Succinylcholine: Adverse effects and alternatives in emergency medicine - ScienceDirect

The American Journal of Emergency Medicine

Volume 17, Issue 7, November 1999, Pages 715-721

The American Journal of Emergency Medicine

https://doi.org/10.1016/S0735-6757(99)90168-7 Get rights and content

Abstract

Succinylcholine has long been the favored neuromuscular blocking agent for emergent airway management because of its rapid onset, dependable effect, and short duration. However, it has a plethora of undesirable side effects, ranging from the inconsequential to the catastrophic. When patients requiring tracheal intubation present with potential contraindications to succinylcholine use, the emergency physician will need to substitute a rapid-onset nondepolarizing neuromuscular blocking agent, such as rocuronium or mivacurium. An understanding of the pharmacology of these agents is essential.

References (124)

BH DeGarmo et al.
Pharmacology and clinical use of neuromuscular blocking agents
Am J Emerg Med
(1983)
NR Connelly et al.
Temporal correlation of succinylcholine-induced fasciculations to loss of twitch response at different frequencies
J Clin Anesth
(1992)
R Cooper et al.
Comparison of intubating conditions after administration of organon 9426 and suxamethonium
Br J Anaesth
(1992)
WDM Paton
Mode of action of neuromuscular blocking agents
Br J Anaesth
(1956)
KE McGoldrick
The open globe: Is an alternative to succinylcholine necessary?
J Clin Anesth
(1993)
JM Hunter
Adverse effects of neuromuscular blocking drugs
Br J Anaesth
(1987)
CE Smith et al.
Pretreatment with nondepolarizing neuromuscular blocking agents and suxamethonium-induced increases in resting jaw tension in children
Br J Anaesth
(1990)
AS Christian et al.
Is there a relationship between masseteric muscle spasm and malignant hyperthermia?
Br J Anaesth
(1989)
MC Laxenaire et al.
Substances anesthetiques responsables de chocs anaphylactiques
Annales Francaises d'Anesthesia et de Reanimacion
(1990)
D Brahams
Fatal reaction to suxamethonium: Case for screening by the radioallergosorbent test?
Lancet
(1989)

DR Cook et al.

Pharmacokinetics of mivacurium in normal patients and in those with hepatic or renal failure

Br J Anaesth

(1992)

JE Caldwell et al.

Comparison of the neuromuscular block induced by mivacurium, suxamethonium and atracurium during nitrous oxide-fentanyl anaesthesia

Br J Anaesth

(1989)

WJ Book et al.

Adverse effects of depolarising neuromuscular blocking agents

Drug Safety

(1994)

Dr Bevan et al.

Succinylcholine

JJ Savarese et al.

Pharmacology of muscle relaxants and their antagonists

DR Cook

Pharmokinetics of SCC

Clin Pharm Ther

(1976)

TA Torda et al.

Pharmacokinetics and pharmacodynamics of suxamethonium

Anaesth Intensive Care

(1997)

DR Cook et al.

Pediatric anesthetic pharmacology

JE Szalados

Effect of d-tubocurare pretreatment on succinylcholine twitch augmentation and neuromuscular blockade

Anesth Analg

(1990)

FK Puhringer et al.

Evaluation of the endotracheal intubating conditions of rocuronium and succinylcholine in outpatient surgery

Anesth Analg

(1992)

JL Benumof et al.

Critical hemoglobin desaturation will occur before return to an unparalyzed state after administration of 1 mg/kg of intravenous succinylcholine

Anesthesiology

(1997)

SM Yentis

Suxamethonium and hyperkalemia

Anaesth Intensive Care

(1992)

J Norman

Succinylcholine

Curr Opin Anesth

(1991)

RD Henning et al.

Plasma potassium after halothane-suxamethonium induction in children

Anaesthesia

(1982)

WF List

Serum potassium changes during induction of anaesthesia

Br J Anaesth

(1967)

W Evers et al.

Changes in plasma potassium and calcium levels and in the electrocardiogram after a single dose of succinylcholine preceded by d-tubocurarine

Can Anaesth Soc J

(1976)

M-E Koller et al.

Synergistic effect of acidosis and succinylcholine-induced hyperkalemia in spinal cord transected rats

Acta Anaesthesiol Scand

(1984)

JH Cook

Effects of suxamethonium on introcular pressure

Anaesthesiology

(1981)

WY Abdulla et al.

Intraocular pressure changes in response to endotracheal intubation facilitated by atracurium or succinylcholine with or without lidocaine

Acta Anaesth Belg

(1992)

RE Kelly et al.

Succinylcholine increases intraocular pressure in the human eye with the extraocular muscles detached

Anesthesiology

(1993)

MM Libonati et al.

Use of succinylcholine in open eye surgery

Anesthesiology

(1985)

RD Miller et al.

Inhibition of succinylcholine-induced increase in intragastric pressure

Anesthesiology

(1971)

G Smith et al.

Gastroesophageal pressure gradient changes produced by induction of anesthesia and suxamethonium

Br J Anaesth

(1978)

AA Artru

Muscle relaxation with succinylcholine or vecuronium does not alter the rate of CSF production or resistance to reabsorption of CSF in dogs

Anesthesiology

(1988)

JE Cottrell et al.

Intracranial and hemodynamic changes after succinylcholine in cats

Anesth Analg

(1983)

AM Lam et al.

Succinylcholine and intracranial pressure: A cause for pause

Anesth Analg

(1984)

WL Lanier et al.

Cerebral stimulation following succinylcholine in dogs

Anesthesiology

(1986)

WD Kovarick et al.

Succinylcholine does not change intracranial pressure, cerebral blood flow velocity or the electroencephalogram in patients with neurologic injury

Anesth Analg

(1994)

MM Brown et al.

The effect of suxamethonium on the intracranial pressure and the cerebral perfusion pressure in patients with severe head injury following blunt trauma

Eur J Anaesth

(1996)

AHF Galindo

Succinylcholine and cardiac excitability

Anesthesiology

(1962)

V Nigrovic

Succinylcholine cholinoceptors and catecholamines

Can Anaesth Soc J

(1984)

EP Sherman et al.

Bradycardia following sufentanil-succinylcholine

Anesthesiology

(1987)

J Lerman

The heart rate response to succinylcholine in children: A comparison of atropine and glycopyrrolate

Can Anaesth Soc J

(1984)

SJ Basta

Modulation of histamine release by neuromuscular blocking drugs

Curr Opin Anesth

(1992)

RD Miller

Advantages of giving d-tubocurare before succinylcholine

Anesthesiology

(1972)

JB Brodsky et al.

Pancuronium pretreatment and post-succinylcholine myalgias

Anesthesiology

(1979)

EC Jansen et al.

Objective measurement of succinylcholine-induced fasciculations and the effects of pretreatment with pancuronium or gallamine

Anesthesiology

(1979)

NL Pace

Prevention of succinylcholine-induced myalgias

Anesth Analg

(1990)

C Lee

Succinylcholine update

Curr Opin Anesth

(1993)

Cited by (54)

Neuromuscular blocking agents and skeletal muscle relaxants
2022, Side Effects of Drugs Annual
Citation Excerpt :
The risk of adverse effects is increased in patients with plasma cholinesterase (butyrylcholinesterase) deficiency due its role in the metabolism of succinylcholine (Fig. 1) (Brazzolotto et al., 2021 [A]; Millet et al., 2021 [c]; Sasidharan & Dhillon, 2021 [A]). Nondepolarizing neuromuscular blocking agents are further classified as aminosteroids (pancuronium, rocuronium, vecuronium) and benzylisoquinoliniums (atracurium, cisatracurium) (Warr et al., 2011 [M]; Orebaugh, 1999 [R]). Adverse effects vary with each agent and some of the most common are as follows: pancuronium—flushing, hypotension, tachycardia, rocuronium– tachycardia, vecuronium —bradycardia, hypotension, flushing, atracurium—flushing, seizure, hypotension, cisatracurium– bronchospasm, bradycardia (Murray et al., 2016) [S].
The purpose of this chapter is to review the adverse effects associated with neuromuscular blocking agents and skeletal muscle relaxants. A literature search using PubMed, Medline, and Cochrane (January 2021–December 2021) was performed utilizing keywords: succinylcholine, suxamethonium, atracurium, cisatracurium, mivacurium, pancuronium, rocuronium, vecuronium, gantacurium, CW002, CW011, adamgammadex, sugammadex, neostigmine, calabadion, l-cysteine, baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, dantrolene, metaxalone, methocarbamol, orphenadrine, tizanidine, neuromuscular blocking agents, skeletal muscle relaxants, adverse effects, and side effects. All English-language reports during the specified year were included for this review. Adverse effects were reported for the following medications: succinylcholine (suxamethonium), cisatracurium, rocuronium, vecuronium, sugammadex, baclofen, cyclobenzaprine, and tizanidine. This chapter outlines the findings from the identified articles including adverse effects, suspected mechanisms underlying these effects, and implications to clinical practice and patient care.
Low-Dose of Rocuronium During Thyroid Surgery: Effects on Intraoperative Nerve-Monitoring and Intubation
2021, Journal of Surgical Research
Citation Excerpt :
Our study demonstrated that a low dose of rocuronium 0.3 mg kg−1 is suitable for the majority of the patients and effects on the neuromuscular system recover quickly. We preferred rocuronium to succinylcholine since the latter has not reversal agent and is characterized by adverse events, such as myalgia, hyperkalemia, increased intracranial and/or intraocular pressure and malignant hyperthermia.35-36 Among the benefits, rocuronium has also intermediated duration of action and when needed, a reversal agent is available.
Intraoperative Neurophysiological Monitoring (IONM) reduces the incidence of Recurrent Laryngeal Nerve (RLN) injuries during thyroid surgery. To preserve nerve function, long acting neuromuscular blocking agents (NMBA) should be avoided. However, NMBA are necessary for laryngoscopy and endotracheal intubation. We designed this double-blinded, randomized, placebo-controlled trial to assess if a low-dose of rocuronium given at intubation would affect the IONM data recorded before the thyroid dissection.
Hundred patients undergoing elective thyroid surgery were randomized to receive either 0.3 mg kg⁻¹ of low dose rocuronium (intervention) or no-NMBA (control). Intubation was performed with video-laryngoscopy. IONM was placed on RLN and nerve stimulation was performed before and after thyroid dissection. The presence of a valid amplitude prior to dissection was defined when the IONM signal was >100 μV. Occurrence of difficult laryngoscopy was reported together with intubation details including time, difficulty and failure. The lowest peripheral saturation (SpO₂) and the number of desaturation episodes during the intubation were also registered.
No patients showed impaired IONM signal before dissection in both groups. Cormack-Lehane grade was higher in the intervention group (1¹^; ²) compared to control one (1¹^; ¹; P = 0.046). No-NMBA patients had increased number of difficult laryngoscopies (21% versus 6%, P = 0.041) and intubations (34% versus 8%; P = 0.003) as well as a longer time to intubation (78 [55; 175] versus 55 [31; 110] sec; P = 0.006). Lower values of peripheral SpO₂ during intubation attempt were registered in the no NMBA group (99 [97; 100] versus 99 [99; 100] %; P = 0.020). However, the number of intubation failure was similar between groups (p=0.495).
Low-dose of rocuronium does not compromise pre-dissection IONM signal and improves intubation condition when compared to a relaxant free strategy.
Approach to Acute Weakness
2021, Emergency Medicine Clinics of North America
Neuromuscular blocking agents and skeletal muscle relaxants
2021, Side Effects of Drugs Annual
Citation Excerpt :
The risk of adverse effects is increased in patients with plasma cholinesterase deficiency (Zhu et al., 2020 [MC]; Bui & Asher, 2020 [A]; Suparschi et al., 2019 [A]). Nondepolarizing neuromuscular blocking agents are further classified as aminosteroids (pancuronium, rocuronium, vecuronium) and benzylisoquinoliniums (atracurium, cisatracurium) (Warr et al., 2011 [M]; Orebaugh, 1999 [R]; Torbic & Duggal, 2019 [R]; Mefford et al., 2020 [M]). Adverse effects vary with each agent and some of the most common are as follows: pancuronium—flushing, hypotension, tachycardia, rocuronium—tachycardia, vecuronium—bradycardia, hypotension, flushing, atracurium—flushing, seizure, hypotension, cisatracurium—bronchospasm, bradycardia (Murray et al., 2016 [S]; Torbic & Duggal, 2019 [R]; Mefford et al., 2020 [M]).
The purpose of this chapter is to review the adverse effects associated with neuromuscular blocking agents and skeletal muscle relaxants. A literature search using PubMed, Medline, and Cochrane (January 2020–December 2020) was performed utilizing keywords: succinylcholine, suxamethonium, atracurium, cisatracurium, mivacurium, pancuronium, rocuronium, vecuronium, gantacurium, CW002, CW011, adamgammadex, sugammadex, neostigmine, calabadion, L-cysteine, baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, dantrolene, metaxalone, methocarbamol, orphenadrine, tizanidine, neuromuscular blocking agents, skeletal muscle relaxants, adverse effects, and side effects. All English-language reports during the specified year were included for this review. Adverse effects were reported for the following medications between January 2020 and December 2020: succinylcholine (suxamethonium), cisatracurium, rocuronium, neostigmine, adamgammadex, sugammadex, baclofen, metaxalone, and tolperisone. This chapter outlines the findings from the identified articles including adverse effects, suspected mechanisms underlying these effects, and implications to clinical practice and patient care.
Contraindications to succinylcholine in the intensive care unit. A prevalence study
2015, Medicina Intensiva
Conocer la prevalencia de contraindicaciones a succinilcolina en pacientes ingresados en unidades de cuidados intensivos (UCI).
Estudio observacional, describiendo la frecuencia de contraindicaciones a succinilcolina por estancias. Análisis univariante de asociación de contraindicaciones con variables poblacionales.
UCI polivalente de hospital de tercer nivel.
Pacientes adultos críticos polivalentes. Se analizan en 30 días consecutivos todas las estancias.
Ninguna.
descriptivas de la población: edad, sexo, APACHE, SOFA, patología, días de ingreso, ventilación mecánica, depuración extrarrenal. Contraindicaciones: hiperpotasemia, encamamiento, rabdomiólisis, traumatismo muscular, quemadura, perfusión de bloqueante neuromuscular, fracaso renal agudo, insuficiencia renal crónica, hipertensión intraocular, hipertensión endocraneal, estatinas crónicas, antecedente de hipertermia maligna, enfermedad neuromuscular, sección medular, bradicardia < 50 lpm, alergia al fármaco, déficit de pseudocolinesterasa.
Ingresan 102 pacientes de 60±16 años, 56,9% varones, que generan 657 estancias. Patologías principales: cirugía cardiaca programada (33%), fallo respiratorio (22%) y sepsis (14%). Documentamos 466 estancias (70,9%) con alguna contraindicación, destacando encamamiento (140), bloqueante neuromuscular (101), fracaso renal agudo (126), estatinas (167), enfermedad neuromuscular (159) y bradicardia (76). Encontramos 74 estancias (11,3%) con alto riesgo de complicación (EARC) al asociarse factor de hiperkalemia con factor de disregulación de receptor. Se asocian a EARC: edad avanzada, hospitalización prolongada, estancia en UCI prolongada, APACHE-II superior, SOFA superior y estar en ventilación mecánica o depuración extrarrenal.
Dada la elevada prevalencia de contraindicaciones a succinilcolina observada desaconsejamos su uso en pacientes ingresados en UCI.
To determine the prevalence of contraindications to succinylcholine in patients admitted to the ICU.
An observational study was carried out, describing the frequency of succinylcholine contraindication by stays, and associating the contraindications to population variables.
The adult general ICU of a reference hospital.
Clinical-surgical critically ill patients. Thirty consecutive days were analyzed.
None.
Population variables: age, sex, APACHE II and SOFA scores, illness, days of hospitalization, mechanical ventilation and renal replacement therapy. Contraindications: hyperkalemia, bedridden patients, rhabdomyolysis, muscle trauma, burns, infusion of neuromuscular blocking agents, acute renal failure, chronic renal failure, intraocular hypertension, intracranial hypertension, statin use, malignant hyperthermia, neuromuscular disease, spinal cord sectioning, bradycardia < 50 bpm, succinylcholine allergy, and pseudo-cholinesterase deficiency.
A total of 102 patients were admitted, aged 60 ± 16 years (56.9% males), with the generation of 657 stays. Main diseases: elective heart surgery (33%), respiratory failure (22%) and sepsis (14%). We documented 466 stays (70.9%) with contraindications, particularly bedridden patients (n = 140), neuromuscular blocking agents (n = 101), acute renal failure (n = 126), statin use (n = 167), neuromuscular disease (n = 159) and bradycardia (n = 76). We recorded 74 stays (11.3%) at high risk of complications, secondary to hyperkalemic risk associated to receptor dysregulation. A high risk of complications was associated to advanced age, prolonged hospitalization, prolonged length of stay in the ICU, higher APACHE II and SOFA scores, mechanical ventilation and renal replacement therapy.
Given the high prevalence of contraindications to succinylcholine observed, we discourage its use in patients admitted to the ICU.
A comparison between succinylcholine and rocuronium on the recovery profile of the laryngeal muscles during intraoperative neuromonitoring of the recurrent laryngeal nerve: A prospective porcine model
2013, Kaohsiung Journal of Medical Sciences
The use of succinylcholine and rocuronium are reportedly feasible during intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) in thyroid surgery. This study aimed to investigate and compare the recovery profiles of succinylcholine and rocuronium on the laryngeal muscle during IONM of the RLN in a porcine model. Nine male Duroc-Landrace piglets were anesthetized with thiamylal and underwent tracheal intubation without neuromuscular blocking agents (NMBAs). Needle electrodes were inserted into the vocalis muscles through the cricothyroid ligament. The RLN was exposed and stimulated. Electromyographic (EMG) signals were obtained before and after the intravenous administration of a NMBA. The EMG amplitudes were measured before and after (at 1-minute intervals) the administration of the study drug until complete recovery. The study NMBA regimen included succinylcholine (1 mg/kg), low-dose rocuronium (0.3 mg/kg), and standard dose rocuronium (0.6 mg/kg). The maximal neuromuscular blockade and 80% recovery (i.e., duration) of the control responses were recorded and analyzed. The 80% recovery of the control response for succinylcholine (1 mg/kg) was 19.7 ± 1.5 minutes; low-dose rocuronium (0.3 mg/kg), 16.3 ± 2.5 minutes; and standard dose rocuronium (0.6 mg/kg), 29.3 ± 5.7 minutes. Succinylcholine (1 mg/kg) and low-dose rocuronium (0.3 mg/kg) had significantly shorter durations than standard dose rocuronium (0.6 mg/kg). The EMG signal recovery returned to baseline within 30 minutes in the succinylcholine and low-dose rocuronium groups, but it did not return to baseline until 1 hour after surgery in the rocuronium (0.6 mg/kg) group. In this study, succinylcholine (1 mg/kg) and low-dose rocuronium (0.3 mg/kg) had favorable recovery profiles on the laryngeal muscle. It is recommended that low-dose rocuronium may replace succinylcholine for the induction of general anesthesia during IONM of the RLN in thyroid surgery.

View all citing articles on Scopus

Copyright © 1999 Published by Elsevier Inc.