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Succinylcholine

Pronunciation

(suks in il KOE leen)

Index Terms

  • Succinylcholine Chloride
  • Suxamethonium Chloride

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Injection, as chloride:

Anectine: 20 mg/mL (10 mL) [contains methylparaben]

Quelicin: 20 mg/mL (10 mL) [contains methylparaben, propylparaben]

Quelicin-1000: 100 mg/mL (10 mL [DSC])

Solution Prefilled Syringe, Intravenous, as chloride:

Generic: 100 mg/5 mL (5 mL); 140 mg/7 mL (7 mL); 200 mg/10 mL (10 mL)

Brand Names: U.S.

  • Anectine
  • Quelicin
  • Quelicin-1000 [DSC]

Pharmacologic Category

  • Neuromuscular Blocker Agent, Depolarizing

Pharmacology

Acts similar to acetylcholine, produces depolarization of the motor endplate at the myoneural junction which causes sustained flaccid skeletal muscle paralysis produced by state of accommodation that develops in adjacent excitable muscle membranes

Distribution

Vd higher in neonates and infants due to larger ECF volume; higher IV doses necessary

Metabolism

Rapidly hydrolyzed by plasma pseudocholinesterase to inactive metabolites

Excretion

Urine (~10% excreted unchanged)

Onset of Action

Dependent on route, age, and dose; data suggest faster onset with higher doses (Coté 2013):

IM: Infants and Children: 3 to 4 minutes (Lui 1981); Adults: 2 to 3 minutes

IV:

Neonates and Infants: ~30 seconds (range: 19 to 40 seconds [dose: 2 to 4 mg/kg]) (Meakin 1990)

Children and Adolescents: 35 to 55 seconds (Coté 2013); Dose-specific: 40 seconds (dose: 1.5 to 2 mg/kg); 50 seconds (dose: 1 mg/kg) (Coté 2013)

Adults: Flaccid paralysis rapid <60 seconds

Duration of Action

Dependent on route, age, and dose:

IM: 10 to 30 minutes; observed to be shorter in infants than children

IV: ~4 to 6 minutes; faster recovery rate in infants and children compared to adults (Fisher 1975)

Use: Labeled Indications

Neuromuscular blockade: As an adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

Note: Does not relieve pain or produce sedation

Off Label Uses

Muscle contractions of electroconvulsive therapy (ECT) (reduce intensity)

Contraindications

Hypersensitivity to succinylcholine or any component of the formulation; personal or familial history of malignant hyperthermia; skeletal muscle myopathies; use after the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury.

Documentation of allergenic cross-reactivity for neuromuscular blockers is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Neuromuscular blockade: Dose to effect; doses will vary due to interpatient variability. Use carefully and/or consider dose reduction in patients with reduced plasma cholinesterase activity due to genetic abnormalities of plasma cholinesterase or when associated with other conditions (eg, electrolyte abnormalities, neuromuscular disease); prolonged neuromuscular blockade may occur.

IM: Up to 3 to 4 mg/kg, maximum total dose: 150 mg

IV:

Intubation: 0.6 mg/kg (range: 0.3 to 1.1 mg/kg)

Intubation (rapid sequence) (off-label dosing): 1 to 1.5 mg/kg (Sluga 2005; Weiss 1997)

Long surgical procedures (intermittent administration): Initial: 0.3 to 1.1 mg/kg; administer 0.04 to 0.07 mg/kg at appropriate intervals as needed.

Note: Pretreatment with atropine may reduce occurrence of bradycardia. Initial dose of succinylcholine must be increased when nondepolarizing agent pretreatment is used because of the antagonism between succinylcholine and nondepolarizing neuromuscular-blocking agents (Miller 2010). When the cumulative dose of succinylcholine exceeds 2 to 4 mg/kg under general anesthesia or succinylcholine is administered by continuous infusion, transition from a phase I to a phase II block may occur. If phase II block is suspected, diagnosis should be confirmed by peripheral nerve stimulation prior to administration of an anticholinesterase drug (Hilgenberg 1981).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Neuromuscular blockade: Dose to effect; doses will vary due to interpatient variability. Use carefully and/or consider dose reduction in patients with reduced plasma cholinesterase activity due to genetic abnormalities of plasma cholinesterase or when associated with other conditions (eg, electrolyte abnormalities, neuromuscular disease); prolonged neuromuscular blockade may occur.

IM: Refer to adult dosing.

IV:

Neonates, Infants ≤ 6 months: Intubation: 2 to 3 mg/kg/dose

Infants >6 months and Children ≤ 2 years: Intubation: 1 to 2 mg/kg/dose

Older Children and Adolescents: Intubation: 1 mg/kg/dose

Note: Pretreatment with atropine may reduce occurrence of bradycardia. Initial dose of succinylcholine must be increased when nondepolarizing agent pretreatment used because of the antagonism between succinylcholine and nondepolarizing neuromuscular-blocking agents (Miller, 2010).

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Obesity

Use total body weight for obese patients (Bentley, 1982; Brunette, 2004; Rose, 2000).

Administration

IM: Administer deep IM only when IV access is not available.

IV: May be administered undiluted by rapid IV injection.

Storage

Manufacturer recommends refrigeration at 2°C to 8°C (36°F to 46°F) and may be stored at room temperature for 14 days; however, additional testing has demonstrated stability for ≤6 months unrefrigerated (25°C) (Ross, 1988; Roy, 2008). Stability in polypropylene syringes (20 mg/mL) at room temperature (25°C) is 45 days (Storms, 2003).

Drug Interactions

AbobotulinumtoxinA: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Acetylcholinesterase Inhibitors: May increase the serum concentration of Succinylcholine. Management: Consider alternatives to this combination due to a risk of prolonged neuromuscular blockade. Consider therapy modification

Amifampridine: Neuromuscular-Blocking Agents may diminish the therapeutic effect of Amifampridine. Amifampridine may diminish the therapeutic effect of Neuromuscular-Blocking Agents. Monitor therapy

Aminoglycosides: May enhance the respiratory depressant effect of Neuromuscular-Blocking Agents. Monitor therapy

Bacitracin (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Bambuterol: May enhance the therapeutic effect of Succinylcholine. Bambuterol may increase the serum concentration of Succinylcholine. Monitor therapy

Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Monitor therapy

Clindamycin (Topical): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Consider therapy modification

Cyclophosphamide: May increase the serum concentration of Succinylcholine. Management: Consider alternatives to succinylcholine in patients who have received cyclophosphamide in the past 10 days, or reduced succinylcholine doses (a serum pseudocholinesterase assay may help inform this reduction) with close monitoring. Consider therapy modification

CycloSPORINE (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Echothiophate Iodide: May increase the serum concentration of Succinylcholine. Management: For patients receiving echothiophate iodide eye drops, consider using a neuromuscular-blocking agents other than succinylcholine. If succinylcholine is used, consider a reduced dose, and monitor for enhanced/prolonged effects. Consider therapy modification

Esmolol: May enhance the neuromuscular-blocking effect of Succinylcholine. Monitor therapy

Estrogen Derivatives: May increase the serum concentration of Succinylcholine. Monitor therapy

Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Local Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Exceptions: Benzocaine; Benzydamine; Cocaine; Dibucaine; Dyclonine; Ethyl Chloride; Hexylresorcinol; Lidocaine (Ophthalmic); Lidocaine (Topical); Pramoxine; Proparacaine; Tetracaine (Ophthalmic); Tetracaine (Topical). Monitor therapy

Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Minocycline: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

OnabotulinumtoxinA: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of OnabotulinumtoxinA. Monitor therapy

Opioid Analgesics: Succinylcholine may enhance the bradycardic effect of Opioid Analgesics. Monitor therapy

Phenelzine: May enhance the neuromuscular-blocking effect of Succinylcholine. Consider therapy modification

Pholcodine: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents. Specifically, anaphylaxis has been reported. Monitor therapy

Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Consider therapy modification

Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Avoid combination

RimabotulinumtoxinB: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of RimabotulinumtoxinB. Monitor therapy

Sertraline: May increase the serum concentration of Succinylcholine. Monitor therapy

Tetracyclines: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Adverse Reactions

Frequency not defined.

Cardiovascular: Bradycardia (higher with second dose; more frequent in children), cardiac arrhythmia, hypertension, hypotension, malignant hyperthermia, tachycardia

Dermatologic: Skin rash

Endocrine & metabolic: Hyperkalemia

Gastrointestinal: Sialorrhea

Hypersensitivity: Anaphylaxis

Neuromuscular & skeletal: Fasciculations, jaw tightness, myalgia (postoperative), rhabdomyolysis (with possible myoglobinuric acute renal failure)

Ophthalmic: Increased intraocular pressure

Respiratory: Apnea, respiratory depression (prolonged)

<1% (Limited to important or life-threatening): Abnormal bone growth (myositis ossificans; prolonged use), myopathy (acute quadriplegic myopathy syndrome; prolonged use)

ALERT: U.S. Boxed Warning

Risk of Cardiac Arrest from Hyperkalemic Rhabdomyolysis:

There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death after the administration of succinylcholine to apparently healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne muscular dystrophy.

This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger). There have also been reports in adolescents.

Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine not felt to be due to inadequate ventilation, oxygenation, or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. This should include administration of intravenous calcium, bicarbonate, and glucose with insulin, with hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. In addition, in the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.

Since there may be no signs or symptoms to alert the practitioner to which patients are at risk, it is recommended that the use of succinylcholine in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary, such as laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible.

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylaxis: Severe anaphylactic reactions (some life-threatening and fatal) have been reported. Cross-sensitivity with other neuromuscular-blocking agents may occur; use extreme caution in patients with previous anaphylactic reactions.

• Bradycardia: Risk of bradycardia may be increased with second dose and may occur more in children. Occurrence may be reduced by pretreating with anticholinergic agents (eg, atropine).

• Increased intraocular pressure (IOP): May increase IOP; avoid use in patients in which an increase in IOP is undesirable (eg, narrow-angle glaucoma, penetrating eye injuries).

• Intracranial pressure: May cause a transient increase in intracranial pressure (adequate anesthetic induction prior to administration of succinylcholine will minimize this effect).

• Intragastric pressure: May increase intragastric pressure, which could result in regurgitation and possible aspiration of stomach contents.

• Malignant hyperthermia: Use may be associated with acute onset of malignant hyperthermia; risk may be increased with concomitant administration of volatile anesthetics.

• Vagal tone: May increase vagal tone.

Disease-related concerns:

• Burn injury: Use with caution in patients with extensive or severe burns; risk of hyperkalemia is increased following injury. Onset of time and duration of risk are variable, but risk is generally greatest 7 to 10 days after injury. Resistance may occur in burn patients (≥20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han 2009).

• Conditions which may antagonize neuromuscular blockade: Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, muscle trauma, and diabetes mellitus may result in antagonism of neuromuscular blockade (Greenberg 2013; Miller 2010; Murray 2002; Naguib, 2002).

• Conditions which may potentiate neuromuscular blockade: Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), neuromuscular diseases, metabolic acidosis, respiratory acidosis, Eaton-Lambert syndrome, and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg 2013; Miller 2010; Naguib 2002).

• Fractures/muscle spasm: Use with caution in patients with fractures or muscle spasm; initial muscle fasciculations may cause additional trauma.

• Hyperkalemia: Use with extreme caution in patients with pre-existing hyperkalemia. Severe hyperkalemia may develop in patients with chronic abdominal infections, burn injuries, multiple trauma, extensive denervation of skeletal muscle, upper motor neuron injury, subarachnoid hemorrhage, or conditions which cause degeneration of the central and peripheral nervous system.

• Plasma pseudocholinesterase disorders: Metabolized by plasma cholinesterase; use with caution (if at all) in patients suspected of being homozygous for the atypical plasma cholinesterase gene. Plasma cholinesterase activity may also be reduced by burns, anemia, decompensated heart disease, infections, malignant tumors, myxedema, pregnancy, severe hepatic or renal dysfunction, peptic ulcer, and certain medications and chemicals.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Elderly: Use with caution in the elderly, effects and duration are more variable.

• Pediatric: [US Boxed Warning]: Use caution in children and adolescents. Acute rhabdomyolysis with hyperkalemia, ventricular arrhythmias and cardiac arrest have been reported (rarely) in children with undiagnosed skeletal muscle myopathy (eg, Duchenne muscular dystrophy); occurs soon after administration and requires immediate treatment of hyperkalemia. Prolonged resuscitation may be required. Use in children should be reserved for emergency intubation when immediate airway control is necessary (eg, laryngospasm, difficult airway, full stomach), or IM use when a suitable vein is inaccessible.

Other warnings/precautions:

• Appropriate use: Maintenance of an adequate airway and respiratory support is critical. If possible, to avoid distress to the patient, do not administer before unconsciousness has been induced.

• Experienced personnel: Should be administered by adequately trained individuals familiar with its use.

Monitoring Parameters

Monitor cardiac, blood pressure, and oxygenation during administration; temperature, serum potassium and calcium, assisted ventilator status; neuromuscular function with a peripheral nerve stimulator

Pregnancy Risk Factor

C

Pregnancy Considerations

Animal reproduction studies have not been conducted. Small amounts cross the placenta. Sensitivity to succinylcholine may be increased due to a ~24% decrease in plasma cholinesterase activity during pregnancy and several days postpartum.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Have patient report immediately to prescriber bradycardia, severe dizziness, passing out, severe headache, muscle pain, twitching, urinary retention, change in amount of urine passed, abnormal heartbeat, angina, ocular pressure, difficulty breathing, slow breathing, shallow breathing, signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling), or signs of malignant hyperthermia (tachycardia, fast breathing, fever, spasm of jaw muscles, or stiffness of jaw muscles) (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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