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Anesthesiology:
doi: 10.1097/ALN.0b013e318173eb78
Correspondence

Successful Use of Succinylcholine for Cesarean Delivery in a Patient with Postpolio Syndrome

Connelly, Neil Roy M.D.*; Abbott, Timothy C. D.O.

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To the Editor:—

We would like to comment on the recent case report on the use of succinylcholine in a patient with postpoliomyelitis syndrome (PPS).1 Poliomyelitis results from infection by a picornavirus. The polio virus can cause destruction of anterior horn motor neurons with resultant limb paralysis. Motor axon terminal sprouting reinnervates previously denervated muscle fibers creating a giant motor unit. This is associated with clinical improvement in motor strength weeks and months after an acute attack of polio. After decades, a postpoliomyelitis syndrome can develop, with muscle atrophy potentially progressing to complete paralysis. This syndrome is thought to occur secondary to increased functional demands, or overuse, of the giant motor unit, which results in the death of its sprouts.2,3
There have been a few reports over the years using succinylcholine in patients with pathology similar to that seen in PPS. For example, succinylcholine-induced hyperkalemia and circulatory collapse were reported in a patient with acute idiopathic anterior horn cell disease4; the serum potassium during this cardiac arrest was 7.9 mEq/l. Another study of denervated baboons found an increase in intravascular potassium up to 5.5 mEq/l.5 PPS is similar in pathophysiology to the baboon denervation study, and one could assume that hyperkalemia could also be seen in PPS patients. There have been numerous reports of hyperkalemia in patients with neuromuscular disease.4–8 It would have been informative to have had the prepotassium and postpotassium measurements from the patient in the report of Wernet et al.1 to determine the magnitude and time frame of the increase of serum potassium.
The avoidance of neuraxial anesthesia was also discussed by Wernet et al. Successful neuraxial anesthesia in patients with PPS has been reported without adverse complications.9,10 Many clinicians provide regional anesthesia for labor and delivery in patients with a history of PPS.11
If general anesthesia needs to be induced, the potential hazard of using succinylcholine in patients with PPS has been acknowledged.12 If the need for rapid sequence induction exists in a PPS patient, we believe one should choose a short-acting nondepolarizing muscle relaxant in lieu of succinylcholine; the only caveat would be to consider using a decreased dose because of the increase risk of muscular weakness.13
The mere fact that succinylcholine was used in the current case does not preclude the possible occurrence of severe, acute hyperkalemia in subsequent cases in patients with PPS. We do not believe that one can conclude from this single case that succinylcholine should be used in patients with PPS.
Neil Roy Connelly, M.D.,*
Timothy C. Abbott, D.O.
*Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts. neil.roy.connelly@bhs.org
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References

1. Wernet A, Bougeois B, Merckx P, Paugam-Burtz C, Mantz J: Successful use of succinylcholine for cesarean delivery in a patient with postpolio syndrome. Anesthesiology 2007; 107:680–1

2. Klingman J, Chui H, Corgiat M, Perry J: Functional recovery: A major risk factor for the development of postpoliomyelitis muscular dystrophy. Arch Neurol 1988; 45:645–7

3. Lambert DA, Giannouli E, Schmidt BJ: Postpolio syndrome and anesthesia. Anesthesiology 2005; 103:638–44

4. Beach TP, Stone WA, Hamelber W: Circulatory collapse following succinylcholine: Report of a patient with diffuse lower motor neuron disease. Anesth Analg 1971; 50:431–7

5. John DA, Tobey RE, Homer LD, Rice CL: Onset of succinylcholine-induced hyperkalemia following denervation. Anesthesiology 1976; 45:294–9

6. Smith RB, Grenvik A: Cardiac arrest following succinylcholine in patients with central nervous system injuries. Anesthesiology 1970; 33:558–60

7. Cooperman LH, Strobel GE Jr, Kennell EM: Massive hyperkalemia after administration of succinylcholine. Anesthesiology 1970; 32:161–4

8. Snow JC, Kripke BJ, Sessions GP, Finck AJ: Cardiovascular collapse following succinylcholine in a paraplegic patient. Paraplegia 1973; 11:199–204

9. Crawford JS, James FM, III, Nolle H, Van Steenberge A, Shah JL: Regional anaesthesia for patients with chronic neurological disorders and similar conditions (letter). Anaesthesia 1981; 36:821–2

10. Higashizawa T, Sugiura J, Takasugi Y: Spinal anesthesia in a patient with hemiparesis after poliomyelitis. Masui 2003; 52:1335–7

11. Chestnut DH: Obstetric Anesthesia: Principles and Practice, 3rd edition. Philadelphia, Elsevier Mosby, 2004, p 883

12. Liu S, Modell JH: Anesthetic management for patients with postpolio syndrome receiving electroconvulsive therapy. Anesthesiology 2001; 95:799–801

13. Gyermek L: Increased potency of nondepolarizing relaxants after poliomyelitis. J Clin Pharmacol 1990; 30:170–3

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