Anaesth. Intens Care (1977).

5, 235

ANAPHYLAXIS TO SUXAMETHONIUM-A CASE REPORT

M. D. MATTHEWS,* J. z. CEGLARSKI,t AND M. PABARIt
Mater Misericordiae Public Hospital, South Brisbane

SUMMARY
.A case history is presented of a woman who developed very severe bronchospasm, hypo-
tenslOn, " lobster-red" erythema and later angio edema of the head and neck after induction
of anaesthesia for caesarean section. Intradermal testing at a later date, showed immediate-
type sensitivity to suxamethonium. Reference is made to the other few reactions to suxame-
thonium reported in the world literature.

HISTORY AND DEFINITIONS During this time there have been reported
Anaphylaxis can be regarded as a neologism, very few cases of severe reactions following its
meaning the opposite to prophylaxis (" on intravenous administration. Severe reactions to
guard ") (Lee and Atkinson 1973). It is more intravenous suxamethonium have been reported
precisely defined by Austen (1974) as immediate by:- Smith (1957), Kepes and Haimovici
hypersensitivity that begins within minutes of (1959), Fellini, Bernstein, Zauder (1963), Jerums,
antigen-antibody interaction resulting in the Whittingham, Wilson (1967), Eustace (1967),
formation and/or the release of chemical media- Bele-Binda and Valeri (1971), Katz and Mulligan
tors which act at secondary sites, namely smooth (1972), Mandappa (1975), Sitarz (1974) and
muscle and vascular tissue causing anyone or Fisher (1975).
more of the clinical manifestations of the As anaesthetic techniques varied in these
response. The manifestations may be of any cases, so too did thoughts of possible mechanisms,
combination of three patterns:- laryngeal in the early reports being "sensitivity" via
oedema, intractable bronchospasm (both may histamine release (Paton 1959) and lately true
cause secondary hypotension) and primary anaphylaxia (Jerums et al.), both mechanisms
vascular collapse. "Minimal experimental data being distinct from the more frequently reported
suggests that the mediators responsible may be idiosyncrasy with prolonged apnoea, due to low
respectively:- histamine, SRS-A and brady- serum pseudocholinesterase (Lehmann and
kinin (Austen)." LiddeI1964).
Suxamethonium chloride B.P. (Succinylcho- Of these "severe reactions" reported, one
line V.S.P.) is a " depolarising" muscle relaxant may attempt to classify them according to
with rapid onset and short duration and is clinical presentation. Firstly some cases merely
metabolised in the blood by pseudocholin- involve oedema and erythematous flushing of
esterase. It was synthesised in 1906 by Hunt various parts (injection site, face, pharynx),
and Taveau. Following its noted effect on the which may occur for 24 hours and seem to be
neuromuscular junction by Bovet in 1949, it has related to histamine release (Smith-first 3
been used widely in clinical practice for over cases). Secondly a category of moderate hypo-
twenty years. tension with tachycardia (Mandappa-2nd case)
or combined with oedema and flushing may be
* M.B., B.S. (N.S.W.), Registrar in Anaesthesia. defined (Kepes and Haimovici). Thirdly there
t M.B., B.S. (Qld.), Registrar in Anaesthesia. is a category of bronchospasm alone, either
t M.B., Ch.B. (Birm.), F.F.A.R.C.S. (Eng.), Deputy de novo (Fellini) or in a known asthmatic (Smith
Director of Anaesthesia. -case 4). Finally and most severely are the
Address for reprints: Dr. M. Pabari, Dept. of
cases which could be considered as " full blown "
Anaesthesia, Mater Misericordiae Public Hospitals, anaphylactic reactions where severe hypotension
Raymond Terrace, South Brisbane, Qld. 4101, Australia. is combined with severe bronchospasm, oedema,

Anaesthesia and Intensive Care, Vol. V, No. 3, August, 1977

236 M. D. MATTHEWS ET AL.

"lobster red flushing" and tachycardia (Man- pain, possibly ruptured membranes and hyper-
dappa-first case and Jerums et all. Generally tension. On ]8.5.76, an artificial rupture of
in this last category major resuscitative measures membranes was performed and on 19.5.76 at
are indicated, including the use of vasopressor 11.50 a.m. a continuous epidural anaesthetic
agents. This report is believed to be such a was administered for maternal distress and
case. hypertension. The drug used was bupivacaine
CASE HISTORY 0·25% (14 ml) and four incremental doses
Presentation: A twenty-four year old nul- were given.
liparous woman presented for general anaes- Pre-Anaesthetic Assessment: Her pre-anaes-
thesia for emergency Caesarean section, for thetic management consisted of oral administra-
disproportion and failure to progress in labour tion of magnesium trisilicate and note was made
after surgical induction. that although she was " allergic to Alloferin "
Past Health: Following a childhood medical she had never suffered from asthma or hay fever.
history of varicella and adeno-tonsillectomy, The anaesthetic technique decided on was:-
at the age of 21 years she underwent general preoxygenation (10 mins), use of wedge pillow,
anaesthesia for plastic repair of cleft lip and " crash induction" with thiopentone and atro-
palate on 9.8.73. On this occasion, following pine and suxamethonium and maintenance with
induction under thiopentone (200 mg), intuba- N 2 0/0 2 (ratio 6 : 3), pancuronium and an
tion under suxamethonium (50 mg) and mainten- automatic Manley Blease ventilator. Pre-
ance under N20j02 and alcuronium (15 mg), operative blood pressure was ]50/100 mm Hg.
the patient's blood pressure became unrecordable Patient arrived in theatre at 12.30 a.m. and
with central cyanosis and flushed skin, necessi- anaesthesia was induced at 12.40 a.m.
tating treatment with :- A naphylactic Episode: After induction of
Hartman's Solution - 1 litre anaesthesia with atropine 0·6 mg, thiopentone
sodium bicarbonate - 20 mEq of 0 ·9% 250 mg, suxamethonium 100 mg and intubation
hydrocortisone - 500 mg with a size 8 mm cuffed Magill endotracheal
metaraminol (Aramine) - 2 mg tube, it was noticed that manual ventilation
isoprenaline (Isuprel) 1/5000 - 1 ml (200 fLg) was extremely difficult. After re checking the
0 2 100% Boyle machine, its connections and the endo-
external cardiac massage tracheal tube, both for position by direct
laryngoscopy, and for patency by passage of
The blood pressure slowly returned to normal,
suction catheter, auscultation of the chest
the patient was successfully reversed and
extubated and post-operatively advised that revealed gross bronchospasm, the precise cause
she was" allergic to Alloferin " and to avoid it of which at this stage was not determined. The
in the future. following drugs were given : -
hydrocortisone - 500 mg
Subsequently, the plastic repair was success-
aminophylline - 250 mg over 10 mins
fully performed under anaesthesia two months
later on 4.10.73. halothane - 1 % for 10 mins
Gradually, ventilation became less difficult
The drugs used then were :- and surgery commenced. However, it was then
propanidid - 300 mg noticed that the blood pressure was unrecordable
pancuronium - 8 mg at the brachial artery although carotid pulse
pethidine 30 mg was palpable. At this stage, a diagnosis of
diazepam 10 mg anaphylactic hypersensitivity to one or more
droperidol 30 mg of the induction agents was made. Hartman's
neostygmine 4 mg Solution 1 litre and stable plasma protein
atropine - 1·5 mg solution (S.P.P.S.) 500 ml were given. As well,
With no untoward effects. whole blood 300 ml was administered with little
Present Pregnancy: The patient was admitted effect. Only after the use of intravenous
at 15 weeks gestation because of vomiting and metaraminol 1·0 mg was the systolic blood
spotting. Following an episode of mental dis- pressure recorded at 90 mm Hg. The E.C.G.
turbance, she was discharged on psycho-active at all times showed sinus tachycardia.
drugs for follow-up by psychiatric care. Meanwhile surgery had proceeded normally,
On 13.5.76, she was admitted at approximately the infant was delivered and showed no signs
38/39 weeks gestation, suffering from abdominal of depression. There was virtually no blood

Anaesthesia and Intensive Care, Vol. V, No. 3, August, 197

 SUXAMETHONIUM ANAPHYLAXIS 237

loss. By this stage, the depth of anaesthesia Discussion: In this patient was observed
had lightened considerably and further drugs profound hypotension, broncho-occ1usion and
were administered :- tachycardia, all of which manifested themselves
pancuronium - 6 mg minutes after intravenous use of suxamethonium.
papaveretum - 15 mg Later she exhibited "lobster red" cutaneous
syntocinon - 10 LV. erythema and laryngeal and facial oedema
The relaxant was reversed with neostygmine causing stridor and necessitating intubation.
2·5 mg and atropine 1·2 mg. It is not known what anaesthetic technique was
Post Op Recovery: Following reversal of used during her childhood adenotonsillectomy,
relaxant the patient was slow to emerge and but her follow-up tests indicate that her ex-
her skin was noticed to be "lobster red" in perience of 1973 was probably wrongly attributed
colour. Finally she breathed spontaneously to alcuronium. On that occasion it is interesting
quite well and was extubated at 2 a.m. Within to note, there was no bronchospasm reported.
a half hour, she was noted to be developing Also use of continuous epidural anaesthesia
swelling of the eyelids, face, neck and tongue prior to this episode would restrict her ability
and to be developing a hoarse voice, stridor and, to compensate for the anaphylaxis. Hence she
eventually, signs of respiratory distress including would require greater volumes of intravenous
use of accessory muscles. The skin was becom- fluid. Her future management consists of pro-
ing more deeply reddened. Direct laryngoscopy vision of a " warning letter" and a disc indicat-
revealed oedema of the tongue, epiglottis and ing her" Anaphylaxis Suxamethonium " and as
pharynx, but normal vocal cords and the patient she may wish to have further children and is
was re-intubated with a size 7.0 mm cuffed certainly a potential candidate for further
Portex endotracheal tube. Promethazine (25 mg general anaesthesia, deep consideration about
+ 25 mg) was administered intravenously for future techniques is warranted.
anti-histaminic and sedative effects and the
patient allowed to breathe spontaneously on ACKNOWLEDGEMENTS
humidified 02' After the second dose of pro-
methazine the erythema of the skin lessened Dr. L. Doyle, Director of Anaesthesia for
and at 5.30 a.m., the patient extubated herself, her valuable advice and encouragement, Dr.
the blood pressure being 120/90 mmHg. Despite L. Brunello, Visiting Obstetrician and Dr.
slight upper airway obstruction still being E. Esler, Medical Superintendent, for permission
present, the patient continued to improve. to report this case.
She was discharged from hospital on 28.5.76
with a healthy male child and was instructed to REFERENCES
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Follow-up: Four weeks later the patient was Immunology", Harrison's Principles of Internal
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dilution of the following agents were injected Bourns, J. G., Collier, H. C. J., and Sommers, G. F.
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recommended by Fisher (1975)) :- Short Duration ", Lancet, 1, 1225.
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(4) neostygmine Nil Nil Eustace, B. R. (1967): "Case Report: Suxame-
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(6) alcuronium Nil Slight Fellini, A. A., Bernstein, R. L., and Zauder, H. L.
(7) suxamethonium 2 cm X 1·5 cm Generalised (1963) : " Bronchospasm due to Suxamethonium ",
at 24 minutes Report of a Case, Brit. j. Anaesth., 35. 657.
(S) d-tubocurarine 1·1 cm X 0·0 cm Generalised Fisher, M. MeD. (1975): "Severe Histamine Mediated
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IgG 970 mg% 500---1600 (normal range) Hunt, R., Taveau, de M. (1911): "Effects of Number
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IgE 20IU/ml 25-700 ID/ml " Laboratory Bulletin 73, Washington D.e.

Anaesthesia and Intensive Care, Vol. V, No. 3, August, 1977

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238 1\1. D. MATTHEWS ET AL.

Jerums, G., Whittingham J., and Wilson, P. (1967) : Lehmann, H., and Liddel, J. (1964) : "Suxamethonium
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FUTURE MEETINGS
1977 March 19-23, San Francisco: Meeting of the Inter-
September 16, London: Autumn Meeting of the national Anesthesia Research Society. Informa-
Obstetric Anaesthetist's Association of U.K. tion: Intnl. Ancsthesia Research Society, CI-
Information: Dr. B. Morgan, Institute of Obstetrics P.O. Box 11083, Richmond, Virginia, 23230, U.S.A.
and Gynaecology, Univ. of London, Queen April 1-7, Honolulu: Fourteenth Congress of the
Charlotte's Maternity Hosp., Goldhawk Rd., Pan-Pacific Surgical Association. Information:
London, W.6, U.K. Cesar B. deJ esus, M.D., Pan-Pacific Surgical
September 19-23, Paris: Second \Vorld Congress on Association, 236 Alexander Young Building, 1077
Intensive Care Information: Dr. R. Nedey, Bishop St., Honolulu, Hawaii, 96813, U.s.A.
Hospital Foch, 40 rue Worth 92151, Suresnes,
France. May, Hirosaki: 25th Congress of Japan Society of
September 30-0ctober 3, Mainz : International Congress Anaesthesiologists. Information: Tsutomu
on Disaster Medicine. Information: Prof. Dr. Oyama, MD, Hirosaki Univ. Schl. of Med.,
Rudholf Frey, Instit fur Anaesthesiologie, Univer- Hirosaki Aomori-Ken, Japan.
sitatskliniken, Langenbeckstr I, D-6500 Mainz, June 1-5, Kyoto: 13th World Congress on Diseases of
Bundesrepublik, Deutschland. the Chest. Information: Dr. A. Soffer, Exc. Dir.,
October 7-9, Nairobi: Fifth Annual Conference of the American College of Chest Physicians, 911 Busse
Society of Anaesthesiologists of East Africa. Highway, Park Ridge, Ill. 60068, U.s.A.
Information: Dr. Mary Miller, P.O. Box 30026, Autumn, Kyoto: 14th Intnl. Congress of Orthopaedic
Nairobi, Kenya. Surgery and Traumatology. Information: SICOT,
October 15-19, New Orleans: Annual Meeting of the 3 rue des Champs Elysees, Brussels 5, Belgium.
American Society of Anesthesiologists. Informa- August 27-September I, Montreal: Second 'World
tion: A.S.A.-Headquarters, 515 Busse Highway, Congress on Pain. Information: Secretariat,
Park Ridge, Illinois 60068, U.S.A. Second World Congress on Pain, 3587 University
October 20-23, Kuala Lumpur: Second Malaysian Street, Montreal, Quebec, H3A 2BI, Canada.
Congress of Anaesthesiologists Information: The September 4-9, Paris: Vth European Congress of
Organizing Honorary Secretary, CI- Malaysian Anaesthesiologists. Information: Congres
Socy. of Anaesthesiologists, P.O. Box S-20, Sentul, Anesthesia, PMV-B.P. No. 246-9220[), Meuilly
124 Jalan Pahang, Kuala Lumpur 02-14, Malaysia. SISein, France.
October 22-25, Tokyo: Fifth World Congress of September 13-15, Haifa: II th Congress of the Isreal
Acupuncture. Information: The Secretariat, 5th Society of Anesthesiologists. Information: Dr. G.
World Congress of Acupuncture, Cf- Japan Gurman, Secretary General, Rothchild University
Convention Services, Ine, 7-3-23, Roppongi, Hospital, P.O. Box 4940, Haifa, Israel.
Minato-ku, Tokyo 106, Japan.
October 23-29, New Delhi: 15th Intnl. Congress of September 17-23, Tokyo: 8th World Congress of
Pediatrics. Information: Prof. O. P. Ghai, Dept. Cardiology. Information: Dr. H. Sasamoto, Cf-
of Pediatrics, All-India Inst. of Medical Sciences, Japan Convention Services, 3-23 Roppongi
Ansari Nagar, New Delhi 110-016, India. 7-chrome, Minato-ku, Tokyo 106, Japan.
November 4-6, Toronto: Paediatric Anaesthesia September 23-27, New Delhi: Fifth Asian and Aust-
Symposium. Information: Co-ordinator, Paedi- ralasian Congress of Anaesthesiologists. Inform-
atric Anaesthesia Symposium, The Hospital for ation: The Secretariat, 5th Asian and Australasian
Sick Children, Toronto, Ontario, Canada. Congress of Anaesthesiologists, All India Institute
of Medical Sciences, New Delhi 110016, India.
1978 September 30-0ctober 5, Perth: Annual General
March 10, Brussels: Spring l\Ieeting of the Obstetric Meeting of the Australian Society of Anaesthetists.
Anaesthetist's Association of U.K. Information: Information: The Secretariat, Australian Society
Dr. A. Van Steenberge, 11 Vleitjeslaan, 1900 of Anaesthetists, P.O. Box 525, Potts Point,
Overyse, Belgium. N.S.W. 2011, Australia.
~Iarch 18-19, San Francisco: Third Annual Meeting of November, Sweden: 5th Intnl. Conference on Tetanus.
the American Society of Ecgional Anesthcsia. Information: Dr. E. Eriksson, Head, Div. of
Information: Secretary, A.S. of RA., P.O. Box Trauma, Kir. Klin. Exp. Karolinska Sjukhuset,
11083, Richmond, Virginia, 23230, U.S.A. 10401 Stockholm 60, Sweden.

Anaesthesia and Intensive Care, Vol. V, No. 3, August, 1977