Succinylcholine-induced hyperkalemia in a patient with mucositis secondary to chemotherapy.

OBJECTIVE: To report a case of fatal hyperkalemia owing to succinylcholine administration in a patient with mucositis secondary to chemotherapy. DESIGN: Case report. SETTING: Adult intensive care unit (ICU) at Dartmouth-Hitchcock Medical Center. PATIENTS: One patient with mucositis secondary to chemotherapy. MEASUREMENTS AND MAIN RESULTS: A 37-yr-old female with recently diagnosed acute myelogenous leukemia was admitted to the ICU with mental status changes and progressive dyspnea requiring intubation and mechanical ventilation. Before ICU admission, the patient had suffered from painful mucositis causing severe dysphagia and bleeding, which was thought to be the result of chemotherapy. By the 10th ICU day, the patient's respiratory and mental status improved and the patient was successfully extubated. However, 8 hrs after extubation, she gradually developed severe respiratory distress, requiring reintubation and mechanical ventilation. The patient was given 14 mg of etomidate and 100 mg of succinylcholine intravenously. Immediately after the intubation, she suffered cardiac arrest. Her serum potassium level was 13.1 mEq/L and HCO3- was 16 mEq/L. The resuscitation attempt was unsuccessful, and the patient was pronounced dead. CONCLUSION: Oral mucositis is a frequent and potentially severe complication of cancer chemotherapy. We believe that mucositis was a contributing factor to this case of fatal hyperkalemia after administration of succinylcholine, with a mechanism similar to that reported with thermal injury. Only nondepolarizing muscle relaxants should be used in patients who are at risk for mucositis. Mucositis should be added to the list of conditions in which succinylcholine is contraindicated.     

Intestinal villus and crypt cell responses to cholera toxin.

Adenylate cyclase activity was measured in rat small intestinal villus and crypt cells after in vivo and in vitro exposure to cholera toxin. The increase in intestinal adenylate cyclase induced by cholera toxin in vivo appeared to be largely confined to the villus cell with the largest increase observed for upper villus cells. Crypt cell adenylate cyclase was not responsive to cholera toxin. No response could be demonstrated for isolated villus or crypt cells incubated with cholera toxin in vitro. In vivo incubation with 125I-cholera toxin demonstrated binding to only villus cells. These results suggest that the major effect of cholera toxin was on villus cells rather than crypt cells and this was due to the greater accessibility or binding capacity of the villus cell to luminal cholera toxin.     

Demonstrating excellence in practice-based teaching for public health.

Demonstrating Excellence in Practice-based Teaching for Public Health is a report intended to provide a resource for practice-based teaching of public health and includes a brief explanation of terms and practices, as well as suggestions on methodologies for implementation. No comparable resource currently exists that assists faculty and practice partners to recognize, implement, and promote practice-based teaching. This article summarizes findings from the report, including an explanation of practice-based teaching, its guiding principles, practical approaches, and recommendations on sustaining and advancing partnerships for professional public health education and training.