Administration Of Succinylcholine Research Articles

Hyperkalemia and cardiac arrest following succinylcholine administration in a 16-year-old boy with acute nonlymphoblastic leukemia and sepsis

To report a case of potentially lethal hyperkalemia related to succinylcholine administration. Case report. A 13-bed pediatric intensive care unit in a tertiary level, university-based children's hospital. A 16-yr-old boy treated in the intensive care unit due to Klebsiella pneumoniae sepsis, which developed after chemotherapy for nonlymphoblastic leukemia. After admission to the intensive care unit, the patient required intubation (uneventful under ketamine and succinylcholine) and mechanical ventilation. On the 15th day of therapy, when his respiratory variables improved significantly, he was extubated. His cardiac rhythm, respiratory rate, arterial blood pressure, and hemoglobin oxygen saturation were continuously monitored. Several hours later, however, he required reintubation due to respiratory insufficiency. For intubation, precurarization with pancuronium, ketamine, propofol, and succinylcholine was used. Before and immediately after reintubation, serum potassium levels were measured. Two minutes after intubation, premature ventricular contractions, ventricular fibrillation, bradycardia, and finally cardiac arrest were recognized. An increase of serum potassium from 3.19 to 8.64 mmol/L was observed in arterial blood. The patient was immediately resuscitated with chest compressions, intravenous adrenaline, atropine, lidocaine, and sodium bicarbonate. Potassium values normalized within 30 mins. Further treatment in the intensive care unit was uneventful, and the patient was weaned from mechanical ventilation and discharged to a hematology clinic. At present his mental and physical state is satisfactory. Succinylcholine may cause dangerous arrhythmias in septic and immobilized children. The alternative nondepolarizing agents should be used in such cases.

A Comparative Study of the Intubating Conditions and Cardiovascular Effects following Succinylcholine and Rocuronium in Adult Elective Surgical Patients

Background: The study was aimed to compare the effect on intubating conditions, onset, clinical duration and cardiovascular effects following administration of Succinylcholine and Rocuronium in Adult Elective Surgical patients. Materials and Methods: In a prospective randomised controlled trial, seventy five adult ASA grade I or II patients of either sex in the age group of 18-65 years undergoing elective surgery under general anaesthesia were given either succinylcholine 1mg/kg (group S), Rocuronium 0.6mg/kg (group R) or Rocuronium 0.9mg/kg (group R) after induction with thiopentone 4-6mg / kg body weight. Results and conclusion: The study revealed a statistically significant difference in onset time between the three groups: fastest in group S (52.8  15 sec) followed by R (102.6  40.8 sec) and R (163.2  58.2 sec) respectively. Intubating conditions were excellent to good in 92% patients in group S, 88% in group R and 100% in group R. Heart rate and mean arterial pressure were increased in all the three groups with persistence in group R+ > R > S.

Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution?

A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.

The effect of lidocaine and sufentanil in preventing intraocular pressure increase due to succinylcholine and endotracheal intubation

Succinylcholine administration, laryngoscopy and tracheal intubation are followed by increased intraocular pressure. Various premedications have been advocated for preventing increases in intraocular pressure, especially in patients undergoing surgical repair of open globe due to penetrating eye trauma. Results of studies in this area have been controversial. In this double-blind study, three groups of 70 patients receiving sufentanil, lidocaine and placebo 90 s prior to intubation were evaluated and compared for intraocular pressure changes following succinylcholine administration, laryngoscopy and tracheal intubation. Mean intraocular pressure measured 2 and 3 min after succinylcholine administration in groups receiving sufentanil and lidocaine was significantly lower than in the placebo group. Mean intraocular pressure changes in the three groups were -1.84, -2.03 and +2.82 mmHg, respectively in minute 2; -4.78, -4.73 and +1.35 mmHg, respectively in minute 5. There was a significant intraocular pressure decrease in the sufentanil and lidocaine groups, compared to the placebo group. The eye surgeons' satisfaction was also significantly higher with the sufentanil and lidocaine groups. Previous studies have yielded controversial results as to the effect of sufentanil and lidocaine in preventing intraocular pressure following succinylcholine administration, laryngoscopy and tracheal intubation. The present study affirms the preventive effect of these drugs on intraocular pressure increase.

Electroconvulsive therapy complicated by life-threatening hyperkalemia in a catatonic patient

Electroconvulsive therapy (ECT) requires brief general anesthesia, and succinylcholine is a depolarizing neuromuscular blocking agent that is frequently used for this procedure. Its use leads to intracellular potassium release into the extracellular space, usually increasing the serum potassium level by 0.5–1 mEq/L, with little clinical significance. However, long-term immobilization has been associated with changes at the neuromuscular junction (up-regulation of nicotinic cholinergic receptors) and subsequent serious hyperkalemia following succinylcholine administration. We report the case of a severely obese patient, immobilized due to her catatonic state, who developed life-threatening ventricular tachycardia after succinylcholine administration for ECT. Resumption of normal physical activity reverses these neuromuscular junctional changes, allowing subsequent safe succinylcholine administration. Current drug development may eliminate the need for succinylcholine use during ECT.

The Dose of Succinylcholine in Morbid Obesity

The appropriate dose of succinylcholine (SCH) in morbidly obese patients is unknown. We studied 45 morbidly obese (body mass index >40 kg/m2) adults scheduled for gastric bypass surgery. The response to ulnar nerve stimulation of the adductor pollicis muscle at the wrist was recorded using the TOF-Watch SX acceleromyograph. In a randomized double-blind fashion, patients were assigned to one of three study groups. In Group I, patients received SCH 1 mg/kg ideal body weight, in Group II 1 mg/kg lean body weight, and in Group III 1 mg/kg total body weight. After SCH administration, endotracheal intubating conditions were scored. The recovery from neuromuscular block was recorded for 20 min. There was no difference in the onset time of maximum neuromuscular blockade among groups, but maximum block was significantly less in Group I. The recovery intervals were significantly shorter in Groups I and II. In one third of the patients in Group I, intubating conditions were rated poor, whereas no patient in Group III had poor intubating conditions. Our study demonstrates that for complete neuromuscular paralysis and predictable laryngoscopy conditions, SCH 1 mg/kg total body weight is recommended.

Gordon syndrome and succinylcholine

We present a case of 6-year-old boy who developed severe hyperkalaemia and ventricular tachycardia after administration of succinylcholine. Ventricular tachycardia was defibrillated and Gordon syndrome, which was diagnosed subsequently, was treated successfully. Paediatric patients with underlying metabolic disorders such as Gordon syndrome are at high risk of developing severe hyperkalaemia after succinylcholine administration.

XXIVth Annual Meeting of the European Malignant Hyperthermia Group.

XXIVth Annual Meeting of the European Malignant Hyperthermia Group.

Pharmacogenetics and Anesthesiologists

Genetic variation contributes to an individual's sensitivity and response to a variety of drugs important to anesthetic practice. Early insights into the clinical impact of pharmacogenetics were provided by anesthesiology--investigations into prolonged apnea after succinylcholine administration, thiopental-induced porphyria and malignant hyperthermia contributed to the novel science of pharmacogenetics in the early 1960s. Genetic polymorphisms involved in pharmacokinetics (absorption, distribution, metabolism, and excretion of drugs) and pharmacodynamics (receptors, ion channels and enzymes) can affect an individual's response to the drugs used in anesthetic practice. In addition, genetic variation in proteins directly unrelated to drug action or metabolism can influence responses to environmental changes that occur during anesthesia. This review will summarize the current knowledge of genetic variation in response to drugs relevant to anesthesia, and how this impacts upon clinical practice.

Landiolol attenuates the cardiovascular response to tracheal intubation

The objective of this prospective study was to compare the cardiovascular responses with or without landiolol to the induction of general anesthesia and tracheal intubation. Twenty-two patients were randomly allocated to receive a loading dose of landiolol 125 microg kg(-1) min(-1) for 1 min followed by an infusion at 40 microg kg(-1) min(-1) for 4 min, or placebo. Four minutes after landiolol or placebo was started, propofol and succinylcholine were administered. Laryngoscopy and tracheal intubation were performed 1 min after the administration of succinylcholine. Heart rate and blood pressure were measured noninvasively every minute. A significant attenuation of the heart rate and blood pressure response were seen in the landiolol group for 3 min after intubation. Heart rate and systolic blood pressure in the landiolol group were decreased for 2 min before intubation and just before intubation compared with baseline, respectively. Continuous administration of landiolol before tracheal intubation results in the attenuation of cardiovascular response for tracheal intubation.

Rocuronium Versus Succinylcholine for Rapid Sequence Induction of Anesthesia and Endotracheal Intubation: A Prospective, Randomized Trial in Emergent Cases

When anesthesia is induced with propofol in elective cases, endotracheal intubation conditions are not different between succinylcholine and rocuronium approximately 60 s after the injection of the neuromuscular relaxant. In the present study, we investigated whether, in emergent cases, endotracheal intubation conditions obtained at the actual moment of intubation under succinylcholine differ from those obtained 60 s after the injection of rocuronium. One-hundred-eighty adult patients requiring rapid sequence induction of anesthesia for emergent surgery received propofol (1.5 mg/kg) and either rocuronium (0.6 mg/kg; endotracheal intubation 60 s after injection) or succinylcholine (1 mg/kg; endotracheal intubation as soon as possible). The time from beginning of the induction until completion of the intubation was shorter after the administration of succinylcholine than after rocuronium (median time 95 s versus 130 s; P < 0.0001). Endotracheal intubation conditions, rated with a 9-point scale, were better after succinylcholine administration than after rocuronium (8.6 +/- 1.1 versus 8.0 +/- 1.5; P < 0.001). There was no significant difference in patients with poor intubation conditions (7 versus 12) or in patients with failed first intubation attempt (4 versus 5) between the groups. We conclude that during rapid sequence induction of anesthesia in emergent cases, succinylcholine allows for a more rapid endotracheal intubation sequence and creates superior intubation conditions compared with rocuronium.

Tracheal intubating conditions and apnoea time after small-dose succinylcholine are not modified by the choice of induction agent

In a randomized, double-blind clinical trial, we studied the effect of different i.v. induction drugs on tracheal intubation conditions and apnoea time after small-dose (0.6 mg kg(-1)) succinylcholine used to facilitate orotracheal intubation at an urban, university-affiliated community medical centre. One hundred and seventy-five ASA I and II adult patients scheduled to undergo surgical procedures requiring general anaesthesia and tracheal intubation were allocated to one of five groups according to i.v. anaesthetic induction drug used. General anaesthesia was induced by i.v. administration of lidocaine 30 mg and propofol 2.5 mg kg(-1) (Group 1), thiopental 5 mg kg(-1) (Group 2), lidocaine 30 mg and thiopental 5 mg kg(-1) (Group 3), etomidate 0.3 mg kg(-1) (Group 4), or lidocaine 30 mg and etomidate 0.3 mg kg(-1) (Group 5). After loss of consciousness, succinylcholine 0.6 mg kg(-1) was given i.v. followed by direct laryngoscopy and tracheal intubation after 60 s. Measurements included intubation conditions recorded during laryngoscopy 60 s after succinylcholine administration, and apnoea time. Overall, clinically acceptable intubation conditions were met in 168 out of the 175 patients studied (96%). They were met in 35/35 patients in Group 1, 33/35 patients in Group 2, 34/35 patients in Group 3, 33/35 patients in Group 4, and 33/35 patients in Group 5. Mean (SD) apnoea time was 4.0 (0.4), 4.2 (0.3), 4.2 (0.6), 4.1 (0.2) and 4.1 (0.2) min respectively in Groups 1-5. There were no differences in the intubation conditions or apnoea times between the groups. The use of succinylcholine 0.6 mg kg(-1) produced the same favourable intubation conditions and a short apnoea time regardless of the induction drug used.

Masseter spasm after succinylcholine administration

We report the case of a 20-year-old woman who developed masseter spasm after receiving succinylcholine for rapid sequence intubation. Sometimes referred to as “jaws of steel,” masseter spasm secondary to anesthetic administration may progress to malignant hyperthermia. Although succinylcholine-induced masseter spasm is uncommon, it is important to be prepared to deal with this entity when administering succinylcholine.

Succinylcholine-induced masseter muscle rigidity during bronchoscopic removal of a tracheal foreign body

Masseter muscle rigidity during general anesthesia is considered an early warning sign of a possible episode of malignant hyperthermia. The decision whether to continue or discontinue the procedure depends on the urgency of the surgery and severity of masseter muscle rigidity. Here, we describe a case of severe masseter muscle rigidity (jaw of steel) after succinylcholine (Sch) administration during general anesthetic management for rigid bronchoscopic removal of a tracheal foreign body. Anesthesia was continued uneventfully with propofol infusion while all facilities were available to detect and treat malignant hyperthermia.

Bispectral Index Changes during Anesthesia Induction with Ketamine in Children

Background: The bispectral index (BIS) is a processed EEG information that has been validated as a means to measure the hypnotic effect of anesthetic drugs. The aim of this study was to evaluate the BIS changes during anesthesia induction with ketamine in children. Methods: Eighty-four ASA class I and II pediatric patients, aged 3-8 years, were enrolled in this study. In each patient the BIS value was recorded before anesthesia induction. Without premedication, eighty-four patients received ketamine bolus, 1.0 mg/kg (Group 1, n = 28) or 1.5 mg/kg (Group 2, n = 28) or 2.0 mg/kg (Group 3, n = 28). When unresponsiveness to verbal commands (UVC) and loss of eyelash reflex (LER) were ascertained, intubation was performed after administration of succinylcholine 1.5 mg/kg and anesthesia was maintained with 2.0% enflurane and 50% N2O-50% . Results: Ketamine bolus induced UVC and LER at which the BIS values were, 92.5 5.6 and 93.9 3.0 for Group 1, 92.5 6.3 and 92.6 4.4 for Group 2, and 93.0 4.3 and 91.0 4.1 for Group 3. BIS from UVC and LER to three minutes after ketamine bolus remained above 90 for Group 1 and 2, whereas lower than Group 1 for Group 3 (P ＜ 0.05). However, the BIS for Group 3 showed above 85 as patient entered into clinical anesthetic state. Conclusions: Our study showed that there is a lack of correlation between the BIS and the anesthetic state induced by ketamine in children aged 3-8 years. Monitoring the depth of ketamine anesthesia remains difficulty.

Hyperkalemic cardiac arrest following succinylcholine administration: The use of extracorporeal membrane oxygenation in an emergency situation

We report an 11-year-old male with undiagnosed myopathy, who developed cardiac arrest secondary to severe rhabdomyolysis and hyperkalemia following succinylcholine administration. The patient required extracorporeal membrane oxygenation support from which he was eventually weaned successfully. He died eleven days after the cardiac arrest as a result of apparent ischemic brain injury.

Muscular Injury After Succinylcholine and Electroconvulsive Therapy

Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1-60.1) ng/mL, compared with 61.2 (31.6-1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did. Both succinylcholine and electroconvulsive therapy cause muscular injury. However, we unexpectedly found that psychiatric patients who received succinylcholine and electroconvulsive therapy had less muscular damage than surgical patients who received succinylcholine for intubation. Therefore, appropriate use of succinylcholine can attenuate the muscular damaging effect from the therapy.

Neuromuscular effects and acute toxicity of an ethyl acetate extract of Spigelia anthelmia Linn.

An ethyl acetate extract of Spigelia anthelmia (EASa), with validated anthelmintic activity, was evaluated for its acute toxicity and general effects in albino Swiss mice and for neuromuscular relaxant activity in the frog sciatic-gastrocnemius and rectus abdominis preparation. The extract induced a dose-related myotonia and muscular paralysis of rapid onset at higher doses. The calculated LD50 after oral and intraperitoneal administration was 345.9 [241.4–484.7] mg/kg and 60.8 [47.4–80] mg/kg, respectively. In broilers, intramuscullar injection of EASa-induced spastic paralysis qualitatively similar to that obtained after succinylcholine administration and contrasting to the flaccid paralysis induced by d-tubocurarine. The contraction elicited by direct stimulation of the gastrocnemius was blocked by EASa by 54.3±4.7% (IC50 = 21.4 [11.2–35.8] μg/ml) and the twitches evoked by stimulation of the sciatic nerve were blocked by 69.1±7.4% (IC50 = 17.9 [4.5–34.23] μg/ml). EASa also blocked acetylcholine-induced contractions in the frog rectus abdominis by 58.6±7.4% (IC50 = 7.4 [1.7–15.28] μg/ml) but did not decrease tonic contractions induced by a high-potassium Ringer solution. In summary, the ethyl acetate extract of Spigelia anthelmia induces tonic paralysis in vivo, and decreases amplitudes of twitches and increases tonus of skeletal muscle in vitro.

Absence of neuromuscular blockade after administration of intratracheal succinylcholine

Bermejo, S.; Gallart, L.; Santiveri, X.; Soler, E.; Escolano, F.; Puig, M. M. Author Information

Neuromuscular effects and acute toxicity of an ethyl acetate extract of Spigelia anthelmia Linn.

An ethyl acetate extract of Spigelia anthelmia (EASa), with validated anthelmintic activity, was evaluated for its acute toxicity and general effects in albino Swiss mice and for neuromuscular relaxant activity in the frog sciatic-gastrocnemius and rectus abdominis preparation. The extract induced a dose-related myotonia and muscular paralysis of rapid onset at higher doses. The calculated LD 50 after oral and intraperitoneal administration was 345.9 [241.4–484.7] mg/kg and 60.8 [47.4–80] mg/kg, respectively. In broilers, intramuscullar injection of EASa-induced spastic paralysis qualitatively similar to that obtained after succinylcholine administration and contrasting to the flaccid paralysis induced by d-tubocurarine. The contraction elicited by direct stimulation of the gastrocnemius was blocked by EASa by 54.3±4.7% (IC 50 = 21.4 [11.2–35.8] μg/ml) and the twitches evoked by stimulation of the sciatic nerve were blocked by 69.1±7.4% (IC 50 = 17.9 [4.5–34.23] μg/ml). EASa also blocked acetylcholine-induced contractions in the frog rectus abdominis by 58.6±7.4% (IC 50 = 7.4 [1.7–15.28] μg/ml) but did not decrease tonic contractions induced by a high-potassium Ringer solution. In summary, the ethyl acetate extract of Spigelia anthelmia induces tonic paralysis in vivo, and decreases amplitudes of twitches and increases tonus of skeletal muscle in vitro.