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SUCCINYLCHOLINE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Succinylcholine is a depolarizing neuromuscular blocking agent.

Specific Substances

    A) SUCCINYLCHOLINE BROMIDE
    1) Choline bromide succinate
    2) Suxamethonium bromide
    3) CAS 55-94-7
    SUCCINYLCHOLINE CHLORIDE
    1) Choline chloride succinate
    2) Succicurarium chloride
    3) Suxamethonii chloridum
    4) Suxamethonium chloride
    5) Suxametonklorid
    6) CAS 6101-15-1

Available Forms Sources

    A) FORMS
    1) Succinylcholine is available only in parenteral preparations, either as a powder to be reconstituted for injection or as an injectable solution containing anywhere from 20 to 100 mg/mL per 10 mL vials or ampules. The powder generally contains 500 mg or 1 gram per vial (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).
    B) USES
    1) Succinylcholine is used as an adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Succinylcholine is a depolarizing neuromuscular blocking drug utilized to temporarily paralyze patients as an adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.
    B) PHARMACOLOGY: Succinylcholine is a depolarizing skeletal muscle relaxant. Like acetylcholine, it depolarizes the postsynaptic membrane, producing repetitive excitation of the motor end plate. With persistent depolarization, flaccid paralysis (phase l block) subsequently follows within 1 minute of an intravenous injection of succinylcholine. Paralysis is rapidly reversed due to hydrolysis of the drug by plasma pseudocholinesterase. With repeated or continuous administration, the depolarizing blockade can change to a phase II block where neuromuscular blockade resembles that of curare. It is characterized by tetanic facilitation and fed in the response to successive stimulation ("train-of-four"). Prolonged apnea may be observed.
    C) TOXICOLOGY: Inadvertent overdose or administration of succinylcholine to patients deficient in pseudocholinesterase is expected to cause prolonged paralysis and apnea. If the patient does not receive respiratory support, this will progress to hypoxia, acidosis, and cardiovascular collapse. Hyperkalemia is caused by excessive stimulation of postsynaptic neuromuscular acetylcholine receptors which are increased in number in patients with certain underlying neuromuscular conditions. Malignant hyperthermia is caused by various genetic defects involving skeletal muscle receptor/regulatory proteins, especially the type 1 ryanodine receptor.
    D) EPIDEMIOLOGY: Overdose is rare. Succinylcholine has rarely been used to commit homicide. While the incidence of malignant hyperthermia from succinylcholine is unknown, the observed incidence of malignant hyperthermia with patients receiving general anesthesia is between 1 in 5000 and 1 in 60,000.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Muscle rigidity, prolonged myalgia, and raised intraocular pressure can occur during therapeutic use. Bradycardia, hypotension, brady- or tachyarrhythmias and cardiac arrest may develop. Severe hyperkalemia and ventricular dysrhythmias may develop in patients in catabolic states or underlying neuromuscular conditions, including extensive burns, traumatic muscle injury, paraplegia, hemiplegia, muscular dystrophy, multiple sclerosis, prolonged pharmacologic neuromuscular blockade, upper motor neuron injury or extensive denervation of skeletal muscle. Malignant hyperthermia may develop in genetically susceptible individuals.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: In mild overdose, patients may demonstrate a mild prolongation in the duration of neuromuscular blockade.
    2) SEVERE TOXICITY:
    a) ACUTE TOXICITY: Inadvertent overdose or administration of succinylcholine to patients deficient in pseudocholinesterase is expected to cause prolonged neuromuscular paralysis and apnea. If the patient does not receive respiratory support, this will progress to hypoxia, acidosis, and cardiovascular collapse, bradycardia, hypotension, brady- or tachyarrhythmias, and cardiac arrest may develop. Severe hyperkalemia and ventricular dysrhythmias may develop in patients with underlying neuromuscular conditions or catabolic states. Malignant hyperthermia, characterized by abrupt onset of tachycardia, hypotension, muscle rigidity, metabolic acidosis and severe hyperthermia, may develop in genetically susceptible individuals.
    b) CHRONIC TOXICITY: Following prolonged administration of succinylcholine patients may develop a prolonged neuromuscular block effect that can last several hours (up to 12 hours in rare cases).
    0.2.3) VITAL SIGNS
    A) WITH THERAPEUTIC USE
    1) Respiratory depression is common; bradycardia and hypotension may occur. Malignant hyperthermia may develop in susceptible individuals.
    0.2.5) CARDIOVASCULAR
    A) WITH THERAPEUTIC USE
    1) Bradycardia, hypotension, cardiac dysrhythmias, and cardiac arrest may occur. Nodal rhythm and ectopic beats have followed single IV doses.
    B) WITH POISONING/EXPOSURE
    1) Hypotension, transient hypertension, and tachycardia may be seen with overdose.
    0.2.6) RESPIRATORY
    A) WITH POISONING/EXPOSURE
    1) Intermittent apnea followed by respiratory arrest may occur.
    0.2.7) NEUROLOGIC
    A) WITH THERAPEUTIC USE
    1) Malignant hyperthermia may occur in genetically susceptible individuals. Severe acidosis, tachycardia, hyperkalemia, and hemoglobinuria or myoglobinuria with elevated CK (creatine kinase) may be noted along with increasing core body temperature.
    2) Succinylcholine administration may lead to a rise in ICP.
    0.2.10) GENITOURINARY
    A) WITH THERAPEUTIC USE
    1) Renal failure may occur secondary to rhabdomyolysis.
    0.2.12) FLUID-ELECTROLYTE
    A) WITH THERAPEUTIC USE
    1) Hyperkalemia may develop and can be severe. It usually occurs in patients predisposed to a catabolic state.
    0.2.19) IMMUNOLOGIC
    A) WITH THERAPEUTIC USE
    1) Allergic and anaphylactic reactions to succinylcholine have been reported, including bronchial spasms and a fatality.
    0.2.20) REPRODUCTIVE
    A) Succinylcholine is classified as FDA pregnancy category C. It has been reported that small amounts of succinylcholine will cross the placental barrier, but it does not adversely affect the neonate when it is used for caesarean section.

Laboratory Monitoring

    A) Monitor vital signs, pulse oximetry, ECG, and end-tidal CO when utilizing succinylcholine.
    B) Serum electrolytes, renal function and CPK should be obtained if rhabdomyolysis, hyperkalemia, or malignant hyperthermia is suspected.
    C) Monitor continuous core temperature, if malignant hyperthermia is suspected.
    D) Obtain an ECG and institute continuous cardiac monitoring.

Treatment Overview

    0.4.6) PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Ventilate as clinically indicated. Most patients will recover if an adequate airway, ventilation and oxygenation are established rapidly. Do NOT administer physostigmine, neostigmine or other anticholinesterase drugs, including edrophonium, since these agents will prolong the toxicity.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Endotracheal intubation and mechanical ventilation will be necessary as apnea may be prolonged. Treat malignant hyperthermia with rapid cooling, mild hyperventilation and dantrolene. Treat severe hyperkalemia with intravenous calcium chloride, sodium bicarbonate, and insulin and dextrose.
    C) DECONTAMINATION
    1) PREHOSPITAL: Administered parenterally; decontamination is not indicated.
    2) HOSPITAL: Administered parenterally, decontamination is not indicated.
    D) AIRWAY MANAGEMENT
    1) Intubate and ventilate as clinically indicated.
    E) MALIGNANT HYPERTHERMIA
    1) Immediately stop any offending xenobiotic therapy. Aggressive treatment includes: rapid cooling, 100% oxygen, correction of hyperkalemia and acidemia, if present. DANTROLENE: ADULT or CHILD: 1 mg/kg IV push initially repeated as needed up to a maximum cumulative dose of 10 mg/kg may be effective. Avoid using calcium channel blockers to treat hypertension as this may worsen the hyperkalemia. If malignant hyperthermia is suspected refer to the Malignant Hyperthermia Association of the US at http://www.mhaus.org or call the MH Emergency Hotline at 1-800-MH-HYPER (1-800-644-9737). Outside the US, call: 00+1+209-417-3722.
    F) HYPERKALEMIA
    1) Treat severe hyperkalemia (associated dysrhythmias, QRS widening) aggressively. These agents may be considered: CALCIUM CHLORIDE: ADULT: 5 mL IV bolus of a 10% solution over 5 minutes; CHILD: 0.2 to 0.3 mL/kg of a 10% solution over 5 to 10 minutes (20 to 30 mg/kg/dose). SODIUM BICARBONATE: ADULT or CHILD: 1 to 2 mEq/kg IV bolus. INSULIN/DEXTROSE: ADULT: 5 to 10 units regular insulin IV bolus with 100 mL of D50 IV immediately. CHILD: 0.5 to 1 g/kg dextrose as D25 or D10 IV followed by 1 unit of regular insulin for every 4 g of dextrose infused. SODIUM POLYSTYRENE SULFONATE: ADULT: 15 to 60 g by NG tube or rectal enema; CHILD: 1 g/kg by NG tube or rectal enema.
    G) HYPOTENSION
    1) Infuse an isotonic fluid at 10 to 20 mL/kg; dopamine; norepinephrine.
    H) BRADYCARDIA
    1) Give atropine as indicated.
    I) RHABDOMYOLYSIS
    1) Early aggressive fluid replacement is indicated to prevent renal insufficiency. Mannitol or furosemide may be needed to maintain urine output. Urinary alkalinization is not routinely recommended.
    J) ANTIDOTE
    1) Dantrolene is the antidote for malignant hyperthermia. DANTROLENE: ADULT or CHILD: 1 mg/kg IV push initially repeated as needed up to a maximum cumulative dose of 10 mg/kg may be effective.
    K) ENHANCED ELIMINATION
    1) Not useful to increase succinylcholine clearance.
    L) PATIENT DISPOSITION
    1) OBSERVATION CRITERIA: Patients experiencing prolonged weakness following the administration of succinylcholine should be observed until their strength returns to baseline.
    2) ADMISSION CRITERIA: Any patient with significant hyperkalemia or malignant hyperthermia should be monitored in an ICU setting for a minimum of 24 hours.
    3) CONSULT CRITERIA: A toxicologist should be consulted on patients with prolonged paralysis or severe hyperkalemia that does not respond to treatment. If malignant hyperthermia is suspected refer to the Malignant Hyperthermia Association of the US at http://www.mhaus.org or call the MH Emergency Hotline at 1-800-MH-HYPER (1-800-644-9737). Outside the US, call: 00+1+209-417-3722.
    M) PHARMACOKINETICS
    1) Onset: IV: 30 to 60 seconds; IM: 1 to 4 minutes. Duration: IV: 6 to 10 minutes; IM: 15 to 30 minutes. It distributes to extracellular fluid. Undergoes rapid hydrolysis by plasma pseudocholinesterase, 70% of a 100 mg bolus is hydrolysed in 1 minute. Renal excretion is 10%.
    N) PITFALLS
    1) Failure to recognize jaw muscle spasm and hypercapnia following the administration of succinylcholine which are early indicators of malignant hyperthermia. Administering succinylcholine to patients at increased risk for hyperkalemia (ie, patients with extensive burns, traumatic muscle injury, paraplegia, hemiplegia, muscular dystrophy, multiple sclerosis, prolonged pharmacologic neuromuscular blockade, upper motor neuron injury or extensive denervation of skeletal muscle).
    O) DIFFERENTIAL DIAGNOSIS
    1) The differential diagnosis for paralysis includes use of other neuromuscular blocking agents, tetrodotoxin poisoning. The differential diagnosis for causes of hyperkalemia includes renal insufficiency, multiple xenobiotics (ie, ACE inhibitors, digoxin, NSAIDs), mineralocorticoid deficiency, massive blood transfusions, acidosis and excessive potassium intake. The differential diagnosis for malignant hyperthermia includes neuroleptic malignant syndrome, propofol infusion syndrome, serotonin syndrome, thyroid storm, pheochromocytoma, baclofen withdrawal, meningitis, salicylate poisoning, sympathomimetic poisoning and anticholinergic poisoning.

Range Of Toxicity

    A) TOXICITY: Succinylcholine is rapidly redistributed, and overdose is rare. An excessive prolonged infusion of succinylcholine may cause a prolonged effect (paralysis) lasting up to 12 hours following the cessation of administration. Hyperkalemia and malignant hyperthermia can occur in a patient predisposed to these events and are not dose dependent.
    B) THERAPEUTIC DOSE: ONSET of action begins within 30 seconds and terminates in 3 to 5 minutes unless there is abnormal pseudocholinesterase.
    1) RAPID SEQUENCE INTUBATION: ADULT: 1.5 mg/kg IV; PEDIATRIC: Older children and adolescents: 1 mg/kg IV; Infants and small children: 2 mg/kg IV.
    2) INDUCTION AND NEUROMUSCULAR BLOCKADE, during surgery, long procedures: ADULT: 2.5 to 4.3 mg/min continuous IV infusion. During surgery, short procedures: ADULT: 0.6 mg/kg IV (range 0.3 to 1.1 mg/kg) over 10 to 30 seconds.

Clinical Effects

Summary Of Exposure

    A) USES: Succinylcholine is a depolarizing neuromuscular blocking drug utilized to temporarily paralyze patients as an adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.
    B) PHARMACOLOGY: Succinylcholine is a depolarizing skeletal muscle relaxant. Like acetylcholine, it depolarizes the postsynaptic membrane, producing repetitive excitation of the motor end plate. With persistent depolarization, flaccid paralysis (phase l block) subsequently follows within 1 minute of an intravenous injection of succinylcholine. Paralysis is rapidly reversed due to hydrolysis of the drug by plasma pseudocholinesterase. With repeated or continuous administration, the depolarizing blockade can change to a phase II block where neuromuscular blockade resembles that of curare. It is characterized by tetanic facilitation and fed in the response to successive stimulation ("train-of-four"). Prolonged apnea may be observed.
    C) TOXICOLOGY: Inadvertent overdose or administration of succinylcholine to patients deficient in pseudocholinesterase is expected to cause prolonged paralysis and apnea. If the patient does not receive respiratory support, this will progress to hypoxia, acidosis, and cardiovascular collapse. Hyperkalemia is caused by excessive stimulation of postsynaptic neuromuscular acetylcholine receptors which are increased in number in patients with certain underlying neuromuscular conditions. Malignant hyperthermia is caused by various genetic defects involving skeletal muscle receptor/regulatory proteins, especially the type 1 ryanodine receptor.
    D) EPIDEMIOLOGY: Overdose is rare. Succinylcholine has rarely been used to commit homicide. While the incidence of malignant hyperthermia from succinylcholine is unknown, the observed incidence of malignant hyperthermia with patients receiving general anesthesia is between 1 in 5000 and 1 in 60,000.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Muscle rigidity, prolonged myalgia, and raised intraocular pressure can occur during therapeutic use. Bradycardia, hypotension, brady- or tachyarrhythmias and cardiac arrest may develop. Severe hyperkalemia and ventricular dysrhythmias may develop in patients in catabolic states or underlying neuromuscular conditions, including extensive burns, traumatic muscle injury, paraplegia, hemiplegia, muscular dystrophy, multiple sclerosis, prolonged pharmacologic neuromuscular blockade, upper motor neuron injury or extensive denervation of skeletal muscle. Malignant hyperthermia may develop in genetically susceptible individuals.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: In mild overdose, patients may demonstrate a mild prolongation in the duration of neuromuscular blockade.
    2) SEVERE TOXICITY:
    a) ACUTE TOXICITY: Inadvertent overdose or administration of succinylcholine to patients deficient in pseudocholinesterase is expected to cause prolonged neuromuscular paralysis and apnea. If the patient does not receive respiratory support, this will progress to hypoxia, acidosis, and cardiovascular collapse, bradycardia, hypotension, brady- or tachyarrhythmias, and cardiac arrest may develop. Severe hyperkalemia and ventricular dysrhythmias may develop in patients with underlying neuromuscular conditions or catabolic states. Malignant hyperthermia, characterized by abrupt onset of tachycardia, hypotension, muscle rigidity, metabolic acidosis and severe hyperthermia, may develop in genetically susceptible individuals.
    b) CHRONIC TOXICITY: Following prolonged administration of succinylcholine patients may develop a prolonged neuromuscular block effect that can last several hours (up to 12 hours in rare cases).

Vital Signs

    3.3.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Respiratory depression is common; bradycardia and hypotension may occur. Malignant hyperthermia may develop in susceptible individuals.
    3.3.2) RESPIRATIONS
    A) WITH THERAPEUTIC USE
    1) Decreased respirations followed by prolonged periods of apnea may occur (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Sapsford & Bush, 1986; Taylor & McCarroll, 1994).
    3.3.3) TEMPERATURE
    A) WITH THERAPEUTIC USE
    1) MALIGNANT HYPERTHERMIA may occur in susceptible patients (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Larach et al, 1987).
    3.3.4) BLOOD PRESSURE
    A) WITH THERAPEUTIC USE
    1) Hypotension may occur with therapeutic use (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010). Cardiovascular collapse may develop in patients with succinylcholine-induced hyperkalemia (Williams et al, 1961; Mazze et al, 1969).
    2) Hypertension may develop with therapeutic use (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010). A transient rise in blood pressure may occur (Williams et al, 1961).
    3.3.5) PULSE
    A) WITH THERAPEUTIC USE
    1) Bradycardia may develop after therapeutic doses (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Williams et al, 1961).
    2) Tachycardia may occur following therapeutic use (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).

Heent

    3.4.3) EYES
    A) WITH THERAPEUTIC USE
    1) Increased intraocular pressure has been reported following therapeutic use of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).

Cardiovascular

    3.5.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Bradycardia, hypotension, cardiac dysrhythmias, and cardiac arrest may occur. Nodal rhythm and ectopic beats have followed single IV doses.
    B) WITH POISONING/EXPOSURE
    1) Hypotension, transient hypertension, and tachycardia may be seen with overdose.
    3.5.2) CLINICAL EFFECTS
    A) BRADYCARDIA
    1) WITH THERAPEUTIC USE
    a) Bradycardia has developed with therapeutic use of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    b) Bradycardia may occur secondary to severe hyperkalemia and may progress rapidly to asystole or ventricular fibrillation in this setting (Rosenberg & Gronert, 1992).
    c) Mild bradycardia is more common in infants and small children (Cook, 1986).
    d) Bradycardia was reported more frequently when multiple therapeutic injections were given at least 3 minutes apart (Williams et al, 1961).
    e) CASE REPORT: Bradycardia and asystole occurred in a 43-year-old woman following administration of d-tubocurare 3 mg, sufentanil 50 mg, thiopental 200 mg, and succinylcholine 120 mg IV (Sherman et al, 1987).
    f) Single IV injections of 100 mg succinylcholine preceded by fentanyl, etomidate and pancuronium Br, have produced severe bradycardia and asystole (Inoue & Reichelt, 1986).
    B) TACHYCARDIA
    1) WITH THERAPEUTIC USE
    a) Sinus tachycardia and a rise in blood pressure (generally transient) may occur after therapeutic use (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010), and have been reported after therapeutic doses given 1.5 to 2 minutes apart (Williams et al, 1961).
    2) WITH POISONING/EXPOSURE
    a) Sinus tachycardia and a rise in blood pressure (generally transient) may occur after overdose (Williams et al, 1961).
    C) HYPOTENSIVE EPISODE
    1) WITH THERAPEUTIC USE
    a) Hypotension may occur following therapeutic use (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010). The degree of hypotension may be related to severity of bradycardia (Williams et al, 1961).
    2) WITH POISONING/EXPOSURE
    a) Hypotension may occur following overdose. The degree of hypotension may be related to severity of bradycardia (Williams et al, 1961).
    D) HYPERTENSIVE DISORDER
    1) WITH THERAPEUTIC USE
    a) Hypertension may develop following therapeutic use of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    E) CARDIAC ARREST
    1) WITH THERAPEUTIC USE
    a) Cardiac dysrhythmias (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010) and cardiac arrest have been noted following succinylcholine administration.
    b) CHILDREN: Nodal rhythm and ectopic beats are seen in about 80% of children given an IV dose of succinylcholine; rarely seen after IM doses (Cook, 1986).
    F) HYPERKALEMIA
    1) WITH THERAPEUTIC USE
    a) Use in patients with extensive burns, traumatic muscle injury, paraplegia, hemiplegia, muscular dystrophy, multiple sclerosis, prolonged pharmacologic neuromuscular blockade, upper motor neuron injury or extensive denervation of skeletal muscle may result in severe hyperkalemia and ventricular dysrhythmias.
    b) Reports in the literature have revealed cases of cardiac arrest in apparently healthy children and adolescents following injection of succinylcholine. Most of these had evidence of acute rhabdomyolysis on autopsy and developed hyperkalemia followed by cardiac arrest (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Rosenberg & Gronert, 1992; Nash et al, 1981).
    1) The earliest sign may be serious dysrhythmias (ventricular tachycardia), profound bradycardia progressing rapidly to asystole or ventricular fibrillation (Rosenberg & Gronert, 1992; Nash et al, 1981).
    c) CASE REPORT: Cardiac arrest and profound hyperkalemia were reported in a 27-year-old woman following administration of succinylcholine for ARDS. She may have been predisposed to these events from previous prolonged treatment with nondepolarizing neuromuscular blocking agents and disuse atrophy (Markewitz & Elstad, 1997).
    d) CASE REPORT: A 19-year-old burn patient developed cardiac arrest within 4 minutes of succinylcholine administration. The authors speculated that the arrest was due to hyperkalemic dysrhythmias and cardiac atony (Tolmie et al, 1967).
    e) CASE REPORT: Hyperkalemic cardiac arrest occurred in a 51-year-old man, status post a complicated coronary artery bypass grafting, shortly after receiving 100 mg succinylcholine for reinsertion of his tracheostomy tube. Precipitating causes of the cardiac arrest were thought to be due to previously prolonged use of neuromuscular blocking drugs combined with prolonged immobility precipitating hyperkalemia and subsequent cardiac arrest (Berkahn & Sleigh, 1997).
    G) BUNDLE BRANCH BLOCK
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: Idioventricular rhythm, characterized by a widening of the QRS complex along with a decrease in heart rate and blood pressure, was observed in a 37-year-old man following a second dose of succinylcholine. Treatment with 0.4 mg atropine IV resulted in rapid reversion to normal heart rate and blood pressure (Elia & Lebowitz, 1988).

Respiratory

    3.6.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Intermittent apnea followed by respiratory arrest may occur.
    3.6.2) CLINICAL EFFECTS
    A) APNEA
    1) WITH THERAPEUTIC USE
    a) RESPIRATORY DEPRESSION and apnea developing into prolonged apnea have occurred following an appropriate dose of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    b) CASE REPORT: Prolonged apnea occurred in a 12-year-old (51 kg) girl following administration of 75 mg succinylcholine with thiopental 200 mg. Spontaneous respiration did not return for over 2 hours (Sapsford & Bush, 1986).
    2) WITH POISONING/EXPOSURE
    a) PROLONGED APNEA is a common overdose event; death may result from respiratory arrest.(Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    b) CASE REPORT: Inadvertent administration of suxamethonium occurred in an 86-year-old woman resulting in prolonged apnea, with a normal pulse and blood pressure (Taylor & McCarroll, 1994).
    B) ACUTE LUNG INJURY
    1) WITH THERAPEUTIC USE
    a) Pulmonary edema has occurred in infants following IM succinylcholine (Cook, 1986).

Neurologic

    3.7.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Malignant hyperthermia may occur in genetically susceptible individuals. Severe acidosis, tachycardia, hyperkalemia, and hemoglobinuria or myoglobinuria with elevated CK (creatine kinase) may be noted along with increasing core body temperature.
    2) Succinylcholine administration may lead to a rise in ICP.
    3.7.2) CLINICAL EFFECTS
    A) MALIGNANT HYPERPYREXIA DUE TO ANESTHETIC
    1) WITH THERAPEUTIC USE
    a) Malignant hyperthermia is a rare complication in patients administered succinylcholine, but is a severe life-threatening event. It most often occurs in genetically susceptible individuals.
    1) Effects include increasing hyperthermia with or without muscular hypertonicity, often fatal cardiovascular complications, severe acidosis, hyperkalemia, and hemoglobinuria or myoglobinuria (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Larach et al, 1987).
    B) RAISED INTRACRANIAL PRESSURE
    1) WITH THERAPEUTIC USE
    a) Succinylcholine administration may lead to a rise in ICP and care should be taken in individuals at risk for herniation. Pretreatment with a defasciculating dose of a nondepolarizing agent may prevent this rise in ICP.

Genitourinary

    3.10.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Renal failure may occur secondary to rhabdomyolysis.
    3.10.2) CLINICAL EFFECTS
    A) RENAL FAILURE SYNDROME
    1) WITH THERAPEUTIC USE
    a) Succinylcholine-induced rhabdomyolysis from prolonged fasciculations or malignant hyperthermia may lead to renal failure (Blanc et al, 1986). Administration of succinylcholine to individuals with renal failure should be approached with caution due to risk of worsening a preexisting hyperkalemia.
    b) CASE REPORT: Myoglobinuric renal failure (serum creatinine 2.3 mg/dL and urine myoglobin 142 mcg/mL) occurred subsequent to succinylcholine-induced rhabdomyolysis and hyperkalemic cardiac arrest in a 54-year-old man with severe necrotizing pancreatitis and a previous spinal cord injury. Renal function continued to deteriorate and progressed to oliguric renal failure (Matthews, 2000).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) WITH THERAPEUTIC USE
    a) Metabolic acidosis accompanies malignant hyperthermia.

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) PARALYSIS
    1) WITH THERAPEUTIC USE
    a) Certain patients may develop prolonged apnea following an appropriate dose of succinylcholine. These patients demonstrate a defect in plasma pseudocholinesterase.
    2) WITH POISONING/EXPOSURE
    a) Succinylcholine blocks neuromuscular transmission, leading to skeletal muscle relaxation, respiratory paralysis and apnea following overdosage (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    B) MUSCLE PAIN
    1) WITH THERAPEUTIC USE
    a) Muscle pain can develop following the use of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    C) INCREASED MUSCLE TONE
    1) WITH THERAPEUTIC USE
    a) Muscle rigidity accompanies malignant hyperthermia and may be a predictor of malignant hyperthermia susceptibility (Larach et al, 1987).
    D) SPASMODIC MOVEMENT
    1) WITH THERAPEUTIC USE
    a) Muscle fasciculations may occur in denervated limb and masseter muscles (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Baraka, 1986).
    2) WITH POISONING/EXPOSURE
    a) Muscle fasciculations may occur in denervated limb and masseter muscles (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Baraka, 1986).
    E) ENZYMES/SPECIFIC PROTEIN LEVELS - FINDING
    1) WITH THERAPEUTIC USE
    a) Elevated serum levels of creatine phosphokinase (CPK) and myoglobin commonly follow IV administration of succinylcholine (Blanc et al, 1986).
    F) RHABDOMYOLYSIS
    1) WITH THERAPEUTIC USE
    a) Acute rhabdomyolysis with hyperkalemia has been reported following use of succinylcholine. In most cases, apparently healthy children and adolescents were affected. Most patients had experienced cardiac arrest associated with rhabdomyolysis and hyperkalemia (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    b) CASE REPORT: A 54-year-old man with necrotizing pancreatitis developed succinylcholine-induced hyperkalemia and rhabdomyolysis and experienced a hyperkalemic cardiac arrest. Creatine kinase peaked at greater than 16,000 Units/L. The patient died after supportive care was withdrawn (Matthews, 2000).

Immunologic

    3.19.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Allergic and anaphylactic reactions to succinylcholine have been reported, including bronchial spasms and a fatality.
    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) WITH THERAPEUTIC USE
    a) Allergic reactions to succinylcholine have been reported, including bronchospasm.
    B) HYPERSENSITIVITY REACTION
    1) WITH THERAPEUTIC USE
    a) Hypersensitivity reactions including anaphylaxis has been reported following administration of succinylcholine (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010), including one fatality (Assem & Ling, 1988; Assem & Symons, 1989).
    1) Anaphylactoid reactions have occurred with as little as 1 mg/kg (Ostergaard et al, 1989). Dermal flushing is common due to histamine release. Urticaria, bronchospasm, and hypotension may also occur (Bowman, 1982).

Reproductive

    3.20.1) SUMMARY
    A) Succinylcholine is classified as FDA pregnancy category C. It has been reported that small amounts of succinylcholine will cross the placental barrier, but it does not adversely affect the neonate when it is used for caesarean section.
    3.20.2) TERATOGENICITY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the teratogenic potential of this agent (Prod Info QUELICIN(R) IV injection, 2005).
    3.20.3) EFFECTS IN PREGNANCY
    A) PLACENTAL BARRIER
    1) Throughout pregnancy and for several days postpartum plasma cholinesterase levels are decreased by about 24%. This suggests that patients may have increased sensitivity to succinylcholine chloride when pregnant. Use during delivery by caesarean section is common and while small amounts are known to cross the placental barrier, single doses of succinylcholine 1 mg/kg during pregnancy have not produced any harmful effects to the fetus. However, the amount of drug that crosses the placental barrier is dependent upon the concentration gradient between the maternal and fetal circulations. In the presence of repeated high maternal doses or atypical plasma cholinesterase, residual neuromuscular blockade (apnea and flaccidity) may occur in the newborn (Prod Info QUELICIN(R) IV injection, 2005).
    2) It has been reported that small amounts of succinylcholine will cross the placental barrier, but it does not adversely affect the neonate when it is used for caesarean section (JEF Reynolds , 2000).
    B) PREGNANCY CATEGORY
    1) The manufacturer has classified succinylcholine as FDA pregnancy category C (Prod Info QUELICIN(R) IV injection, 2005).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during lactation in humans (Prod Info QUELICIN(R) IV injection, 2005)
    3.20.5) FERTILITY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects on fertility from exposure to this agent (Prod Info QUELICIN(R) IV injection, 2005).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs, pulse oximetry, ECG, and end-tidal CO when utilizing succinylcholine.
    B) Serum electrolytes, renal function and CPK should be obtained if rhabdomyolysis, hyperkalemia, or malignant hyperthermia is suspected.
    C) Monitor continuous core temperature, if malignant hyperthermia is suspected.
    D) Obtain an ECG and institute continuous cardiac monitoring.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Measurement of plasma pseudocholinesterase levels to detect abnormally low levels may be undertaken in patients with unexpectedly prolonged effects. However, many of the patients who react abnormally to succinylcholine have qualitative rather than quantitative defects in plasma pseudocholinesterase.
    2) Monitored serum potassium in patients with neuromuscular disorders, catabolic states or dysrhythmias.
    3) Monitor renal function tests and creatine phosphokinase (CPK) levels in patients with malignant hyperthermia.
    4.1.3) URINE
    A) OTHER
    1) Urine should be monitored for the presence of myoglobin in patients with malignant hyperthermia.
    4.1.4) OTHER
    A) OTHER
    1) OXYGEN SATURATION
    a) Pulse oximetry and arterial blood gases should be monitored; decreased respirations and acidosis are common following overdose.
    2) CARDIAC MONITORING
    a) Obtain a baseline ECG; repeat as indicated. Institute continuous cardiac monitoring.

Methods

    A) OTHER
    1) Routine measurement of plasma succinylcholine levels is not generally available.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.2) DISPOSITION/PARENTERAL EXPOSURE
    6.3.2.1) ADMISSION CRITERIA/PARENTERAL
    A) Any patient with significant hyperkalemia or malignant hyperthermia should be monitored in an ICU setting for a minimum of 24 hours.
    6.3.2.3) CONSULT CRITERIA/PARENTERAL
    A) A toxicologist should be consulted on patients with prolonged paralysis or severe hyperkalemia that does not respond to treatment. If malignant hyperthermia is suspected refer to the Malignant Hyperthermia Association of the US at http://www.mhaus.org or call the MH Emergency Hotline at 1-800-MH-HYPER (1-800-644-9737). Outside the US, call: 00+1+209-417-3722.
    6.3.2.5) OBSERVATION CRITERIA/PARENTERAL
    A) Patients experiencing prolonged weakness following the administration of succinylcholine should be observed until their strength returns to baseline.

Monitoring

    A) Monitor vital signs, pulse oximetry, ECG, and end-tidal CO when utilizing succinylcholine.
    B) Serum electrolytes, renal function and CPK should be obtained if rhabdomyolysis, hyperkalemia, or malignant hyperthermia is suspected.
    C) Monitor continuous core temperature, if malignant hyperthermia is suspected.
    D) Obtain an ECG and institute continuous cardiac monitoring.

Range Of Toxicity

Summary

    A) TOXICITY: Succinylcholine is rapidly redistributed, and overdose is rare. An excessive prolonged infusion of succinylcholine may cause a prolonged effect (paralysis) lasting up to 12 hours following the cessation of administration. Hyperkalemia and malignant hyperthermia can occur in a patient predisposed to these events and are not dose dependent.
    B) THERAPEUTIC DOSE: ONSET of action begins within 30 seconds and terminates in 3 to 5 minutes unless there is abnormal pseudocholinesterase.
    1) RAPID SEQUENCE INTUBATION: ADULT: 1.5 mg/kg IV; PEDIATRIC: Older children and adolescents: 1 mg/kg IV; Infants and small children: 2 mg/kg IV.
    2) INDUCTION AND NEUROMUSCULAR BLOCKADE, during surgery, long procedures: ADULT: 2.5 to 4.3 mg/min continuous IV infusion. During surgery, short procedures: ADULT: 0.6 mg/kg IV (range 0.3 to 1.1 mg/kg) over 10 to 30 seconds.

Therapeutic Dose

    7.2.1) ADULT
    A) SUMMARY
    1) SHORT SURGICAL PROCEDURE: The average dose to produce neuromuscular blockade and to facilitate tracheal intubation is 0.6 mg/kg IV. The optimum dose will vary and may range from 0.3 to 1.1 mg/kg for an adult. Following administration of doses within this range, neuromuscular blockade can develop in about a minute (maximum blockade can last about 2 minutes, with recovery in about 4 to 6 minutes) (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).
    2) LONG SURGICAL PROCEDURE: An average infusion rate for an adult ranges between 2.5 and 4.3 mg/min IV (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).
    7.2.2) PEDIATRIC
    A) EMERGENCY TRACHEAL INTUBATION
    1) INTRAVENOUS, INFANTS AND SMALL CHILDREN: 2 mg/kg IV (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).
    2) INTRAVENOUS, OLDER CHILDREN AND ADOLESCENTS: 1 mg/kg IV (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012).
    3) INTRAMUSCULAR, INFANTS AND OLDER CHILDREN: 3 to 4 mg/kg up to 150 mg total dose (Prod Info Quelicin(TM) intravenous injection solution, intramuscular injection solution, 2012),
    B) SKELETAL MUSCLE RELAXATION
    1) INFANT 29 DAYS to 1 YEAR OF AGE: INTRAVENOUS: 1 to 2 mg/kg IV immediately prior to intubation (Prod Info ANECTINE(R) intravenous injection solution, 2010; Choong et al, 2010; Kumar et al, 2010; Ghanta et al, 2007; Oei et al, 2002; Barrington et al, 1989; Barrington & Byrne, 1998; Cook-Sather et al, 1998). Repeat doses of 1 mg/kg up to a maximum total dose of 4 mg/kg have been used if muscle relaxation was not attained by 1 to 3 minutes after administration (Ghanta et al, 2007; Oei et al, 2002).
    2) Must be accompanied by adequate analgesia or sedation (Prod Info ANECTINE(R) intravenous injection solution, 2010).
    3) 1 YEAR AND OLDER: INTRAVENOUS: 1 to 1.5 mg/kg IV immediately prior to intubation (Prod Info ANECTINE(R) intravenous injection solution, 2010; Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010; Kulkarni et al, 2010; Cheng et al, 2002; Naguib et al, 1997; Cook et al, 1995; Brown et al, 1990).
    4) INTRAMUSCULAR: 2 to 4 mg/kg may be given via the IM route only if IV route not accessible (Prod Info ANECTINE(R) intravenous injection solution, 2010; Kumar et al, 2010; Bottor, 2009). Maximum: 150 mg total dose (Prod Info ANECTINE(R) intravenous injection solution, 2010).

Minimum Lethal Exposure

    A) CASE REPORT
    1) CASE REPORT: A 40-year-old woman suffered an anaphylactic reaction following administration of papaveretum 10 mg, hyoscine 0.2 mg, metoclopramide 10 mg, thiopentone 350 mg, and succinylcholine 60 mg intramuscularly. The patient subsequently died 4 days later (Assem & Ling, 1988).

Maximum Tolerated Exposure

    A) SUMMARY
    1) The dose necessary to produce neuromuscular blockade and respiratory paralysis in adults ranges from 0.3 to 1.1 mg/kg in adults (mean 0.6 mg/kg) (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010)
    2) Action begins in 30 seconds and terminates in 3 to 5 minutes unless there is abnormal pseudocholinesterase.
    3) Prolonged respiratory paralysis may occur following therapeutic doses in individuals with a deficiency of pseudocholinesterase (Prod Info QUELICIN(TM) intravenous injection solution, intramuscular injection solution, 2010).
    4) Toxicity from oral or rectal administration has not been described. Succinylcholine is poorly absorbed by these routes, and the potency is at least 100 times less than with parenteral routes (Foldes, 1975).
    5) Tachyphylaxis is expected in infants following a cumulative dose of 4 mg/kg; phase II block is expected at 6 mg/kg (Cook, 1986).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) ANIMAL DATA
    1) LD50- (ORAL)MOUSE:
    a) 125 mg/kg
    2) LD50- (SUBCUTANEOUS)MOUSE:
    a) 7500 mcg/kg
    3) LD50- (SUBCUTANEOUS)RAT:
    a) 3400 mcg/kg

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Succinylcholine is a myoneural blocking agent that produces relaxation of skeletal muscles.
    1) It acts by depolarizing the myoneural junction, leading to block which is not responsive to neurotransmitters such as acetylcholine. This is in contrast to the competitive block produced by curare.
    B) During such sustained relaxation, the degree of relaxation can be altered appreciably within 30 seconds by regulating the rate of infusion.

Toxicologic Mechanism

    A) HYPERKALEMIA - Patients with prior muscle damage have an increased chemosensitivity of the muscle membrane due to the development of receptor sites in extrajunctional areas. In normal muscle, succinylcholine induces small releases of potassium. In damaged muscle it produces a potentially lethal efflux in the presence of increased sensitivity (Gronert & Theye, 1975). Depolarization of skeletal muscle resulted in an immediate increase in plasma potassium concentrations (JEF Reynolds , 1997).

References

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    58) Product Information: QUELICIN(R) IV injection, succinylcholine chloride IV injection. Hospira,Inc., Lake Forest, IL, 2005.
    59) Product Information: QUELICIN(TM) intravenous injection solution, intramuscular injection solution, succinylcholine chloride intravenous injection solution, intramuscular injection solution. Hospira, Inc. (per DailyMed), Lake Forest, IL, 2010.
    60) Product Information: Quelicin(TM) intravenous injection solution, intramuscular injection solution, succinylcholine chloride intravenous injection solution, intramuscular injection solution. Hospira, Inc. (per DailyMed), Lake Forest, IL, 2012.
    61) Product Information: dopamine hcl, 5% dextrose IV injection, dopamine hcl, 5% dextrose IV injection. Hospira,Inc, Lake Forest, IL, 2004.
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