BACKGROUND: Anesthesia-associated rhabdomyolysis is a rare complication of surgery that causes postoperative myalgia, weakness, and potential renal failure if not managed promptly. Predisposing conditions that may lead to this complication include muscular dystrophies and myopathies.
METHODS: This rare case describes a pediatric non-Indigenous Australian patient developing this complication, with no known predisposing risk factors, and no clear etiology. A 9-year-old child with a background of asthma underwent an elective removal of keloid scar on her chest wall. The procedure was brief and uncomplicated, with an uneventful induction of anesthesia. During the emergence period, she developed acutely raised airway pressures with bronchospasm and laryngospasm requiring the use of salbutamol and suxamethonium with good effect. In the initial postoperative period, the patient complained of generalized myalgia and muscle weakness and was unable to mobilize independently. There was transient recovery to normal function; however, a recurrence of symptoms the following day with associated myalgias warranted admission to hospital. She was found to have rhabdomyolysis that was managed conservatively with a full recovery of several weeks. She was thoroughly investigated for any underlying cause, including genetic testing for malignant hyperthermia susceptibility (she had a variant of unknown significance but was negative for the known genetic abnormalities that cause malignant hyperthermia).
CONCLUSIONS: This case report demonstrates the importance of considering anesthesia-associated rhabdomyolysis as a differential for acute postoperative weakness, and outlines an investigative approach. To the best of our knowledge, it is the first case described in the pediatric literature to report biphasic progression of symptoms.

The evidence base for the widely accepted standard regimen of succinylcholine for rapid sequence induction (1.0 mg kg- 1) remains unclear.
We performed a systematic review and meta-analysis of randomized trials comparing any succinylcholine regimen with the standard regimen (1.0 mg kg- 1) and reporting on intubating conditions and/or apnoea times. Results were expressed as absolute risk differences (ARD) for dichotomous data and mean differences (MD) for continuous data.
We retrieved six trials with relevant data of 864 patients (ASA 1 or 2, aged 18-65 years, body mass index < 30 kg m- 2). Four regimens (0.3, 0.4, 0.5, 0.6 mg kg- 1) were compared with 1.0 mg kg- 1 in at least three trials each, and three (0.8, 1.5, 2 mg kg- 1) in one each. With 0.3 to 0.5 mg kg- 1, the likelihood of excellent intubating conditions was significantly decreased (ARD - 22% to - 67%). With 0.3 and 0.4 mg kg- 1, but not with 0.5, 0.6, 0.8, 1.5 and 2.0 mg kg- 1, the likelihood of unacceptable intubating conditions was significantly increased (ARD + 22% and + 32%, respectively). With 2.0 mg kg- 1, but not with 0.8 or 1.5 mg kg- 1, the likelihood of excellent intubating conditions was significantly increased (ARD + 23%). Apnoea times were significantly shorter with regimens ≤0.8 mg kg- 1 (MD - 1.0 to - 3.4 min) but were not reported with 1.5 or 2.0 mg kg- 1.
With succinylcholine regimens ≤0.5 mg kg- 1, excellent intubating conditions are less likely and apnoea times are shorter, compared with 1 mg kg- 1. With 0.3 and 0.4 mg kg- 1, unacceptable intubating conditions are more common. Succinylcholine 1.5 mg kg- 1 does not produce more often excellent conditions compared with 1 mg kg- 1, while 2.0 mg kg- 1 does, but the database with these regimens is weak and apnoea times remain unknown. Limited information size and strong statistical heterogeneity decrease the certainty of the evidence.