Can Succinylcholine Be Can Succinylcholine Be AbandonedAbandoned ? ?

Presented by R2 Presented by R2 康庭瑞康庭瑞

HistoryHistory

The introduction of succinylcholine into clinThe introduction of succinylcholine into clinical practice in 1951 was a seminal develoical practice in 1951 was a seminal development in the history of anesthesiapment in the history of anesthesia

Succinylcholine, despite its many side effeSuccinylcholine, despite its many side effects, has been used for more than 50 yr as cts, has been used for more than 50 yr as the standard neuromuscular blocking drug the standard neuromuscular blocking drug (NMBD) to facilitate tracheal intubation(NMBD) to facilitate tracheal intubation

Features of succinylcholin Features of succinylcholin

A rapid onset of action (30~60 seconds), short-dA rapid onset of action (30~60 seconds), short-duration (typically less than 10 minutes) depolariziuration (typically less than 10 minutes) depolarizing NMBDng NMBD

Rapidly produces a more profound effect at the Rapidly produces a more profound effect at the vocal cords than at the adductor pollicis musclevocal cords than at the adductor pollicis muscle

Can be used in relatively small doses to treat intrCan be used in relatively small doses to treat intractable laryngospasm and is effective in infants actable laryngospasm and is effective in infants and small children when given IM and small children when given IM

Side effectsSide effects

CardiovascularCardiovascular Hyperkalemia and myoglobinemiaHyperkalemia and myoglobinemia Increase intragastric, intraocular, intracranial preIncrease intragastric, intraocular, intracranial pre

ssuressure Malignant hyperthermia Malignant hyperthermia Pulmonary edema and hemorrhagePulmonary edema and hemorrhage Occult myopathiesOccult myopathies Prolong paralysisProlong paralysis Generalized contractions / Masseter spasm Generalized contractions / Masseter spasm

Profound cardiovascular effectsProfound cardiovascular effects

Resembling to Ach, they affect cholinergic recepResembling to Ach, they affect cholinergic receptors in addition to NMJtors in addition to NMJ entire para-sympatheti entire para-sympathetic nervous system and parts of the sympathetic nc nervous system and parts of the sympathetic nervous systemervous system

Variable and paradoxical effects on the cardiovaVariable and paradoxical effects on the cardiovascular systemscular system

Nicotinic receptors in parasym. And sym. ganglia Nicotinic receptors in parasym. And sym. ganglia and muscarinic receptors in SA nodeand muscarinic receptors in SA node increase increase or decreased BP and HRor decreased BP and HR

The metabolite, succinylmonocholin, excites SA The metabolite, succinylmonocholin, excites SA node and results in breadycardianode and results in breadycardia

Anesthesiology 1957; 58:519–23Anesthesiology 1957; 58:519–23

Profound cardiovascular effectsProfound cardiovascular effects

In the infant and small child, profound sustained sinus brIn the infant and small child, profound sustained sinus bradycardia (50–60 bpm) is often observed; rarely asystole adycardia (50–60 bpm) is often observed; rarely asystole occursoccurs

Nodal rhythm and ventricular ectopic beats are seen in aNodal rhythm and ventricular ectopic beats are seen in approximately 80% of children given a single IV injection opproximately 80% of children given a single IV injection of S.C.Cf S.C.C

In adults and in children, the incidence of bradycardias aIn adults and in children, the incidence of bradycardias and other dysrhythmias are more frequent after a second nd other dysrhythmias are more frequent after a second dose of succinylcholine without atropine protectiondose of succinylcholine without atropine protection

The use of S.C.C in children should be reserved for emeThe use of S.C.C in children should be reserved for emergency intubation or immediate securing of the airway is rgency intubation or immediate securing of the airway is necessary, e.g., laryngospasm, difficult airway, full stomanecessary, e.g., laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccch, or for intramuscular use when a suitable vein is inaccessible essible

HyperkalemiaHyperkalemia

In normal adults, S.C.C increases plasma potassium concenIn normal adults, S.C.C increases plasma potassium concentration by 0.3–0.5 mmol/Ltration by 0.3–0.5 mmol/L

Not reliably prevented by pretreatment with nondepolarizerNot reliably prevented by pretreatment with nondepolarizer Conditions causing susceptibility to S.C.C induced hyperkalConditions causing susceptibility to S.C.C induced hyperkal

emiaemia ： ： Anaesthesia 1982; 37:802–5Anaesthesia 1982; 37:802–5

Burn injuryBurn injury Massive traumaMassive trauma Severe intra-abdominal Severe intra-abdominal infectioninfectionSpinal cord injurySpinal cord injury EncephalitisEncephalitis

StrokeStroke TetanusTetanus Guillain-Barre symdromeGuillain-Barre symdrome

PolyneuropathyPolyneuropathy Close head injuryClose head injury Severe Parkinson’s dizSevere Parkinson’s diz

Prolong total body Prolong total body immobilizationimmobilization

Ruptured cerebral Ruptured cerebral aneurysmaneurysm

Myopathies (eg, DuchenMyopathies (eg, Duchenne’s dystrophy)ne’s dystrophy)

Hemorrhagic shock with metabolic acidosisHemorrhagic shock with metabolic acidosis

Intragastric pressureIntragastric pressure

Directly related to the intensity of muscle fDirectly related to the intensity of muscle fasciculations asciculations

Pressures as high as 40 cm HPressures as high as 40 cm H22O, cardioesO, cardioesophageal sphincter mechanism may becoophageal sphincter mechanism may become incompetent and regurgitation and aspime incompetent and regurgitation and aspiration may occurration may occur

Intraocular pressureIntraocular pressure

The major increase in IOP is caused by contractiThe major increase in IOP is caused by contraction of extraocular muscles, dilation of choroidal von of extraocular muscles, dilation of choroidal vessels is a contributory factoressels is a contributory factor

IOP begins to increase within 60 s, peaks at 2~3 IOP begins to increase within 60 s, peaks at 2~3 min, then decreases to control in 5~7 min after smin, then decreases to control in 5~7 min after succinylcholine administration uccinylcholine administration

Increased IOP can result in extrusion of vitreous Increased IOP can result in extrusion of vitreous and possible loss of vision in a penetrating wounand possible loss of vision in a penetrating wound of the eyed of the eye

Can Anaesth Soc J 1986; 33: 195–208Can Anaesth Soc J 1986; 33: 195–208Anesthesiology 2003; 99: 220-3 Anesthesiology 2003; 99: 220-3

intracranial pressureintracranial pressure

Caused an increase in afferent muscle spindle aCaused an increase in afferent muscle spindle activity as well as an increase in cerebral blood flctivity as well as an increase in cerebral blood flowow

Increased central venous and intracerebral venoIncreased central venous and intracerebral venous pressureus pressure

More dramatic in the face of diminished autoregMore dramatic in the face of diminished autoregulation associated with acute brain injuryulation associated with acute brain injury

Anesth Analg. 1983; 62:1006-9Anesth Analg. 1983; 62:1006-9

Br JAnaesth. 1996; 77: 607-11Br JAnaesth. 1996; 77: 607-11

Malignant hyperthermiaMalignant hyperthermia

The incidence of MH in patients anesthetized witThe incidence of MH in patients anesthetized with volatile anesthetics and given succinylcholine h volatile anesthetics and given succinylcholine has been estimated at 1:4,000 to 1:40,000has been estimated at 1:4,000 to 1:40,000

Trismus or masseter spasm accompanied by rigiTrismus or masseter spasm accompanied by rigidity of the entire body may be associated with a dity of the entire body may be associated with a high incidence of MHhigh incidence of MH

Profound rigidity or violent fasciculation, increasProfound rigidity or violent fasciculation, increase in heart rate, a rapid increase in temperature, e in heart rate, a rapid increase in temperature, and in increase in etCOand in increase in etCO22

History and family history of MHHistory and family history of MHAnesth Analg 2000; 90: S24-8Anesth Analg 2000; 90: S24-8

Pulmonary edema and hemorrhagePulmonary edema and hemorrhage

Several young children who developed fulSeveral young children who developed fulminant pulmonary edema within minutes aminant pulmonary edema within minutes after IM succinylcholine fter IM succinylcholine

Responded to continuous positive pressurResponded to continuous positive pressure ventilation e ventilation

Acute elevation of systemic vascular resistAcute elevation of systemic vascular resistance and an acute decrease in pulmonary ance and an acute decrease in pulmonary vascular resistance vascular resistance

Anesth Analg 1981; 60:220–3Anesth Analg 1981; 60:220–3. .

Alternatives to succinylcholineAlternatives to succinylcholine

RocuroniumRocuronium A nondepolarizing, steroidal NMBD similar to vecuronium A nondepolarizing, steroidal NMBD similar to vecuronium

but with one-eighth to one-tenth the potency. The reducebut with one-eighth to one-tenth the potency. The reduced potency produces a more rapid onset of paralysis d potency produces a more rapid onset of paralysis Anesthesiology 1989; 70:915–20Anesthesiology 1989; 70:915–20

Bolus administration of 0.6 mg/kg (2 × ED95) produces cBolus administration of 0.6 mg/kg (2 × ED95) produces complete neuromuscular blockade of the adductor pollicis omplete neuromuscular blockade of the adductor pollicis in infants and children in 1.1 and 1.3 minin infants and children in 1.1 and 1.3 min

The onset time to maximal block was shorter with succinThe onset time to maximal block was shorter with succinylcholine but intubating conditions were comparable ylcholine but intubating conditions were comparable Pediatr Anaesth 1994; 4:173–7Pediatr Anaesth 1994; 4:173–7

Larger doses of rocuronium (0.9–1.2 mg/kg) have been sLarger doses of rocuronium (0.9–1.2 mg/kg) have been suggested as part of a rapid sequence induction techniquuggested as part of a rapid sequence induction technique e Br J Anaesth 1996; 77:335–8Br J Anaesth 1996; 77:335–8

Rocuronium versus succinylcholRocuronium versus succinylcholine for rapid sequence induction ine for rapid sequence induction

intubation (Cochrane Review)intubation (Cochrane Review) Cochrane Database of Systematic Cochrane Database of Systematic

Reviews. (1):CD002788, 2004Reviews. (1):CD002788, 2004

Objectives: Objectives: To determine if rocuronium creates To determine if rocuronium creates comparable intubating conditions to succinylcholcomparable intubating conditions to succinylcholine during RSI intubationine during RSI intubation

Search strategy: Search strategy: MEDLINE (1966-March 2000), MEDLINE (1966-March 2000), EMBASE (1988-March 2000) and the Cochrane EMBASE (1988-March 2000) and the Cochrane Central Register of Controlled Trials (March 200Central Register of Controlled Trials (March 2000) for randomized controlled trials (RCT) or contr0) for randomized controlled trials (RCT) or controlled clinical trials (CCT) relating to the use of roolled clinical trials (CCT) relating to the use of rocuronium and succinylcholine curonium and succinylcholine

40 studies were identified; 26 were combined for 40 studies were identified; 26 were combined for analysisanalysis

Overall, rocuronium was inferior to succinylcholiOverall, rocuronium was inferior to succinylcholine, with a RR=0.87 (95%CI = 0.81 to 0.94) (N=1ne, with a RR=0.87 (95%CI = 0.81 to 0.94) (N=1606)606)

In the group that used propofol for induction of aIn the group that used propofol for induction of anesthesia, the intubation conditions were similar, nesthesia, the intubation conditions were similar, with a RR=0.96 (95%CI = 0.87 to 1.06) (N=640)with a RR=0.96 (95%CI = 0.87 to 1.06) (N=640)

Conclusion:Conclusion: Succinylcholine created superior in Succinylcholine created superior intubation conditions to rocuronium when comparitubation conditions to rocuronium when comparing excellent intubation conditionsng excellent intubation conditions

Intubation conditions were not statistically differeIntubation conditions were not statistically different between succinylcholine and rocuronium whent between succinylcholine and rocuronium when propofol was usedn propofol was used

RapacuroniumRapacuronium

The first nondepolarizing relaxant to have both rapid onsThe first nondepolarizing relaxant to have both rapid onset and a short duration of neuromuscular blockadeet and a short duration of neuromuscular blockade

In a large multicenter study, rapacuroniurn 1.5 mg/kg waIn a large multicenter study, rapacuroniurn 1.5 mg/kg was compared with S.C.C 1.0 mg/kg. When laryngoscopy ws compared with S.C.C 1.0 mg/kg. When laryngoscopy was started at 50 s, good-to-excellent intubating conditionas started at 50 s, good-to-excellent intubating conditions were seen in 89.4% and 97.4% of cases, respectively s were seen in 89.4% and 97.4% of cases, respectively Br J Anaesth 1999; 82:537–41Br J Anaesth 1999; 82:537–41

Cardiovascular side effects and histamine release tend tCardiovascular side effects and histamine release tend to be more common with low potency drugs, which also ho be more common with low potency drugs, which also have faster onsets. Rapacuroniurn produces mild dose-relave faster onsets. Rapacuroniurn produces mild dose-related tachycardia and hypotension, but these changes arated tachycardia and hypotension, but these changes are short-lived, and do not seem to be histamine-relatede short-lived, and do not seem to be histamine-related

Anesth Analg 2000; 90: S2-6Anesth Analg 2000; 90: S2-6

RapacuroniumRapacuronium

Bronchospasm or increased airway pressures afBronchospasm or increased airway pressures after tracheal intubation have been reported by seter tracheal intubation have been reported by several investigators. The incidence of such events veral investigators. The incidence of such events was 10.7% after rapacuronium compared with 4.was 10.7% after rapacuronium compared with 4.1% after succinylcholine1% after succinylcholine

Br J Anaesth 1999; 82:537–41Br J Anaesth 1999; 82:537–41 Conclusion: The onset time approaches that of sConclusion: The onset time approaches that of s

uccinylcholine, but duration is still slightly longer. uccinylcholine, but duration is still slightly longer. Cardiovascular side effects are larger than those Cardiovascular side effects are larger than those of most drugs introduced recently into clinical prof most drugs introduced recently into clinical practice. Respiratory effects still require investigatiactice. Respiratory effects still require investigationon

Anesth Analg 2000; 90: S2-6Anesth Analg 2000; 90: S2-6

GW280430AGW280430A Asymmetric mixed-tetrahydroisoquinolinium chlorofumar

ate Of the drugs in clinical practice, the closest structural res

emblance is mivacuriumJ Med Chem 2003; 46:2502–15

The onset, almost as rapid as succinylcholine, may be sufficient to facilitate RSI in most clinical situations

Anesth Analg 2001; 93:954–9 Clinically significant histamine release occurred in one of

four subjects Anesthesiology 2004; 100:768–73 May never be released into clinical practice, but it is quit

e conceivable that a drug closely related to it will be.Anesthesiology 2004; 100:763–4

Priming techniquesPriming techniques

Small subparalyzing dose, “priming dose,” of a nondepolSmall subparalyzing dose, “priming dose,” of a nondepolarizing NMBD several minutes before the “intubating dosarizing NMBD several minutes before the “intubating dose”e”

Large enough to cause approximately 75% occupancy of Large enough to cause approximately 75% occupancy of end-plate receptors but small enough not to cause unpleend-plate receptors but small enough not to cause unpleasant symptomsasant symptoms

Depends on the choice of the relaxant, the size of the priDepends on the choice of the relaxant, the size of the priming dose (approximately 15%–20% of the ED95), the inming dose (approximately 15%–20% of the ED95), the intubating dose (multiple of the ED95), and the interval bettubating dose (multiple of the ED95), and the interval between the two dosesween the two doses

Atracurium, vecuronium, pipecuronium, pancuronium, anAtracurium, vecuronium, pipecuronium, pancuronium, and rocuroniumd rocuronium

Anesthesiology 1985; 62:392–5Anesthesiology 1985; 62:392–5Anesth Analg 1997; 85:663–6Anesth Analg 1997; 85:663–6

Timing techniquesTiming techniques

Administration of a single bolus of nondepolariziAdministration of a single bolus of nondepolarizing NMBD before the IV induction drugng NMBD before the IV induction drug

Ptosis with diplopia or a reduction in hand grip arPtosis with diplopia or a reduction in hand grip are the usual clinical end points of weaknesse the usual clinical end points of weakness

The onset of neuromuscular blockade seems fasThe onset of neuromuscular blockade seems faster with timing techniques (60 s) than priming tecter with timing techniques (60 s) than priming techniques (90 s) and with larger doses of NMBDshniques (90 s) and with larger doses of NMBDs

Atracurium, vecuronium, and rocuronium Atracurium, vecuronium, and rocuronium Anesth Analg 1993; 76:998–1003Anesth Analg 1993; 76:998–1003

Synergistic mixtures Synergistic mixtures

Combinations of nondepolarizing relaxants, acceCombinations of nondepolarizing relaxants, accelerated onset and delayed recovery lerated onset and delayed recovery

Pancuronium with mivacuriumPancuronium with mivacurium Vecuronium with mivacuriumVecuronium with mivacurium Rocuronium with mivacuriumRocuronium with mivacurium Atracurium with mivacurium Atracurium with mivacurium Atracurium with vecuroniumAtracurium with vecuronium The clinical use of these observations is unclearThe clinical use of these observations is unclear

Anesth Analg 1993; 76:998–1003Anesth Analg 1993; 76:998–1003Anesthesiology 1994; 81:388–95Anesthesiology 1994; 81:388–95

Pre-preparation of succinylcholiPre-preparation of succinylcholine: significant waste for questione: significant waste for questio

nable benefitnable benefit

AnaesthesiaAnaesthesia 2004; 59:211 2004; 59:211

Past— “This is a powerful reason to alwayPast— “This is a powerful reason to always have succinylcholine drawn up before ans have succinylcholine drawn up before any anaesthetic” when considering the treaty anaesthetic” when considering the treatment of laryngospasmment of laryngospasm

Lee's Synopsis of Anaesthesia, 12th edn., 1999: 266Lee's Synopsis of Anaesthesia, 12th edn., 1999: 266

Now— More “airway-friendly” drugs (e.g. pNow— More “airway-friendly” drugs (e.g. propofol and sevoflurane), advances in fibreropofol and sevoflurane), advances in fibreoptic intubating techniques and improved optic intubating techniques and improved monitoringmonitoring

Laryngospasm—perioperativeLaryngospasm—perioperative

Remove the stimulus including stopping the surgRemove the stimulus including stopping the surgery if appropriateery if appropriate

CPAP with 100% O2 with or without positive preCPAP with 100% O2 with or without positive pressure ventilationssure ventilation

Jaw thrust with pressure in the “laryngospasm nJaw thrust with pressure in the “laryngospasm notch”otch”

Deepen anesthesia with propofol or sevofluraneDeepen anesthesia with propofol or sevoflurane Using a short-acting potent intravenous opioid Using a short-acting potent intravenous opioid

(e.g. alfentanil) if a painful stimulus is the cause(e.g. alfentanil) if a painful stimulus is the cause Consider succinylcholine in a dose as low as 0.1Consider succinylcholine in a dose as low as 0.1

 mg/kg mg/kg

Laryngospasm—postoperativeLaryngospasm—postoperative

Propofol used at a dose of 0.8 mg.kg 1 has been Propofol used at a dose of 0.8 mg.kg 1 has been shown to relieve laryngeal spasm successfully in shown to relieve laryngeal spasm successfully in most children following the removal of a LMAmost children following the removal of a LMA

In the adult population the equivalent dose of prIn the adult population the equivalent dose of propofol is approximately one quarter of the standopofol is approximately one quarter of the standard induction doseard induction dose

Deepening of anesthesia can also be achieved Deepening of anesthesia can also be achieved with inhalational agentswith inhalational agents

Intravenous succinylcholine is the relaxant of chIntravenous succinylcholine is the relaxant of choice for most clinicians; the dose used varies cooice for most clinicians; the dose used varies considerably, from a standard dose of 1.0 mg/kg to nsiderably, from a standard dose of 1.0 mg/kg to as little as 0.1 mg/kg as little as 0.1 mg/kg

SummarySummary

S.C.C is still the standard NMBD for rapid sS.C.C is still the standard NMBD for rapid sequence intubation until a non-depolarizing equence intubation until a non-depolarizing muscle relaxant with rapid onset, short duratmuscle relaxant with rapid onset, short duration of action and minimal side-effect profile ion of action and minimal side-effect profile becomes availablebecomes available

Its routine pre-preparation prior to every aneIts routine pre-preparation prior to every anesthetic is no longer necessary sthetic is no longer necessary

Have a nice day !!Have a nice day !!