquired deficiency of butyrylcholinesterase, the serum enzyme responsible for succinylcholine hydrolysis, are susceptible to succinylcholine-induced apnea, which manifests as paralysis, lasting hours beyond the normally brief half-life of succinylcholine. We hypothesized that intravenous administration of plant-derived recombinant BChE, which also prevents mortality in nerve agent poisoning, would rapidly reverse the effects of succinylcholine.Recombinant butyrylcholinesterase was produced in transgenic plants and purified. Further analysis involved murine and guinea pig models of succinylcholine toxicity. Animals were treated with lethal and sublethal doses of succinylcholine followed by administration of butyrylcholinesterase or vehicle. In both animal models vital signs and overall survival at specified intervals post succinylcholine administration were assessed.Purified plant-derived recombinant human butyrylcholinesterase can hydrolyze succinylcholine in vitro. Challenge of mice with an LD100 of succinylcholine followed by BChE administration resulted in complete prevention of respiratory inhibition and concomitant mortality. Furthermore, experiments in symptomatic guinea pigs demonstrated extremely rapid succinylcholine detoxification with complete amelioration of symptoms and no apparent complications.Recombinant plant-derived butyrylcholinesterase was capable of counteracting and reversing apnea in two complementary models of lethal succinylcholine toxicity, completely preventing mortality. This study of a protein antidote validates the feasibility of protection and treatment of overdose from succinylcholine as well as other biologically active butyrylcholinesterase substrates.