<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=Windows-1252">
<style type="text/css" style="display:none;"> P {margin-top:0;margin-bottom:0;} </style>
</head>
<body dir="ltr">
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Hey all,</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
To summarize our conversation from earlier (with references)</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Avoid succinylcholine in kids (risk of undiagnosed muscular dystrophy - see BIG warning on package insert attached). </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Avoid in pts suspected of having hyperkalemia (dialysis patient, rhabdomyolysis, etc)</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Ok in the IMMEDIATE management, but higher risk after 24-48 hrs. Duration of risk indeterminate and variable:</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Burns - safe first 24 hrs. Risk out to 1 year post-burn </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Stroke - safe first 24-48 hrs. Risk out to 3-6 months? </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Spinal cord injury - safe first 24-48 hrs. Risk out to 3-6 months? </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Not ok initially or after </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Crush injury (beyond inital rhabdo concerns) - would not use initially at all due to risk of hyperkalemia from rhabdomyolysis. Duration of avoidance - unsure </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span style="background-color: rgb(255, 255, 0);"><b>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.</b></span></div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Hope this helps! </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
Mike </div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
See references below</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span style="background-color: rgb(255, 128, 0);">Burn:</span></div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span class="access-state-logos all-viewports" style="box-sizing:border-box;margin:0px;font-size:13px;line-height:1.5em;font-family:"Source Sans Pro", Helvetica, Arial, sans-serif;text-transform:uppercase;letter-spacing:1px;color:rgb(42, 42, 42);background-color:rgb(255, 255, 255)"><span class="journal-info__format-label" style="box-sizing: border-box; margin: 0px 0.5rem 0.25rem 0px; padding: 3px 8px 4px; font-size: 0.8125rem; line-height: 1em; display: inline-block; background-color: rgb(255, 128, 0); letter-spacing: 0.075em;">JOURNAL
ARTICLE</span></span>
<div class="widget-items" style="box-sizing:border-box;margin:0px;font-size:17px;font-family:"Source Sans Pro", Helvetica, Arial, sans-serif;color:rgb(42, 42, 42);background-color:rgb(255, 255, 255)">
<div class="title-wrap" style="box-sizing:border-box;margin:0px">
<h1 class="wi-article-title article-title-main accessible-content-title at-articleTitle" style="box-sizing:border-box;margin:0px 10px 0.1rem 0px;font-weight:700;font-size:24px !important;line-height:1.37 !important;font-family:Merriweather, serif;display:inline">
<span style="background-color: rgb(255, 128, 0);">Anaesthesia and intensive care for major burns</span><span style="background-color: rgb(255, 128, 0);"> </span><i class="icon-availability_free" title="Free" style="box-sizing:border-box;margin:0px;font-style:normal;font-weight:normal;line-height:1;font-family:icomoon !important;speak:none;color:rgb(47, 145, 98)"></i></h1>
</div>
<div class="wi-authors at-ArticleAuthors" style="box-sizing:border-box;margin:0px">
<div class="al-authors-list" style="box-sizing:border-box;margin:0px 0px 11px"><span class="al-author-name-more js-flyout-wrap" style="box-sizing:border-box;margin:0px;display:inline-block"><a class="linked-name js-linked-name-trigger" data-google-interstitial="false" style="box-sizing:border-box;margin:0px;color:rgb(0, 111, 183);hyphens:auto;overflow-wrap:break-word;word-break:break-word"><span style="background-color: rgb(255, 128, 0);">Sophie
Bishop, MBChB (Euro) FRCA</span></a><span class="delimiter" style="box-sizing:border-box;margin:0px"><i class="icon-general-mail" style="box-sizing:border-box;margin:0px;padding:0px 2px 0px 6px;font-style:normal;font-weight:normal;font-size:0.8em;line-height:1;font-family:icomoon !important;speak:none"></i></span><span class="delimiter" style="box-sizing: border-box; margin: 0px; background-color: rgb(255, 128, 0);">,</span></span><span style="background-color: rgb(255, 128, 0);"> </span><span class="al-author-name-more js-flyout-wrap" style="box-sizing:border-box;margin:0px;display:inline-block"><a class="linked-name js-linked-name-trigger" data-google-interstitial="false" style="box-sizing:border-box;margin:0px;color:rgb(0, 111, 183);hyphens:auto;overflow-wrap:break-word;word-break:break-word"><span style="background-color: rgb(255, 128, 0);">Simon
Maguire, MBChB, FRCA</span></a><span class="delimiter" style="box-sizing:border-box;margin:0px"></span></span></div>
</div>
<div class="pub-history-wrap clearfix js-history-dropdown-wrap" style="box-sizing:border-box;margin:11px 0px">
<div class="pub-history-row clearfix" style="box-sizing:border-box;margin:0px">
<div class="ww-citation-primary" style="box-sizing:border-box;margin:0px 15px 0px 0px;display:inline">
<span style="background-color: rgb(255, 128, 0);"><em style="box-sizing:border-box;margin:0px">Continuing Education in Anaesthesia Critical Care & Pain</em></span><span style="background-color: rgb(255, 128, 0);">, Volume 12, Issue 3, June 2012, Pages 118–122,</span><span style="background-color: rgb(255, 128, 0);"> </span><a href="https://urldefense.com/v3/__https://doi.org/10.1093/bjaceaccp/mks001__;!!GobTDDpD7A!LmtLy-p8lFSOLdWSEqxK1KgGuSETnyb1UKXBxq6ZIB2Hjv-FGcX__59XljwfVrP8DpTeXn85lgkpwJLSBqgGMuqlYA$" data-google-interstitial="false" style="box-sizing:border-box;margin:0px;color:rgb(0, 111, 183);hyphens:auto;overflow-wrap:break-word;word-break:break-word"><span style="background-color: rgb(255, 128, 0);">https://doi.org/10.1093/bjaceaccp/mks001</span></a></div>
</div>
<div class="pub-history-row clearfix" style="box-sizing:border-box;margin:0px">
<div class="ww-citation-date-wrap" style="box-sizing:border-box;margin:0px 20px 0px 0px;display:inline-block">
<div class="citation-label" style="box-sizing:border-box;margin:0px 5px 0px 0px;font-weight:700;display:inline">
<span style="background-color: rgb(255, 128, 0);">Published:</span></div>
<span style="background-color: rgb(255, 128, 0);"> </span><br>
<span class="citation-date" style="box-sizing: border-box; margin: 0px; display: inline; background-color: rgb(255, 128, 0);">23 February 2012</span></div>
</div>
</div>
</div>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span style="color: rgb(42, 42, 42); font-family: Merriweather, serif; font-size: 15px; background-color: rgb(255, 255, 0); display: inline !important;">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.</span><br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<br class="Apple-interchange-newline">
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span style="background-color: rgb(128, 255, 128);">Stroke, spinal cord injury</span></div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<span style="color: rgb(17, 17, 17); font-family: "carrois gothic", sans-serif; font-size: 18px; font-weight: 700; text-indent: -9999px; background-color: rgb(128, 255, 128); display: inline !important;">Open Anesthesia</span><br>
</div>
<div style="font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);" class="elementToProof">
<header class="entry-header" style="box-sizing:border-box;display:block;color:rgb(51, 51, 51);font-family:"open sans", "helvetica neue", Helvetica, Arial, sans-serif;font-size:18px;font-weight:300">
<h1 class="entry-title" style="box-sizing:border-box;font-size:2.25rem;margin:0px 0px 1rem;font-family:"carrois gothic", sans-serif;font-weight:400;line-height:1.3;padding:0px 20px">
<span style="background-color: rgb(128, 255, 128);">Sux in neuromuscular disease</span></h1>
</header>
<div class="entry-content" style="box-sizing:border-box;padding:0px 20px 20px;color:rgb(51, 51, 51);font-family:"open sans", "helvetica neue", Helvetica, Arial, sans-serif;font-size:18px;font-weight:300">
<div class="aba-keyword" style="box-sizing:border-box">
<h3 style="box-sizing:border-box;font-family:"carrois gothic", sans-serif;font-weight:700;line-height:1.5;margin:0px 0px 1rem;font-size:1.5rem">
<span style="background-color: rgb(128, 255, 128);">Definition</span></h3>
<div class="aba-keyword-definition" style="box-sizing:border-box">
<p style="box-sizing:border-box;margin:0px 0px 1.563rem"><span style="background-color: rgb(128, 255, 128);">After the administration of succinylcholine, an 0.5 – 1.0 mEq/mL increase in serum potassium is normal.</span></p>
<p style="box-sizing:border-box;margin:0px 0px 1.563rem"><span style="background-color: rgb(255, 255, 0);"><strong style="box-sizing:border-box;font-weight:700">Patients with neuromuscular disease such as a stroke have risk of serious hyperkalemia after succinylcholine.</strong></span><strong style="box-sizing:border-box;font-weight:700"><span> </span></strong><span style="background-color: rgb(255, 255, 0);">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.</span>
<span style="background-color: rgb(255, 255, 0);">Duration of risk has not been adequately characterized but is suspected to be for 3-6 months</span>.
<span style="background-color: rgb(128, 255, 128);">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.</span></p>
<p style="box-sizing:border-box;margin:0px 0px 1.563rem"><span style="background-color: rgb(128, 255, 128);">Dunn agrees that renal failure itself does not increase the risk of SCh administration as long as hyperkalemia is well-controlled.</span></p>
<p style="box-sizing:border-box;margin:0px 0px 1.563rem"><br>
</p>
<p style="box-sizing:border-box;margin:0px 0px 1.563rem"><span style="background-color: rgb(0, 255, 255);">Kids: From package insert</span></p>
<div style="box-sizing: border-box; margin: 0px 0px 25.008px;"><span style="background-color: rgb(0, 255, 255);">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).</span>
<br>
</div>
</div>
</div>
</div>
</div>
</body>
</html>