Intra-lingual succinylcholine for the treatment of adult laryngospasm in the absence of IV access.

Sir,

A 76-year-old female, American Society of Anesthesiology Class 3 and weighing 143 pounds was scheduled to undergo an upper gastrointestinal endoscopy with ultrasound examination of pancreas under monitored anesthesia care (MAC). Pre-operative history included obstructive sleep apnea, type II diabetes, hypertension, chronic kidney disease, and severe rheumatoid arthritis. Airway assessment revealed mouth opening of less than 2 cm [Figure 1] with the minimal neck extension and flexion [Figures 2 and 3]. She had undergone a colectomy in 2009 and her trachea was intubated using a flexible laryngoscope at that time. However, due to difficulties during intubation and possible laryngeal edema, she was electively ventilated post-operatively for 2 days. About 4 months prior to the current admission she had undergone an uncomplicated colonoscopy under propofol-fentanyl sedation. As in the previous anesthetic, in view of difficult peripheral access, the left external jugular vein (EJV) was cannulated with a 20G IV cannula.

Figure 1

Maximum mouth opening

Figure 2

Position of the neck in full extension

Figure 3

Position of the neck in full flexion

Anesthesia was induced with propofol administered in incremental doses, up to 40 mg preceded by 40 mg of lidocaine. Maintenance was achieved with an infusion of propofol at 80 ∝g/kg/min. Intra-procedural hypoxemia necessitated endoscope withdrawal and mask ventilation that did not establish effective ventilation. Insertion of an laryngeal mask airway and an oropharyngeal airway failed to restore oxygenation. Complete laryngospasm ensued, and when an attempt was made to administer more propofol followed by suxamethonium to break laryngospasm, it was noticed that the IV cannula in the left EJV had accidentally been dislodged. Immediately, 200 mg of suxamethonium was injected into the tongue muscle. Mask ventilation was successfully established in 30 s and oxygen saturation restored to 100% within 60 s. She developed supraventricular tachycardia requiring adenosine about 5 min later. Mask ventilation was continued for about 6-8 min when the patient started breathing spontaneously. She was fully awake soon after with no recollection of any intra-operative events.

This is the first case of intralingual succinylcholine use in a patient undergoing endoscopy under MAC, to treat severe laryngospasm.[12345] With increasing use of propofol and ketamine by non-anesthesia providers and their use in the non-operating room settings, one should be aware of a situation like this and be prepared to treat it. Seeking an IV line especially in patients with difficult IV access could be potentially fatal. Injecting suxamethonium into the tongue while preparations are made to secure a surgical airway is a safer option.