British Journal of Anaesthesia 1998; 80: 406–410 Anaesthesia after exhaustive exercise

Sir,—There are no reports on the effect of preceding exhaustive exercise, such as marathon running, on the course of anaesthesia. We report an extreme case. A healthy 21-yr old (65 kg,173 cm) active jogger (40–60 km/week) presented for day-case tonsillectomy under general anaesthesia. Three days earlier he had run his first marathon and told the anaesthetist that his legs were painful. He had difficulty in lying down on the operating table. After operation, he told us that after 30 km of the marathon he had become so exhausted that he could remember little of the rest of the race. An i.v. anaesthetic was used, supplemented with 70% nitrous oxide in oxygen. The drugs given and their total doses were as follows: glycopyrrolate 0.2 mg, propofol 280 mg, fentanyl 300 g and rocuronium 50 mg. Residual neuromuscular block was antagonized at the end of operation with neostigmine 2.5 mg and glycopyrrolate 0.5 mg. During surgery, 2500 ml of crystalloid i.v. solutions were given. Postoperative analgesia was achieved with ketoprofen. After operation the patient was able to breathe satisfactorily but despite normal responses to peripheral nerve stimulation he appeared extremely weak, that is he was unable to lift his head or even his hand. Because his condition had not improved after 6 h, he was moved to the local university hospital. Thirteen hours after operation the patient had to be escorted to the toilet by two people. Next morning he was able to walk but still complained of muscle pain, especially in his legs. The muscle pain disappeared gradually over the next 3 days. Eight hours after operation total blood count, C-reactive protein concentrations, serum concentrations of creatinine, sodium, potassium and chloride, and blood-gas analysis, serum lactate, ammonium ion and insulin concentrations were normal. The only abnormal value was serum creatine kinase (1572 u. litre 1, normal value 285 u. litre 1), which was still high 2 days after operation (5 days after the marathon it was 338 u. litre 1), but was within normal limits by 10 days after operation (114 u. litre 1). The patient underwent 31P-magnetic resonance spectroscopy (MRS) 33 h after the beginning of anaesthesia to assess the status of skeletal muscle energy metabolism.1 2 He was re-examined 5 months later for comparison. The patient resumed his usual training schedule 1 month after surgery. From the MRS studies we found no evidence of altered energy metabolism of striated muscle to anaesthesia after exhaustive exercise. Variables assessing the main energy producing pathways (phosphocreatinine hydrolysis, glycolysis or aerobic oxidative phosphorylation) were similar immediately after the incident compared with 5 months later. In contrast, resting concentrations of phosphodiesters were substantially higher immediately after the incident (4.5 compared with 2.7 mmol litre 1). Phosphodiesters are hypothesized to be indicators of release of membrane molecules in muscle cell damage.3 But muscle overuse is associated with damage to the muscle contractile elements.4 This damage to the contractile elements could also be an explanation for our phosphodiester results. After exhaustive exercise, a general anaesthetic could cause some type of interaction between the exhausted muscles and anaesthetic agents. Importantly, significant rhabdomyolysis may occur if succinylcholine is used. M. ERKINTALO M. KOMU K. MATTILA Department of Diagnostic Radiology