[toxvtc] Follow up on succinylcholine discussion

[Michael P. Keenan]

Hey all,

To summarize our conversation from earlier (with references)

Avoid succinylcholine in kids (risk of undiagnosed muscular dystrophy - see BIG warning on package insert attached).

Avoid in pts suspected of having hyperkalemia (dialysis patient, rhabdomyolysis, etc)

Ok in the IMMEDIATE management, but higher risk after 24-48 hrs. Duration of risk indeterminate and variable:
Burns - safe first 24 hrs. Risk out to 1 year post-burn
Stroke - safe first 24-48 hrs. Risk out to 3-6 months?
Spinal cord injury - safe first 24-48 hrs. Risk out to 3-6 months?

Not ok initially or after
Crush injury (beyond inital rhabdo concerns) - would not use initially at all due to risk of hyperkalemia from rhabdomyolysis. Duration of avoidance - unsure

Overall take away - I personally like to keep it simple and avoid succinylcholine in these patients all together, even on initial visit. It makes it easier to keep everything straight. However, I generally extend it to any patient I see with these risk factors. ie, stroke patient comes in and needs to be intubated. I am not sure exactly when the stroke was, etc - going to use rocuronium. I just stick to a non-depolarizing agent in these cases. In all honestly, I primarily use roc for all my intubations because it takes this decision out of my head and I personally do not have an issue with it.

Hope this helps!

Mike



See references below

Burn:
JOURNAL ARTICLE
Anaesthesia and intensive care for major burns
Sophie Bishop, MBChB (Euro) FRCA, Simon Maguire, MBChB, FRCA
Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 3, June 2012, Pages 118–122, https://urldefense.com/v3/__https://doi.org/10.1093/bjaceaccp/mks001__;!!GobTDDpD7A!LmtLy-p8lFSOLdWSEqxK1KgGuSETnyb1UKXBxq6ZIB2Hjv-FGcX__59XljwfVrP8DpTeXn85lgkpwJLSBqgGMuqlYA$  
Published:

23 February 2012
Succinylcholine is safe in the first 24 h after a burn—after this time, its use is contraindicated due to the risk of hyperkalaemia leading to cardiac arrest, thought to be due to release of potassium from extrajunctional acetylcholine receptors. This can persist up to 1 year post-burn.


Stroke, spinal cord injury
Open Anesthesia
Sux in neuromuscular disease
Definition

After the administration of succinylcholine, an 0.5 – 1.0 mEq/mL increase in serum potassium is normal.

Patients with neuromuscular disease such as a stroke have risk of serious hyperkalemia after succinylcholine. This usually peaks 7-10 days after insult, but increased K+ release may occur as soon as 2-4 days after denervation injury, or after several days of immobility. Duration of risk has not been adequately characterized but is suspected to be for 3-6 months. Our current understanding of this phenomenon is incomplete, but is thought to be related to the up-regulation (increase) of AChRs. Note that renal failure itself does not place patients at risk for exaggerated release ] and succinylcholine can be administered, although the margin for error is lower.

Dunn agrees that renal failure itself does not increase the risk of SCh administration as long as hyperkalemia is well-controlled.


Kids: From package insert

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's 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, e.g. laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible (see PRECAUTIONS: Pediatric Use and DOSAGE AND ADMINISTRATION).

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