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Succinylcholine

Class: Neuromuscular Blocking Agents
VA Class: MS300
CAS Number: 71-27-2
Brands: Anectine, Quelicin

Medically reviewed by Drugs.com on Oct 12, 2021. Written by ASHP.

Warning

    Rhabdomyolysis with Hyperkalemia
  • Risk of acute rhabdomyolysis with hyperkalemia followed by ventricular arrhythmias, cardiac arrest, and death in apparently healthy children and adolescents who subsequently were found to have undiagnosed skeletal muscle myopathy (e.g., Duchenne’s muscular dystrophy).

  • Use in children and adolescents should be reserved for those undergoing emergency intubation, those in whom an airway should be secured immediately (e.g., patients with laryngospasm, difficult airway, or full stomach), or those in whom a suitable vein is not accessible and IM administration is needed. (See Pediatric Use under Cautions.)

    Experience of Clinician
  • Should be administered only by individuals experienced in the use of neuromuscular blocking agents.

Introduction

Depolarizing neuromuscular blocking agent.

Uses for Succinylcholine

Skeletal Muscle Relaxation

Production of skeletal muscle relaxation during procedures of short duration (e.g., endotracheal intubation) after general anesthesia has been induced; neuromuscular blocking agent of choice for procedures lasting <3 minutes.

Facilitation of endotracheal intubation; because of its rapid onset and short duration of action, generally considered neuromuscular blocking agent of choice in emergency situations when rapid intubation (e.g., rapid sequence intubation) is required.

Also used to facilitate mechanical ventilation; however, not used for prolonged neuromuscular blockade in the ICU.

Because of serious adverse effects, restrict use in pediatric population. (See Boxed Warning.)

Succinylcholine Dosage and Administration

General

Dispensing and Administration Precautions

  • Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available. (See Boxed Warning.)

  • Take special precautions (e.g., segregate storage, limit access, affix warning labels to storage containers and final administration containers) to ensure that the drug is not administered without adequate respiratory support. Institute for Safe Medication Practices (ISMP) recommends the following wording on auxiliary labels: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”

  • To avoid patient distress, generally administer only after unconsciousness has been induced; however, may administer before sedative administered in emergency situations.

  • To evaluate patient’s ability to metabolize succinylcholine and to determine individual patient sensitivity and recovery time, a test dose may be administered to spontaneously breathing patient after anesthesia has been induced. (See Test Dose under Dosage and Administration.)

  • Assess neuromuscular blockade and recovery in patients undergoing anesthesia; careful assessment with a peripheral nerve stimulator is recommended during continuous IV infusions to monitor the degree of neuromuscular blockade, to detect the development of phase II block, and to minimize the possibility of overdosage.

Administration

Administer IV or IM. IV administration is preferred; if necessary, may administer IM in infants or older patients in whom a suitable vein is not accessible. Some clinicians recommend that IM administration be reserved for life-threatening situations.

For specific procedures and techniques of administration, consult specialized references.

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

For prolonged procedures, may administer by continuous IV infusion (preferably) or intermittent IV injection.

Multiple fractional doses generally should not be used; repeated fractional doses and, to a lesser extent, continuous infusion, may lead to tachyphylaxis. (See Prolonged or Repeated Administration under Cautions.)

Dilution

For continuous IV infusion, dilute succinylcholine chloride to the desired concentration (usually 1–2 mg/mL) in a compatible IV solution (e.g., 5% dextrose injection, 0.9% sodium chloride injection). A concentration of 1 mg/mL usually is used for optimum dosage control; 2 mg/mL may be preferred if amount of fluid should be limited.

Do not admix with alkaline solutions. (See Compatibility under Stability.)

IM Administration

May administer by IM injection if IV access not available.

Dosage

Available as succinylcholine chloride; dosage expressed in terms of the salt.

Carefully adjust dosage according to individual requirements and response.

Pediatric Patients

Skeletal Muscle Relaxation
IV

Infants and small children: 2 mg/kg.

Older children and adolescents: 1 mg/kg.

Continuous IV infusions considered unsafe in neonates and children. (See Pediatric Use under Cautions.)

IM

Infants and older children: If IM administration necessary, a dose of up to 3–4 mg/kg (maximum 150 mg) may be given. Onset of effect approximately 2–3 minutes.

Adults

Skeletal Muscle Relaxation
Test Dose
IV

To evaluate sensitivity to succinylcholine in patients with reduced plasma cholinesterase activity, administer test dose of 5–10 mg or cautiously administer a 1-mg/mL solution by slow IV infusion.

Dosage for Procedure
IV

For short procedures, usual dose is 0.6 mg/kg (range 0.3–1.1 mg/kg). Following administration of this dose, neuromuscular blockade generally is attained in approximately 1 minute and persists for 4–6 minutes.

For prolonged procedures, usual dosage is 2.5–4.3 mg/minute by continuous IV infusion; adjust rate (range: 0.5–10 mg/minute) depending on patient’s response and requirements. Alternatively, administer by intermittent IV injection: initially 0.3–1.1 mg/kg, followed by additional doses of 0.04–0.07 mg/kg as necessary to maintain adequate muscle relaxation.

For rapid sequence intubation, usual dose is 1.5 mg/kg; generally produces onset of effect within 45 seconds and duration of paralysis of about 10 minutes.

IM

If IM administration necessary, a dose of up to 3–4 mg/kg (maximum 150 mg) may be given. Onset of effect approximately 2–3 minutes.

Prescribing Limits

Pediatric Patients

Skeletal Muscle Relaxation
IM

Maximum total dose 150 mg.

Adults

Skeletal Muscle Relaxation
IM

Maximum total dose 150 mg.

Special Populations

Geriatric Patients

Careful dosage selection recommended due to possible age-related decrease in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy; initiate therapy at low end of dosage range.

Patients with Reduced Plasma Cholinesterase Activity

Administer small test dose (5–10 mg) or cautiously administer 1-mg/mL solution by slow IV infusion. (See Reduced Plasma Cholinesterase Activity under Cautions.)

Cautions for Succinylcholine

Contraindications

  • Personal or familial history of malignant hyperthermia.

  • Skeletal muscle myopathies.

  • Upper motor neuron injury, multiple trauma, extensive or severe burns, extensive denervation of skeletal muscle because of CNS disease or injury. (See Hyperkalemia under Cautions.)

  • Known hypersensitivity to succinylcholine or any ingredient in the formulation.

Warnings/Precautions

Warnings

Hyperkalemia

Potential for acute rhabdomyolysis with hyperkalemia. (See Boxed Warning and also see Pediatric Use under Cautions.)

Possible severe hyperkalemia resulting in serious cardiac arrhythmias or cardiac arrest in patients with upper motor neuron injury, multiple trauma, extensive or severe burns, or extensive denervation of skeletal muscle because of CNS disease or injury; use is contraindicated in these patients. Risk of hyperkalemia depends on extent and location of the injury, increases over time, usually peaks 7–10 days after the injury, and can persist for >6 months after neural injury.

Use with extreme caution in patients with preexisting hyperkalemia or those at increased risk of hyperkalemia (e.g., those with paraplegia, chronic abdominal infection, tetanus, subarachnoid hemorrhage, degenerative or dystrophic neuromuscular disease, or conditions that may cause degeneration of central and peripheral nervous systems).

Use with extreme caution in patients receiving quinidine or cardiac glycosides or those with suspected cardiac glycoside toxicity (due to potential for hyperkalemia).

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, reported rarely. Potential for cross-sensitivity with other neuromuscular blocking agents (both depolarizing and nondepolarizing).

Take appropriate precautions; emergency treatment for anaphylaxis should be immediately available.

General Precautions

Administration Precautions

Because of the potential for severely compromised respiratory function and other complications, take special precautions during administration. (See Boxed Warning and also see General under Dosage and Administration.)

Malignant Hyperthermia

Possible fatal malignant hyperthermia; manifested by a rapid, profound elevation in body temperature and sometimes extreme muscular rigidity. Risk increases with concomitant administration of inhalation anesthetics. (See Specific Drugs under Interactions.)

If malignant hyperthermia occurs, discontinue all anesthetic agents and initiate IV dantrolene therapy in conjunction with supportive measures (e.g., administering oxygen, treating metabolic acidosis, instituting cooling procedures); maintain urinary output and monitor serum electrolytes.

Bradycardia

Possible profound bradycardia resulting from vagal stimulation and accompanied by hypotension and cardiac arrhythmias (e.g., nodal rhythms, extrasystoles, bigeminy, AV block, cardiac arrest).

Occurs most commonly with repeated administration and in children (see Pediatric Use under Cautions).

Prior administration of atropine may inhibit vagal stimulation and reduce occurrence of bradycardia.

Use with extreme caution in patients with electrolyte disturbances, those receiving quinidine or cardiac glycosides, or those with suspected cardiac glycoside toxicity.

Prolonged or Repeated Administration

Possible tachyphylaxis with repeated administration; multiple fractional doses alone generally should not be used.

Possible prolonged neuromuscular blockade due to change of the characteristic depolarizing neuromuscular block (phase I block) to a phase II block.

To reverse phase II block, may administer a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium), in conjunction with an antimuscarinic (e.g., atropine, glycopyrrolate) to prevent disturbances in cardiac rhythm. Use a peripheral nerve stimulator to confirm change to phase II block prior to administering cholinesterase inhibitor.

To ensure complete hydrolysis of succinylcholine by plasma pseudocholinesterase prior to administration of cholinesterase inhibitor, do not attempt reversal unless spontaneous recovery of muscle twitch has been observed for ≥20 minutes and has plateaued, with further recovery from neuromuscular blockade occurring slowly. (See Actions.)

Intracranial Pressure

Possible slight, transient increase in intracranial pressure.

Intragastric Pressure

Possible increased intragastric pressure secondary to fasciculation of abdominal muscles; potential for regurgitation and possible aspiration of stomach contents. May be prevented by prior administration of small dose of nondepolarizing neuromuscular blocking agent.

Reduced Plasma Cholinesterase Activity

Possible prolonged respiratory depression and muscle relaxation in patients with reduced plasma cholinesterase activity.

Plasma cholinesterase activity may be reduced in patients heterozygous or homozygous for the atypical pseudocholinesterase gene, pregnant women, and patients with severe hepatic or renal disease, malnutrition, infections, severe anemia, severe dehydration, burns, cancer, collagen diseases, myxedema, decompensated heart disease, peptic ulcer disease, or abnormal body temperature.

Some clinicians recommend determining plasma pseudocholinesterase activity prior to administration.

Administer with extreme caution and in reduced doses, if at all, in patients with abnormally low pseudocholinesterase concentrations. If low concentrations are suspected, a test dose or cautious continuous IV infusion may be administered. (See Patients with Reduced Plasma Cholinesterase Activity under Dosage and Administration.)

Treat apnea or prolonged muscle paralysis with controlled respiration. Administration of fresh whole blood or plasma may restore pseudocholinesterase concentrations.

Electrolyte Disturbances

Possible prolonged neuromuscular blockade in patients with electrolyte disturbances (e.g., hypocalcemia, hypokalemia). Use with caution. (See Hyperkalemia and also Bradycardia under Cautions.)

Histamine Release

Possible histamine release; manifestations associated with histamine release (e.g., flushing, erythema, pruritus, urticaria, wheal formation, wheezing, bronchospasm, hypotension) uncommon at usual dosages.

Orthopedic Precautions

Use with caution in patients with fractures, dislocations, or muscular spasms; initial muscle fasciculation may cause additional trauma.

Ophthalmic Effects

Possible increased intraocular pressure.

Use not recommended in patients with angle-closure glaucoma or penetrating eye injuries. Use with extreme caution, if at all, during ocular surgery; nondepolarizing neuromuscular blocking agent may be preferred.

Specific Populations

Pregnancy

Category C. (See Reduced Plasma Cholinesterase Activity under Cautions.)

Lactation

Not known whether succinylcholine is distributed into milk. Caution advised if succinylcholine is used.

Pediatric Use

Possible acute rhabdomyolysis with hyperkalemia followed by ventricular arrhythmias, cardiac arrest, and death; usually occurs in males ≤8 years of age. If cardiac arrest occurs, initiate treatment for hyperkalemia. Prolonged or extraordinary resuscitative measures may be required. Use in children and adolescents should be reserved for those undergoing emergency intubation, those in whom an airway should be secured immediately (e.g., those with laryngospasm, difficult airway, or full stomach), or those in whom a suitable vein is not accessible and IM administration is needed.

Possible profound bradycardia or, rarely, asystole when administered by rapid IV injection. Risk increases with repeated doses; consider pretreatment with atropine.

Possible risk of malignant hyperthermia; institute appropriate therapy if malignant hyperthermia occurs. Rarely, myoglobinuria and myoglobinemia have been reported in conjunction with malignant hyperthermia and muscle rigidity. Continuous IV infusions are considered unsafe in neonates and children due to risk of malignant hyperthermia. (See Malignant Hyperthermia under Cautions.)

Geriatric Use

Use with caution due to greater frequency of decreased hepatic, renal, and/or cardiac function and of concomitant disease and drug therapy observed in the elderly. Titrate dosage carefully.

Hepatic Impairment

Possible decreased plasma cholinesterase activity in patients with severe hepatic impairment; use with caution. (See Elimination: Special Populations, under Pharmacokinetics.)

Renal Impairment

Possible decreased plasma cholinesterase activity in patients with severe renal impairment. Possible accumulation of succinylmonocholine, resulting in prolonged apnea. Use with caution.

Common Adverse Effects

Various degrees of skeletal muscle weakness.

Interactions for Succinylcholine

Specific Drugs

Drug

Interaction

Comments

β-Adrenergic blocking agents

Possible increased neuromuscular blockade

Use with caution

Anesthetics, inhalation (e.g., isoflurane)

Possible increased neuromuscular blockade

Use with caution

Antiarrhythmic agents (lidocaine, procainamide, quinidine)

Possible increased neuromuscular blockade

Use with caution

Anti-infective agents (aminoglycosides, bacitracin, clindamycin, lincomycin, polymyxins, tetracyclines)

Possible increased neuromuscular blockade

Use with caution

Antimalarials (chloroquine, quinine)

Possible increased neuromuscular blockade

Use with caution

Cholinesterase inhibitors (demecarium, isofluorophate, organophosphate insecticides)

Decreased activity of plasma pseudocholinesterase

Use with caution

Contraceptives, oral

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Corticosteroids

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Cyclophosphamide

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Lithium

Possible increased neuromuscular blockade

Use with caution

Magnesium salts

Possible increased neuromuscular blockade

Use with caution

MAO inhibitors

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Metoclopramide

Possible increased neuromuscular blockade

Use with caution

Neostigmine

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Oxytocin

Possible increased neuromuscular blocking effect

Use with caution

Phenothiazines

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Procaine

Potential decreased metabolism of succinylcholine

Concurrent IV administration not recommended

Skeletal muscle relaxants (pancuronium)

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Terbutaline

Possible increased neuromuscular blockade

Use with caution

Thiotepa

Possible decreased plasma cholinesterase activity and increased neuromuscular blockade

Use with caution

Succinylcholine Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract.

Onset

Following IV administration, onset is rapid; complete muscle relaxation occurs within 0.5–1 minute following 10- to 30-mg dose.

Following IM administration, onset occurs in about 2–3 minutes.

Duration

Following IV administration, duration of action is short (about 2–3 minutes following 10- to 30-mg dose; effects gradually dissipate within 10 minutes). Duration of action may be prolonged when administered as continuous IV infusion or in fractional doses.

Following IM administration, duration of action ranges from 10–30 minutes.

Special Populations

Duration of action is prolonged in patients with low plasma pseudocholinesterase concentrations.

Distribution

Extent

Crosses the placenta in small amounts.

Elimination

Metabolism

Rapidly hydrolyzed by plasma pseudocholinesterase to succinylmonocholine and then more slowly to succinic acid and choline.

Elimination Route

Excreted in urine as active and inactive metabolites and small amounts of unchanged drug.

Special Populations

Severe hepatic impairment may decrease plasma pseudocholinesterase activity, resulting in increased duration of action due to reduced metabolism.

In patients with renal impairment, possible decreased plasma pseudocholinesterase activity and possible accumulation of succinylmonocholine.

Stability

Storage

Parenteral

Injection

2–8°C. Multiple-dose vials stable up to 14 days at room temperature.

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

May be incompatible with alkaline solutions with pH >8.5 (e.g., barbiturate solutions).

Solution CompatibilityHID

Compatible

Dextrose–Ringer’s injection combinations

Dextrose–Ringer’s injection, lactated, combinations

Dextrose 5% in Ringer’s injection, lactated

Dextrose–saline combinations

Dextrose 5% in sodium chloride 0.9%

Dextrose 2.5, 5, or 10% in water

Ionosol products

Ringer’s injection

Ringer’s injection, lactated

Sodium chloride 0.45 or 0.9%

Sodium lactate 1/6 M

Drug Compatibility
Admixture CompatibilityHID

Compatible

Amikacin sulfate

Isoproterenol HCl

Meperidine HCl

Methyldopate HCl

Morphine sulfate

Norepinephrine bitartrate

Scopolamine HBr

Incompatible

Pentobarbital sodium

Phenobarbital sodium

Sodium bicarbonate

Y-Site CompatibilityHID

Compatible

Dexmedetomidine HCl

Etomidate

Heparin sodium with hydrocortisone sodium succinate

Hetastarch in lactated electrolyte injection (Hextend)

Palonosetron HCl

Potassium chloride

Propofol

Actions

  • Produces skeletal muscle relaxation by causing a decreased response to acetylcholine (ACh) at the myoneural (neuromuscular) junction of skeletal muscle.

  • Exhibits high affinity for ACh receptor sites and produces depolarization of motor end-plate at myoneural junction, resulting in transient twitching or fasciculation of skeletal muscles, followed by muscle paralysis (phase I block).

  • Prolonged or repeated administration results in gradual and variable transition to phase II block, which resembles nondepolarizing block.

  • Phase I block is potentiated by cholinesterase inhibitors and can be reversed by nondepolarizing neuromuscular blocking agents; fully established phase II block can be reversed by cholinesterase inhibitors and potentiated by nondepolarizing agents.

  • Stimulates cardiac vagus and subsequently sympathetic ganglia.

Advice to Patients

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

  • Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, neuromuscular disease).

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Succinylcholine Chloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

20 mg/mL

Anectine

Sandoz

Quelicin

Hospira

AHFS DI Essentials™. © Copyright 2022, Selected Revisions October 22, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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