Succinylcholine

Aka: Succinylcholine, Suxamethonium Chloride, Anectine

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II. Precautions

  1. Used only in Anesthesia, emergency and Intensive Care
  2. Airway and Respiratory Control is critical after use
  3. Paralytic Agents do not alter Level of Consciousness
    1. Must be used with sedation and analgesia

III. Indication

  1. Paralysis in Rapid Sequence Intubation

IV. Contraindications (use Rocuronium as alternative)

  1. Hyperkalemia risk
    1. Malignant Hyperthermia
    2. Burn Injury (more than 5 days from injury until healed)
    3. Muscle crush injury (more than 3 days from injury until healed)
    4. Spinal Cord Injury or stroke (more than 3 days from onset until 6 months later)
    5. Neuromuscular disorder (e.g. MS, Muscular Dystrophy, Myopathy)
    6. Serious intra-abdominal infection (more than 5 days from onset until infection resolved)
    7. Myopathy with elevated Creatine Phosphokinase
  2. Malignant Hyperthermia history or Family History
  3. Penetrating Eye Injury
  4. Narrow Angle Glaucoma
  5. Increased Intracranial Pressure
  6. Congestive Heart Failure

V. Mechanism

  1. Depolarizing Neuromuscular Blocking Agent (prototype)
    1. Cholinergic Agonist that blocks Acetylcholine from binding until it dissociates from receptor site
    2. Depolarization (Fasciculations) prior to paralysis is unique to Succinylcholine (other paralytics are non-depolarizing)
  2. Paralysis progression
    1. Chest and abdomen Fasciculations (depolarization)
    2. Paralysis of neck, arms and legs
    3. Paralysis of face, pharynx and Larynx
    4. Paralysis of respiratory Muscles

VI. Preparations

  1. Succinylcholine 20 mg/ml in 200 mg/10 ml vial

VII. Dose (based on Ideal Body Weight in obese patients)

  1. Initial dose
    1. IV Dose: 1 to 1.5 mg/kg up to 150 mg IV
      1. Example: 120 mg for an 80 kg patient
    2. IM Dose: 2-4 mg/kg up to 150 mg IM
    3. Raise dose if used with non-depolarizing agent
    4. Wait at least one minute for defasciculation prior to intubating (risk of Emesis)
    5. Avoid under-dosing (risk of difficult intubation)
  2. Maintenance dosing (if needed)
    1. Starts 5-10 minutes after initial dose
    2. Please see other references for maintenance dosing
    3. May be used as a continuous infusion

VIII. Pharmacokinetics

  1. Onset: <1 minute
  2. Duration: 4-6 minute (up to 8 minutes)
  3. Hydrolyzed by Acetylcholinesterase after it dissociates from Acetylcholine receptor sites

IX. Adverse Effects

  1. Bradycardia
  2. Hyperkalemia
    1. Routine Succinylcholine use in healthy patients raises Serum Potassium approximately 0.5 mEq
    2. Acetylcholine receptor up-regulation may significantly increase the Serum Potassium with Succinylcholine
      1. Acetylcholine receptor up-regulation occurs with specific conditions (see contraindications as above)
  3. Masseter Muscle spasm
  4. Malignant Hyperthermia
  5. Increased Intracranial Pressure
  6. Oxygen Saturation drops more quickly with Succinylcholine due to oxygen utilization for paralysis (depolarization)

X. References

  1. Miller in Katzung (1989) Pharmacology, p. 323-33
  2. Savarese in Miller (2000) Anesthesia, p. 412-90
  3. (2003) Lexicomp Drug database for Pocket PC

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