Br. J. Anaesth. (1981), 53, 981 RHABDOMYOLYSIS, MYOGLOBINURIA AND HYPERPYREXIA CAUSED BY SUXAMETHONIUM IN A CHILD WITH INCREASED SERUM CREATINE KINASE CONCENTRATIONS K. B. LEWANDOWSKI Rhabdomyolysis, myoglobinuria, hyperpyrexia, muscle weakness and stiffness occurred in a 4-yr-old boy after halothane anaesthesia and a single dose of suxamethonium. Neurological examination of the patient and his mother revealed no physical abnormality although in both the serum creatine kinase and lactic dehydrogenase concentrations were increased. McArdle's disease was excluded by a normal response to an ischaemic work test. Apparently normal individuals may show minimal signs of muscle destruction following the administration of suxamethonium or halothane or both, as demonstrated by slight increases in serum concentrations of creatine phosphokinase (CK), but without clinical manifestation. Subjects with an increase in their resting serum CK concentra- tion may develop significant destruction of striated muscles with clinical signs varying from muscle weakness, hyperaesthesia, myoglobinuria, mild increase in body temperature, mild metabolic acidosis, and marked increases in concentrations of their serum enzyme, to fulminating hyper- pyrexia, grave hypoxia, marked disorder of serum electrolyte concentrations and death. A case of anaesthesia complicated by rhabdomyolysis, myoglobinuria, muscle rigidity and a moderate increase in body temperature is presented. CASE REPORT A previously healthy, 4-yr-old boy presented for tonsillectomy. He had never been anaesthetized before, had no allergies and was considered a good anaesthesia risk. Before opera- tion the arterial pressure, heart rate, body temperature, haemoglobin concentration and packed cell volume were normal. Forty-five minutes before induction anaesthesia, pethidine 20mg and atropine 0.25 mg were given i.m. (body weight 19 kg). Anaesthesia was induced with nitrous oxide 41itremin~', oxygen 41itremin~' and 1.5% halothane given by mask. Breathing was K. B. LEWANDOWSKI, M.D., Department of Anaesthesiology, Central Hospital, PI 87, 50101 Mikkeli 10, Finland. 0007-0912/81/090981-04 501.00 spontaneous. Suxamethonium 25 mg was injected i.v.; muscle fasciculation was unusually strong and the jaw was not relaxed. Intubation of the trachea was performed with difficulty, although no additional neuromuscular blocker was given. There was no cyanosis. Anaesthesia was continued with a mixture of nitrous oxide and halothane in oxygen with spontaneous breathing. At the beginning of the operation the patient received thiopentone 25 mg because his limbs were stiff and the level of anaesthesia was considered inadequate. The later course of anaesthesia was judged to be normal except for slight stiffness of the upper limbs and a heart rate of 140-160 beat min" 1 Breathing was satisfactory and there was no cyanosis. Body temperature was not monitored. The operation lasted 30min. The trachea was extubated, oxygen administered via a face mask and the patient regained consciousness normally. Five hours later dark brown urine was voided and rhabdomyolysis and myoglobinuria were suspected. The rectal temperature was 38 °C; measurements were now made at frequent intervals. Oxygen 6 litre min" 1 was given via a mask. The rectal temperature never exceeded 38.2 °C. Body temperature was decreased to normal with electric fans. The possibility of malignant hyperpyrexia was appreciated and provision made for rapid lowering of the body temperature. The patient was conscious, orientated, and willing to drink water. Examination of urine showed a positive test for occult blood, but the urine contained no red cells on microscopic examination. A test for urine ketones was positive. The urine contained no © Macmillan Publishers Ltd 1981
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