Adult Dosing

Neuromuscular blockade for short surgical procedures

• IV
• 0.3-1.1 mg/kg IV x 1 given over 10-30 seconds
• Administer a 5- to 10-mg test dose to determine the sensitivity of the patient and the individual recovery time

• IM
• 3-4 mg/kg IM x 1
• Max: 150 mg total dose

Neuromuscular blockade for long surgical procedures

• IV
• Continuous IV infusion of solutions containing 1-2 mg/mL may be administered at a rate of 0.5-10 mg/min
• Alt: Intermittent IV injections of 0.3-1.1 mg/kg IV may be given initially, followed at appropriate intervals, by further injections of 0.04-0.07 mg/kg IV to maintain the degree of relaxation required
• Average rate of infusion ranges between 2.5 and 4.3 mg/minute

• IM
• 3-4 mg/kg IM x 1
• Max: 150 mg total dose

• Consider pretreatment with anticholinergic agents to reduce the occurrence of bradyarrhythmias
• Onset of neuromuscular blockade following IV administration develops in 1 min; maximum blockade persists for about 2 min, after which recovery occurs within 4-6 min (IV)
• Onset of effect of succinylcholine IM is observed in about 2-3 minutes

Pediatric Dosing

Neuromuscular blockade

• IV
• 2 mg/kg IV for infants and small children; 1 mg/kg IV x 1 for older children and adolescents

• IM
• 3-4 mg/kg IM x 1
• Max: 150 mg total dose

• Continuous IV infusions of succinylcholine are considered unsafe in neonates and children due to the risk of malignant hyperthermia
• Consider pretreatment with anticholinergic agents to reduce the occurrence of bradyarrhythmias
• Onset of neuromuscular blockade following IV administration develops in 1 min; maximum blockade persists for about 2 min, after which recovery occurs within 4-6 min (IV)
• Onset of effect of succinylcholine IM is observed in about 2-3 minutes

[Outline]

• Adult Dosing
• Pediatric Dosing

• Indicated as an adjunct to general anesthesia, to facilitate tracheal intubation, and to produce skeletal muscle relaxation during surgery or mechanical ventilation

• Hypersensitivity to any of the ingredients of the product
• Familial/personal history of malignant hyperthermia
• Skeletal muscle myopathies
• Acute phase of injury following major burns
• Multiple trauma
• Extensive denervation of skeletal muscle
• Acute upper motor neuron injury
• Angle-closure glaucoma
• Penetrating eye injury

• Acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest and death have been reported rarely following succinylcholine administration to apparently healthy pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most commonly Duchenne's muscular dystrophy
• This syndrome often manifests as peaked T-waves and sudden cardiac arrest within minutes after drug administration in healthy appearing pediatric patients; there have also been reports in adolescent patients
• If a healthy appearing infant or child develops cardiac arrest soon after the administration of the drug, immediate treatment for hyperkalemia should be instituted which includes administration of IV calcium, bicarbonate, and glucose with insulin, with hyperventilation. Routine resuscitative measures are likely to be unsuccessful, due to the abrupt onset of this syndrome. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation. Institute appropriate treatment for signs of malignant hyperthermia
• Reserve use of succinylcholine in pediatric patients for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or for IM use when a suitable vein is inaccessible)

Renal Dose Adjustment

• Renal impairment: Dose adjustments not defined
• Severe impairment: Caution advised

Hepatic Dose Adjustment

• Hepatic impairment: Dose adjustments not defined
• Severe impairment: Caution advised

• Therapy should be administered only by those skilled in the management of artificial respiration and when facilities are readily available for tracheal intubation and for providing adequate ventilation of the patient, including oxygen administration under positive pressure and elimination of carbon dioxide. Physician must be prepared to assist or control respiration
• Avoid therapy administration before unconsciousness has been induced to avoid distress to the patient. However, in emergency situations, it may be necessary to administer succinylcholine before unconsciousness is induced
• Use therapy cautiously in patients known to be or suspected of being homozyygous for the atypical plasma cholinesterase gene
• Use cautiously in patients suffering from electrolyte abnormalities and massive digitalis toxicity, as succinylcholine may induce serious cardiac arrhythmias or cardiac arrest due to hyperkalemia
• Exercise caution if therapy is administered to patients during the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury, as there may be an increased risk of hyperkalemia in these patients
• Use succinylcholine cautiously in patients with chronic abdominal infection, subarachnoid hemorrhage, or conditions causing degeneration of central and peripheral nervous systems due to the potential for developing severe hyperkalemia
• Life-threatening and sometimes fatal severe anaphylactic reactions have been reported with succinylcholine use. Closely monitor patients who have had previous anaphylactic reactions to neuromuscular blocking agents since cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported in this class of drugs
• Acute onset of malignant hyperthermia, a potentially fatal hypermetabolic state of skeletal muscle, has been associated with succinylcholine use. This risk may increase with the concomitant administration of volatile anesthetics. Malignant hyperthermia may commonly manifest as intractable spasm of the jaw muscles which may progress to generalized rigidity, increased oxygen demand, tachycardia, tachypnea and profound hyperpyrexia
• Skin mottling, rising temperature, and coagulopathies may occur later in the course of the hypermetabolic process
• Continuous monitoring of temperature and expired CO2 is recommended as an aid to early recognition of malignant hyperthermia
• Incidence of bradycardia, which may progress to asystole, is higher after a second dose of succinylcholine; the incidence and severity of bradycardia is higher in pediatric patients than adults. Repeated exposure to succinylcholine may lead to bradycardia in adults. Pretreatment with anticholinergic agents such as atropine may reduce the occurrence of bradyarrhythmias
• Therapy may cause an increase in intraocular pressure. Not indicated in instances in which an increase in IOP is undesirable unless the potential benefit of its use outweighs the potential risk
• Prolonged use of therapy may change Phase I block to Phase II block. Prolonged respiratory muscle paralysis or weakness may be seen in patients manifesting this transition to Phase II block
• Use cautiously in patients with fractures or muscle spasm, as the initial muscle fasciculations may cause additional trauma
• Therapy may cause a transient increase in intracranial pressure and may also increase intragastric pressure resulting in regurgitation and possible aspiration of stomach contents
• Neuromuscular blockade may be prolonged in patients with hypocalcemia or hypokalemia
• Use cautiously in patients with reduced plasma cholinesterase (pseudocholinesterase) activity

Caution: Use cautiously in

• Severe renal impairment
• Severe hepatic impairment
• Pseudocholinesterase deficiency
• Neuromuscular disorder
• Myasthenia gravis
• Eaton-Lambert syndrome
• Pulmonary disorder
• Hx of severe anaphylactic reaction
• Paraplegia
• Hyperkalemia
• Cardiovascular disorder
• Arrhythmias
• Febrile patients
• Nerve degeneration
• Spinal cord injury
• Pediatric patients

Pregnancy Category:C

Breastfeeding: No information is available regarding succinylcholine use during breastfeeding. A general anesthetic regimen that included succinylcholine for cesarean section caused a delay in the time to the first breastfeeding, but the part that succinylcholine played in this difference in outcome is unknown. This information is (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 9 June 2011). Manufacturer advises caution.

• CV: Cardiac arrest (pediatric patients), arrhythmias, bradycardia, tachycardia, hypertension, hypotension, ventricular arrhythmias (pediatric patients)
• CNS: Malignant hyperthermia
• GI: Excessive salivation
• GU: Myoglobinuric acute renal failure
• METABOLIC: Hyperkalemia, myoglobinemia
• DERM: Rash
• EENT: Increased IOP
• RESP: Respiratory depression, apnea
• MUSC: Muscle fasciculation, postoperative muscle pain, rhabdomyolysis w/ hyperkalemia (pediatric patients)
• HYPERSENSITIVITY: Anaphylaxis, hypersensitivity reactions
• MISC: Jaw rigidity, prolonged paralysis

• Depolarizing skeletal muscle relaxant; combines with the cholinergic receptors of the motor end plate to produce depolarization
• Metabolized rapidly by plasma cholinesterase to succinylmonocholine and then to succinic acid and choline
• Excreted in urine (10% unchanged)
• Half-life: Unknown

US Trade Name(s)

• Anectine
• Quelicin

US Availability

Anectine

• INJ: 20 mg/mL

Quelicin

• INJ: 20 mg/mL
• INJ: 100 mg/mL

Canadian Trade Name(s)

• Quelicin

Canadian Availability

succinylcholine (generic)

• INJ: 20 mg/mL

Quelicin

• INJ: 20 mg/mL
• INJ: 100 mg/mL

UK Trade Name(s)

• N/A

UK Availability

• N/A

Australian Trade Name(s)

• N/A

Australian Availability

• N/A

[Outline]

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