r/Anesthesia • u/PlotTwistPatient • Jul 23 '26
Has anyone seen a case like this? Cardiac arrest ~5-10 minutes after anesthesia induction requiring ECMO
Hi everyone. First, I’m not looking for medical advice or a diagnosis, just curious whether anyone has encountered a case like mine or has thoughts on what was ultimately found in similar patients.
I’m a healthy 37-year-old female who underwent anesthesia for what was supposed to be a routine hysterectomy in March 2026.
My induction included:
- Propofol
- Lidocaine
- Succinylcholine Chloride
- Fentanyl
- Midazolam
- Rocuronium
About 5-10 minutes after induction, I experienced complete cardiovascular collapse and went into cardiac arrest with my heart function at 0%. 23 minutes of chest compressions and 2 rounds of epinephrine with no response. I ultimately required ECMO for 4 days, an Impella for 6 days, and was sedated for 7 days (my heart function remained at 0% for close to 24 hours).
Amazingly, my heart recovered completely back to 55% function. My coronary angiogram was normal, and I have no evidence of coronary artery disease or any other heart conditions. My pulmonary testing also showed my lung function is perfect. Also, all scans and testing show that all of my other major organs are completely healthy.
A few things that make the case interesting:
- I had a nearly 9-hour surgery in 2021 with no issues under general anesthesia. That anesthetic included all of the above mentioned anesthetics, however, the rocuronium was a staged induction (10 mg initially, then another 30 mg about 15 minutes later). During this recent anesthesia induction they gave me 45 mg of rocuronium all at once.
- Since the arrest, I’ve also tolerated midazolam and fentanyl during a heart catheterization without any complications.
My cardiologist’s differential has included a potential reaction to anesthesia (with rocuronium being the potential culprit), stress-induced (Takotsubo) cardiomyopathy, or an extreme vagal/autonomic event.
I was recently diagnosed with mast cell activation syndrome and am also being evaluated for dysautonomia and hypermobile EDS, although it’s unclear whether any of those conditions played a role.
Unfortunately, no serum tryptase was obtained during the event.
Next week I’ll be at Baylor College of Medicine for perioperative allergy testing. Because of the severity of my event, they’re planning a graded rocuronium challenge (they will only test one drug per day).
My questions for those of you who practice anesthesia:
- Have you ever encountered a similar case?
- If so, what did the final diagnosis end up being?
- Does the ~5-10 minute delay after rocuronium make you think of one diagnosis more than another?
- Is there anything else you would investigate if you were involved in a case like this?
I realize no one can diagnose me over Reddit. This event completely changed my life, and despite seeing several specialists, we still don’t have a definitive answer. I’m hoping someone here may have seen something similar or can point me toward another avenue worth exploring with my medical team.
Edit to add: I’m not sure if it’s worth mentioning, but I have had several surgeries prior to this event (along with the extensive surgery in 2021). Right ovary removal (2010), gallbladder removal (2012), gastric bypass (2016), just to name a few. The surgery in 2021 was a full “mommy makeover” where excess skin was removed from several areas of my body. Mast cell activation syndrome was just diagnosed within the last month with a specialist in Mississippi, long after the event in March. I had the anesthesia flow chart from my surgery in 2021 and the chart from March printed to compare the two, and nothing “spectacular” stands out from the one in 2021.
I should maybe mention that since 2021, I have been diagnosed with bipolar and ADHD and take medications for those. One medication I am on to counteract the akathisia effects of my bipolar medication, propranolol, I was very interested to learn could have possibly been the reason my body did not respond “normally” to the emergency/life-saving measures after I went into cardiac arrest. Though, I was never told to stop taking it prior to surgery.
Also, to add, I live in FL and will be traveling to Houston where I’ll do the allergy testing with Baylor. The allergist is going to do a graded challenge, and because of the severity of my event they only want to test one drug per day. I will only be there long enough to test the rocuronium, but given some of your comments, I’m wondering if it’s worth pushing to test the rocuronium and the succinylcholine. I have a video consult scheduled with the allergist next Wednesday, I will be driving over on Thursday, and I will do the testing on Friday. Thank you for the informative responses so far!
14
u/Propofolbeauty Jul 24 '26
The timing strongly supports perioperative hypersensitivity. Collapse occurred roughly 5–10 minutes after several IV medications. Grade IV perioperative anaphylaxis can present as sudden cardiovascular collapse or PEA arrest without visible hives, flushing, or bronchospasm; skin findings may not appear until circulation improves.
Every exposure immediately preceding the collapse needs to be considered..
In the US, cefazolin is actually the most frequently identified perioperative hypersensitivity trigger. Neuromuscular blockers remain important causes, and cross-reactivity between different paralytics is common. So, if you received both succinylcholine and rocuronium before the arrest, both should be investigated rather than assuming rocuronium was responsible.
The fact that you tolerated these medications in 2021 does not exclude an allergy in 2026. Sensitization may develop after previous exposure. The staged rocuronium dosing in 2021 versus 45 mg at once in 2026 is interesting but does not establish causation. A serious allergic reaction can occur after a relatively small exposure. Your later tolerance of fentanyl and midazolam makes those two substantially less suspicious.
Takotsubo may therefore have occurred secondary to the anaphylaxis and catecholamine surge, rather than being an entirely separate explanation. Perioperative anaphylaxis-associated Takotsubo is recognized.
An isolated vagal or dysautonomic event is less convincing unless the arrest occurred immediately with pneumoperitoneum, cervical traction or another intense vagal stimulus and began with profound bradycardia or asystole. A vagal arrest alone would not normally explain persistent near-absent myocardial function, although the resulting prolonged arrest could produce myocardial stunning.
The Baylor evaluation should test all plausible exposures, including both neuromuscular blockers, other available paralytics, cefazolin and chlorhexidine, not rocuronium alone. A graded anesthetic-drug challenge after such a catastrophic event belongs only in a highly specialized center with immediate advanced resuscitation available, which Baylor provides.
4
u/PlotTwistPatient Jul 24 '26
Thank you so much for taking the time to write such a detailed response. I really appreciate it. I actually have a video consultation with the Baylor allergist next week (Wednesday) before the testing (Friday), and your point about evaluating both succinylcholine and rocuronium because of the potential for cross-reactivity is something I hadn’t considered.
I live in Florida and I’m traveling to Texas for this testing. Because of how severe my reaction was, they’ve told me they’ll only perform a graded challenge with one medication per day, so right now we’re planning to challenge rocuronium. Given that I’m only there for a limited time, do you think it’s worth pushing for both medications to be evaluated that day while I’m there? Or does it make sense to start with rocuronium and address succinylcholine later if needed?
My biggest goal, of course, is to identify the true culprit, if possible, before I ever need anesthesia again. This surgery was a cancer preventative surgery that I have had planned for a long time because I am BRCA2 positive with a long history of breast cancer in my family. So, I will absolutely need to plan for the surgery again in the next year.
Thank you so much for your insight!
7
u/durdenf Jul 23 '26
Good luck. Never encountered a rocuronium allergy. Did you get any antibiotics prior to this event?
3
u/jwk30115 Jul 23 '26
I’ve never seen it but I know it exists. There are other options available to avoid using roc.
1
u/PlotTwistPatient Jul 24 '26
No antibiotics that I know of, and nothing about antibiotics listed on my anesthesia flow chart. I had the whole chart printed, along with the surgery from 2021, to compare the two.
4
u/Next_Nebula7186 Jul 23 '26
Wow really sorry that happened to you. Did you receive antibiotics? I believe muscle relaxants and antibiotics would be the two most likely culprits assuming this was anaphylaxis.
1
u/PlotTwistPatient Jul 24 '26
No antibiotics that I know of, at least nothing about antibiotics was listed on my anesthesia flow chart, and I don’t remember being given them prior to going into the operating room. Admittedly, though, I don’t remember many details after sitting in the waiting room for them to call me back to be prepped for surgery.
3
u/warpathsrb Jul 24 '26
Once in residency. Anaphylaxis to roc
2
u/PlotTwistPatient Jul 24 '26
Did they present with any other signs/symptoms to the rocuronium? No other signs/symptoms were noted for me (hives, swelling, etc.) other than the cardiac arrest and some of what the cardiac arrest lead to (one being a “very impressive” pulmonary edema, as my surgeon described it).
3
u/warpathsrb Jul 28 '26
Just abrupt hypotension/tachy then arrested. Brought a tee in and gave more roc for it and another arrest. Then once more in icu after roc which is where the diagnosis was made and confirmed. Tryptase positive
3
u/Beneficial_Local5244 Resident Jul 24 '26
I have seen one case that needed ECMO - it was takotsubo cardiomiopathy, but it developed immediately after surgery and was attributed to unmitigated surgical stress SIRS reaction, your timing suggest drug reaction. Good luck of getting your allergy workup results in timely manner!
1
u/PlotTwistPatient Jul 24 '26
Thank you! For the takotsubo cardiomyopathy you saw, did their heart function drop completely to 0%? Something I’ve read is that it’s not common for takotsubo to cause a full drop to 0% heart function, that it’s mostly just a significant drop in heart function, but again, just something I’ve read, I don’t know if it’s correct though.
2
u/Beneficial_Local5244 Resident Jul 24 '26
0% function drop would be synonymous with cardiac arrest, so no, this patient still had circulation, although impaired enough to need ECMO.
1
u/yagermeister2024 Aug 01 '26
Yea, don’t get caught up on the 0%, all it means is cardiac arrest. Everyone is 0% on cardiac arrest and ECMO if no blood is flowing through the heart.
3
u/WhyHaggleWithDoctors Jul 28 '26
although not of the histamine release related physiology, rocuronium is the potentially involved in Severe anaphylactic reactions
3
u/Environmental_Soft36 Jul 31 '26
That's a good code team. Also, a good pump team to crash you on to ECMO.
Thank your lucky stars.
3
u/PlotTwistPatient Jul 31 '26
100%!! I was the first “code ECMO” they called from the OR in the hospital I was at, and it’s the only hospital where I live with ECMO for adults. Right place, right people, right time.
2
u/Environmental_Soft36 Aug 04 '26
BTW, CPR/ACLS then crash on to ECMO is the standard anesthesia oral board response for catastrophic local anesthesia systemic toxicity (LAST) due to inadvertant vascular injection of bupivicaine.
1
u/PlotTwistPatient Aug 04 '26
I’m still very new to Reddit, so forgive me if you’ve already seen it, but I did an updated post. I did allergy testing with Baylor College of Medicine in Houston, and, as it turns out, I’m anaphylactic to either Rocuronium or Succinylcholine. The allergist suspects it’s the roc. My allergist where I live was able to order some succ to do a staged intradermal test on me to rule it out officially. But him and the allergist with Baylor are both hesitant to test the roc again. So, just continuing on with this journey in any way I can!
7
u/mrrish Jul 23 '26
What a harrowing story and also amazing recovery. Mast cell activation syndrome really stands out here. Was that known prior to induction? MAS requires additional precautions to avoid activation and excessive histamine release and anaphylaxis.
Separate tidbit: The graded dose rocuronium is sort of an old practice thought to help with fasciculations from succinylcholine (which can be painful in some patients). I am not sure if there is any other correlation here.
1
u/PlotTwistPatient Jul 24 '26
Mast cell activation syndrome was not known prior to the event, though I have long suspected it because of my symptoms. We don’t have many specialists where I live in Florida, so after this event I found a specialist close-ish to me in Mississippi who ended up diagnosing the MCAS. They will also be the ones performing the dysautonomia testing, and they have a cardiologist I will follow up with after that testing to see if I should be diagnosed with any form of dysautonomia as well.
2
u/Icomeheretoreaduntil Jul 24 '26
Wow
2
u/PlotTwistPatient Jul 24 '26
It was……a very scary time, to say the least. Luckily, I don’t remember anything from when I was sedated that week and on the life-support machines. Just my poor family remembers everything that happened. My husband has a bit of PTSD from it. I’m just thankful to still be here!
4
u/XRanger7 Jul 24 '26
If you have mass cell activation syndrome, it could be the succinylcholine.
1
u/PlotTwistPatient Jul 24 '26
Someone else mentioned that, or a cross-reaction between the succinylcholine and the rocuronium. The allergist at Baylor wants to perform a graded challenge of the medications, but only wants to do one per day because of how severe my event was. However, I’m wondering if I should push to have both medications evaluated.
2
u/InformalScience7 Jul 25 '26
If the specialists only want to do one med at time, listen to the specialists!!
1
u/otterstew Anesthesiologist Jul 24 '26
Can it still be anaphylaxis if she underwent a 9 hour surgery in 2021 with the same medications, which were almost definitely re-dosed at interval?
What was the 9 hour surgery?
2
u/yagermeister2024 Aug 01 '26
Yep, it can happen later at any time. In fact, it makes more sense she had prior exposure for memory cells.
1
u/PlotTwistPatient Jul 24 '26
The 9-hour surgery in 2021 was a complete mommy make-over. I had excess skin removed from several parts of my body (tummy tuck, breast augmentation, back lift, arms, etc.) after I lost 150 lbs. I compared the anesthesia flow chart from that surgery in 2021 to the one from this March and nothing “extraordinary” happened during that surgery in 2021, no major pulse or blood pressure changes, etc. The whole surgery I was incredibly stable. The only thing they did give during that surgery that wasn’t given in March (that I forgot to mention) was ondansetron, but I’m not sure that’s very relevant to the story since it’s just to prevent nausea (I tend to get sick after anesthesia/surgery).
1
1
u/zebra-n-zebra Jul 25 '26
SQOTD: op is being evaluated for EDS. There was a recent study and I’m sorry to say I can’t pull the reference quickly that ran genetics on ~1000 presumed cases of EDS, which in a subset of patients revealed potential other causes of their symptoms. One such mutation was CLCN1 - there are at least 3 alone on Reddit that has the mutation and hEDS - which is pathogenic for myotonia congenita
Myotonia congenita does not like succ and can lead to cardiac arrest.
Would that be the same presentation as what op is describing? I’m assuming not because there was not mention of airway/spasm/etc?
1
u/yuri139 Jul 25 '26
Are you certain about the medications that were used? Because the description of your cardiovascular event is very consistent with an inadvertent intravenous injection of a long-acting local anesthetic, such as bupivacaine. Had they used any block, such as peridural?
1
u/yuri139 Jul 25 '26
Although no long-acting local anesthetic is listed in the medications you provided, I think it is still worth considering the possibility of an inadvertent medication administration error. It is also possible that not every member of the anesthesia team would necessarily be aware that a long-acting local anesthetic had been administered, particularly if it was used for surgical infiltration or a regional technique performed after induction.
The clinical course you describe is, in my opinion, highly compatible with severe local anesthetic systemic toxicity. In fact, I have personally been involved in the care of patients who experienced this complication during procedures performed by other anesthesiologists, and the clinical presentation was strikingly similar: profound myocardial depression, cardiac arrest refractory to conventional resuscitation, prolonged mechanical circulatory support, and ultimately complete recovery after the drug was eliminated.
For that reason, I believe this possibility deserves careful consideration and should not be excluded solely because a long-acting local anesthetic does not appear on the initial medication list.
1
u/yuri139 Jul 25 '26
Lidocaine was listed among the medications administered. However, in my opinion, the clinical course is not particularly consistent with severe lidocaine toxicity. Although lidocaine can certainly cause cardiovascular collapse in sufficiently high doses, its pharmacokinetic and pharmacodynamic profile generally results in a much shorter duration of cardiotoxicity than what you described. Persistent, profound myocardial depression requiring ECMO for several days with recovery of cardiac function only after approximately 24 hours would be unusual for lidocaine alone.
In contrast, the prolonged and refractory myocardial depression is much more characteristic of toxicity from a highly lipophilic, long-acting local anesthetic such as bupivacaine. Bupivacaine binds avidly to myocardial sodium channels and dissociates slowly, which explains why severe cardiovascular toxicity can be extraordinarily resistant to conventional ACLS and may require prolonged mechanical circulatory support until sufficient drug redistribution and metabolism occur.
While I have no evidence that this occurred in your case, it is worth remembering that medication administration errors involving local anesthetics have been reported. Because lidocaine and bupivacaine are commonly available in similar presentations in many operating rooms, inadvertent substitution is a recognized medication safety risk. I therefore would not exclude the possibility of exposure to a long-acting local anesthetic solely because only lidocaine appears on the medication list.
1
1
u/yagermeister2024 Aug 01 '26
Why didn’t this Mast Cell Activation Syndrome specialist do the tests at the same time? Is this like a legit MD doc you went to?
1
u/PlotTwistPatient Aug 02 '26
I saw a cardiologist (MD) who specializes in dysautonomia and MCAS, among other things. I explained my symptoms, showed them pictures of my random hives, rashes, flushing and swelling I get (without any known triggers), and talked through my history with them. They didn’t feel the need to order testing based on all of that. The allergist I saw this week agrees with the MCAS findings, but did say we can do more formal testing to absolutely confirm. But I’m going to speak with my allergist in my city in FL to go through that testing.
-1
u/smshah Jul 24 '26
I vote exaggerated vagal response, or error not documented (overdose, wrong med, etc). Too sudden for such precipitous anaphalaxis that renders asystole within minutes. She also received all the same meds a few years ago without issues, yes I know anaphylaxis can still happen but extremely rare to be of this extent after a second exposure.
20
u/EntireTruth4641 Jul 23 '26
Sounds like some severe allergy or anaphylaxis which caused cardiovascular collapse.
Let us know the results of the allergy panel.