Airway management of postburn neck contracture in pediatric patient - A challenge for anesthesiologist!

Pediatric difficult airway management is more challenging for an anesthesiologist due to anatomical and physiological differences as compared to adults. Moreover, the familiarity with the use of difficult airway equipment in adults does not equate to proficiency for the same in children. So, here we are presenting the management of a unique case of a difficult airway due to postburn neck contracture in a 4-year-old child, which was managed successfully with the help of a video laryngoscope after the failure attempt with a flexible fiberoptic bronchoscope.

Quantitative Neuromuscular Monitoring Permits Early Diagnosis of Abnormal Butyrylcholinestrase: Two Case Studies Demonstrating Prevention of Awareness from Premature Awakening

Administration of succinylcholine to patients with a variant in the butyrylcholinesterase (BChE) gene increases the risk of anesthesia emergence prior to recovery from neuromuscular blockade (NMB). Application of quantitative neuromuscular monitoring (NMM) can identify residual NMB. We present two patients with abnormal BChE gene variants. In the first case, quantitative monitoring was applied too late to prevent awareness, but allowed diagnosis and prevented admission to the intensive care unit. In the second case, monitoring was applied prior to NMB, which enabled early diagnosis and prevented premature awakening from anesthesia. These cases illustrate the importance of quantitative NMM, even in short cases and with short-acting depolarizing agents such as succinylcholine. The clinical implications of this report include a more consistent use of NMM to identify and manage patients with undiagnosed abnormal BChE and to prevent premature anesthesia emergence.

Laryngospasm Treated With Intramuscular Rocuronium in a Pediatric Patient Without Intravenous Access: A Case Report

We present a case in which intramuscular rocuronium was used successfully to treat laryngospasm in a pediatric patient. An 11-month-old infant weighing 9.7 kg was scheduled for an elective laparoscopic inguinal hernia repair surgery. Anesthesia was induced with oxygen, nitrous oxide, and sevoflurane. After loss of consciousness, mask ventilation became impossible, and laryngospasm was suspected. Intravenous access was attempted without success; as there was no immediate access to succinylcholine, rocuronium 10 mg (1.0 mg/kg) was injected intramuscularly into the vastus lateralis muscle. We were able to mask-ventilate the patient within one minute of intramuscular rocuronium, followed by successful endotracheal intubation with a video laryngoscope. The duration of hypoxia (saturation of peripheral oxygen (SpO2) < 90%) was approximately two minutes, and the patient's lowest oxygen saturation during induction was 76%. At the end of the surgery, the patient was uneventfully extubated. We conclude that intramuscular rocuronium may provide an alternative treatment for laryngospasm in pediatric patients with no intravenous access and no availability of succinylcholine.

A Randomized Double-Blind Comparative Study of the Intubating Conditions and Hemodynamic Effects of Rocuronium and Succinylcholine in Pediatric Patients

BACKGROUND

The incidence of unanticipated difficult airways is higher in pediatric age groups than in adults due to the different airway anatomy, difficulty in airway examination, and congenital malformations. Rocuronium bromide has a comparable onset time to succinylcholine at its proportionate dose. Hence, we compared rocuronium bromide with succinylcholine to assess intubating conditions and their side effects, if any.

METHOD

A total of 200 pediatric patients of American Society of Anesthesiologists (ASA) grades I and II between one and 14 years of age of either sex posted for elective surgery were included in the study. After randomization, group R (n = 100) received 1.2 mg/kg rocuronium, and group S (n = 100) received 2 mg/kg succinylcholine intravenously. After confirming the mask ventilation, the study drugs were administered, and intubating conditions were assessed as excellent, good, poor, or impossible. Hemodynamic changes post-intubation were recorded as our secondary outcome.

RESULT

Intubating conditions were excellent( 65%), good( 25%) and fair (10%) in patients of group R, while results in group S were excellent( 60%), good( 20%), fair (15%), and poor (5%) (p = 0.010). The heart rate was significantly increased post-intubation in group S, while there was no significant increase in systolic or diastolic blood pressure in either group.

CONCLUSION

At a dose of 1.2 mg/kg body weight, rocuronium was a better alternative to succinylcholine for providing rapid intubating conditions and stable hemodynamics without associated adverse effects.

The Effects of Prophylactic Intravenous Lignocaine vs Vecuronium on Succinylcholine-Induced Fasciculation and Postoperative Myalgia in Patients Undergoing Elective Surgery at Debre Markos Comprehensive Specialized Hospital, Ethiopia, 2022: Prospective Cohort Study

Background

The incidence and severity of succinylcholine-induced fasciculation and postoperative myalgia have been shown to decrease when vecuronium bromide or preservative-free 2% plain lignocaine hydrochloride is administered before induction. The aim of this study is to examine the effectiveness of defasciculation dosages of vecuronium bromide and 2% preservative-free plain lignocaine hydrochloride in decreasing succinylcholine-induced fasciculation and postoperative myalgia in patients undergoing elective surgery.

Methods

A total of 110 participants were included in a prospective observational cohort study that was located in an institution. Patients were randomly assigned to (Group L) and (Group V) based on the prophylactic measures they received from the responsible anesthetist utilizing preservative-free 2% plain lignocaine and defasciculation dose of vecuronium bromide, respectively. We recorded, socio-demographic variables, fasciculation, postoperative myalgia, total number of analgesics administered following surgery in 48hrs, and kind of procedure. The descriptive data were compiled using descriptive statistics. Categorical and continuous data were evaluated, respectively, using chi-square statistics and the independent sample t-test. To compare the prevalence of fasciculation and myalgia across the various groups, the Fischer exact test was performed. A 0.05 p-value was deemed statistically significant.

Results

This study found that the incidence of fasciculation in the groups receiving the defasciculation doses of vecuronium bromide and preservative-free 2% plain lignocaine hydrochloride was 14.6% and 20% (p-value 0.007), respectively. The rate of mild-to-moderate postoperative myalgia in the vecuronium bromide group was 23.7%, 30.9%, and 16.4% in the first, 24th, and 48th hours, respectively (p-value 0.001), as opposed to 0%, 37.3%, and 9.1%, respectively (p-value 0.008) in the group receiving preservative-free 2% plain lignocaine hydrochloride.

Conclusion

Pretreatment with 2% plain lignocaine that is preservative-free is more efficient than vecuronium bromide at reducing the frequency and intensity of postoperative succinylcholine-induced myalgia, whereas defasciculation dose of vecuronium was more effective prevention of succinylcholine-induced fasciculation.

Delayed diagnosis of butyrylcholinesterase deficiency with insufficient neuromuscular monitoring and a confounding effect of SedLine® brain function monitoring: a case report

Intraoperative monitoring has always been a vital part of the care of an anaesthetised patient. Neuromuscular monitoring is important to use when patients have received neuromuscular blocking agents. Quantitative neuromuscular monitors are preferred over qualitative monitors and clinical judgement alone in reducing residual neuromuscular block and the associated respiratory complications. Additionally, brain function monitors can be utilised to assess the level of consciousness in anaesthetised patients. These monitors can be useful during surgical procedures and at the conclusion of a procedure to show the progress of a patient emerging from anaesthesia. We describe a case where a lack of neuromuscular monitoring after a single dose of succinylcholine coupled with an overemphasis on SedLine® brain function monitor values delayed the diagnosis of butyrylcholinesterase deficiency in a patient undergoing a mastectomy for breast cancer. This case shows the fundamental importance of using neuromuscular monitors in patients who receive neuromuscular blocking agents. It also stresses the necessity to utilise brain function monitors as clinical aids, but not allow them to hinder thinking about broader differential diagnoses when faced with challenging clinical scenarios.

A Case Report

Background

We present a case study of a man with coronavirus disease 2019 (COVID-19) who developed cardiac arrest as a result of hyperkalemia following administration of chlororsuccinylcholine during endotracheal intubation.

Case Summary

A patient with a severe course of COVID-19, hospitalized in the Intensive Care Unit, underwent reintubation on day 16. The applied scheme was rapid sequence induction and intubation with administration of chlororsuccinylcholine. Immediately after intubation, there was a sudden cardiac arrest due to hyperkalemia (cK + 10.2 meq/L). Treatment was initiated as per guidelines, which resulted in a return to spontaneous circulation after 6 min.

Conclusion

Chlorsucynylcholine may cause life-threatening hyperkalemia. We recommend using rocuronium as a neuromuscular blocking agent in critically ill COVID-19 patients due to its more optimal safety profile.

Rocuronium on Apnea Duration for Rapid Sequence Induction: A Prospective Cohort Study

OBJECTIVE

The present study aimed to evaluate the impact of 1.5 mg/kg succinylcholine or 1.2 mg/kg rocuronium, vs. 1.0 mg/kg succinylcholine on apnea duration in patients underwent rapid sequence induction (RSI).

METHODS

This prospective cohort study was conducted in the Department of Anesthesiology in Shanghai General Hospital from July 2020 to November 2020. Apnea duration was defined as the time from apnea prompted by the PETCO2 waveform to the time the point of oxygen saturation declined to 90% (T90) and 95% (T95) after succinylcholine or rocuronium administration. The primary outcome included T90 and T95 changes in 1.5 mg/kg vs. 1.0 mg/kg succinylcholine groups and 1.5 mg/kg succinylcholine vs. 1.2 mg/kg rocuronium groups.

RESULTS

A total of 265 participants were subjected for analysis. The succinylcholine (1.0 mg/kg) group had a significantly longer T90 (50.72, 95% confidence interval [CI, 7.60, 94.38], P = 0.015) and T95 (48.09, 95% CI [7.11, 89.07], P = 0.012) than the succinylcholine (1.5 mg/kg) group. In addition, significantly longer T90 (56.84, 95% CI [16.24, 97.44], P = 0.003) and T95 (50.57, 95% CI [12.58, 88.57], P = 0.003) were observed in the rocuronium (1.2 mg/kg) group than those in the succinylcholine (1.5 mg/kg) group. No severe side events were observed during the operation.

CONCLUSION

Rocuronium and the lower dose of succinylcholine may be recommended to patients underwent RSI.

Spinal cord injury-related thermoregulatory impairment masks a fatal malignant hyperthermia crisis: a case report

PURPOSE

Malignant hyperthermia (MH) is a hypermetabolic disorder that can occur in genetically susceptible individuals exposed to halogenated anesthetics and succinylcholine. Spinal cord injury (SCI) above the sixth thoracic vertebra is associated with dysfunction of the sympathetic/parasympathetic nervous pathways, including thermoregulatory dysfunction, presenting as hypothermia in cold environments because of vasodilation and heat loss. This effect could mitigate or obscure an MH episode. Here, we describe development of a fatal MH crisis in a patient with SCI.

CLINICAL FEATURES

A 27-yr-old male patient with an SCI after fracture of the sixth cervical vertebra was admitted for spinal arthrodesis. Anesthetic medications included remifentanil, propofol, succinylcholine, rocuronium, and isoflurane. After the start of the surgery, muscular contractures resembling myoclonus were noted, which resolved with pancuronium administration. Four hours after the start of anesthesia, the patient presented with hyperthermia, hypercarbia, hypotension, muscle rigidity, arrhythmia, and cardiogenic shock, with metabolic/respiratory acidosis. Malignant hyperthermia was suspected and the treatment was started, but he developed cardiopulmonary arrest and died an hour and a half after the first cardiac arrest. Both parents were investigated and were found to have normal creatine kinase levels and positive in vitro contracture tests. His mother carried a variant in the ryanodine receptor type 1 (RYR1) gene (c.14918C>T), which is associated with MH.

CONCLUSION

Spinal cord injury-induced thermoregulatory dysfunction may obscure the early diagnosis of MH and lead to fatal outcome.

Comparison of hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is nowadays used commonly as one the most effective treatment methods in psychiatric disorders. In patients undergoing ECT, succinylcholine is usually used. In addition, cisatracurium is occasionally used on a case report basis globally. In this study, we compared the hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in ECT.

MATERIALS AND METHODS

The current crossover clinical trial was performed on 45 patients who were candidates for ECT between 2017 and 2018. The patients were given succinylcholine or cisatracurium randomly on two separate occasions of ECT. The independent t-test and Chi square Test were used to compare the data.

RESULTS

Comparison of mean systolic blood pressure (P = 0.14), diastolic blood pressure (P = 0.33), and mean arterial pressure (P = 0.23) did not show any significant difference between the two groups. The induced seizure duration (P = 0.002), return of spontaneous respiratory from seizure ending (P = 0.001), and apnea duration (P = 0.01) were significantly higher in the cisatracurium group compared to the succinylcholine group. However, the frequency of tachycardia in cisatracurium group was lower than the succinylcholine group (P < 0.001). In addition, the serum potassium level had a significant difference (P < 0.001) between the two groups.

CONCLUSION

Using cisatracurium can be an alternative to succinylcholine during ECT since it causes less elevation in serum potassium and creates a longer duration of induced seizure, more rapid re emergence of spontaneous breathing at the end of seizure (P = 0.001), and a lower prevalence of tachycardia compared to succinylcholine (P < 0.001).

Effect of Non-depolarizing Muscle Relaxants Rocuronium Versus Vecuronium in the Assessment of Post-Succinylcholine Complications in Surgeries Under General Anesthesia: A Randomized Double-Blind Study at a Tertiary Care Hospital

Background and objective

Several drugs have been used to prevent or attenuate succinylcholine-induced muscle fasciculations and myalgia. We designed the present study to evaluate the efficacy of rocuronium (ROC) and vecuronium (VEC) in preventing succinylcholine-induced fasciculations and postoperative myalgia (POM) in patients undergoing surgery under general anesthesia.

Materials and methods

After obtaining written informed consent, 125 patients were randomly selected to receive either ROC 0.06 mg/kg or VEC 0.01 mg/kg, with both diluted up to 2 ml, 90 seconds before the administration of propofol followed by succinylcholine. A standardized balanced anesthetic technique was used for all patients. The intensity of fasciculations and intubating conditions were assessed using a 4-point rating scale. All patients were evaluated up to the third postoperative day for the presence of POM, the severity of which was graded on a 4-point scale.

Results

The incidence of post-succinylcholine fasciculations during induction was nil in 74.58% of patients in the ROC group and 51.52% in the VEC group. Mild fasciculation was seen in 22.03% in the ROC group and 33.33% in the VEC group. Moderate fasciculation was seen in 3.39% and 15.15% in ROC and VEC groups respectively. When comparing both the groups, a significant decrease (p=0.015) in intraoperative fasciculation was observed in the ROC group than in the VEC group. Both drugs provided good intubating conditions without any statistical significance and with an overall intubating score of 8-9 in both groups as per Lund. On day one, 91.53% (n=54) of the ROC group and 65.15% (n=43) of the VEC group patients did not have any myalgia symptoms. Mild myalgia was observed in 8.47% (n=5) in the ROC group and 31.82% (n=21) in the VEC group, and only 1.8% had moderate myalgia in the VEC group. The results of the study showed that POM was significantly decreased in the ROC group than in the VEC group on day one (p=0.001). The incidence of POM on day two was significantly low in both groups. There was no statistical significance between the two groups based on Fisher's exact test (p=1.000). None of the patients had myalgia on day three.

Conclusion

Our results showed that the incidence and severity of fasciculations and POM were significantly decreased by pretreatment with ROC in contrast to that with VEC. Hence, ROC is a better option than VEC to combat succinylcholine-related complications like fasciculation and myalgia.

Impact of duloxetine on succinylcholine-induced postoperative myalgia after direct microlaryngoscopic surgeries: Randomized controlled double-blind study

BACKGROUND

Succinylcholine is a preferred muscle relaxant for rapid sequence intubation. Postoperative myalgia (POM) is one of its commonest adverse effects with unknown pathogenesis. Various modalities were examined to reduce POM. We hypothesized that duloxetine may reduce the incidence and severity of fasciculation or succinylcholine-induced POM in outpatient surgeries.

METHODS

This randomized double-blinded trial involved controlled 70 adult participants scheduled for elective direct microlaryngoscopic surgeries. Before induction of general anesthesia by 2 h, 35 patients received duloxetine 30 mg orally (group D) and 35 patients received similar oral starch placebo capsules (group C). Fasciculations, POM, sedation score, time to first rescue analgesia, total analgesic consumption 24 h after surgery, patients' satisfaction, and adverse effects were recorded.

RESULTS

Incidence of fasciculation was 77.1% and 94.3% in groups D and C (p value = 0.04), whereas its severity was not significant between groups (p value = 0.09). Incidence and severity of POM were significantly lower in group D (p values = 0.004 and 0.021). Positive correlation was recorded between fasciculations and POM scores (r = 0.732 and p < 0.001). Time required for first analgesia was prolonged in group D (p value < 0.001) with less total analgesic consumption (p value = 0.039). The potassium and creatine kinase levels showed significant differences between both groups after 30 min and 24 h, respectively (p value < 0.05). Sedation scores and patients' satisfaction were better in duloxetine group (p value < 0.05) with no severe complications.

CONCLUSIONS

Preoperative oral duloxetine 30 mg administration decreased incidence and severity of succinylcholine-related muscle POM and fasciculations. It was also effective in reducing postoperative rescue analgesic requirement with better patients' satisfaction and no serious adverse effects.

Malignant Hyperthermia Syndrome: A Clinical Case Report

Malignant hyperthermia is a pharmacogenetic disorder. It manifests as a hypercatabolic skeletal muscle syndrome linked to inhaled volatile anesthetics or depolarizing muscle relaxants. Its clinical signs and symptoms are tachycardia, hyperthermia, hypercapnia, acidosis, muscle rigidity, rhabdomyolysis, hyperkalemia, arrhythmia and renal failure. Mortality without specific treatment is 80% and decreases to 5% with the use of dantrolene sodium. This article presents the case of a 39-year-old patient admitted to the Intensive Care Unit for malignant hyperthermia after surgery for septoplasty plus turbinoplasty.

Patient Safety during Rapid Sequence Intubation When Using Succinylcholine Instead of Nondepolarizing Paralytic Agents: Should We Change a Common Rapid Sequence Intubation Pathway?

Background

Succinylcholine is a depolarizing agent used for rapid sequence intubation (RIS). While the agent is the most widely used drug of choice in most emergency departments (EDs), the adverse effect profile is lengthy compared to nondepolarizing paralytic agents included rocuronium and vecuronium.

Objectives:

Our objective in this analysis is to detect potential safety signals and differences in safety related outcomes between patients that received succinylcholine compared to those that received rocuronium or vecuronium when undergoing RSI. Specifically, we asked whether there was a difference in all-cause mortality, whether succinylcholine was used in patient later found to have contraindications to the medication, as well as differences in the rates of rescue airway or difficult airway algorithms utilized.

Methods:

We utilize two clinical cases as a framework to review adverse events among ED patients undergoing RSI when using succinylcholine compared to nondepolarizing agents over a 7 years’ period at our institution as part of a quality review project. The review is retrospective and does not allow us to link adverse events specifically with drug but, instead, considers aggregate level event frequency.

Results:

From January 31, 2013, to January 31, 2018, there were 36,059 intubations with paralytics in the ED (75.39% with succinylcholine and 24.61% with rocuronium or vecuronium). There was no evidence of death or associated adverse events in 98.49% of patients. Of 36,059 intubations, 14 patients expired, representing 0.039% of all RSI encounters. There were 39/100,000 total deaths during RSI events. There was a higher rate of mortality in the combined vecuronium/rocuronium group (90/100,000) compared to the sample of patients intubated with succinylcholine (22/100,000).

Conclusions:

While the succinylcholine adverse effect profile is concerning, data from our institution does not support removal of the agent as an available option for RSI as the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents. Patient level data will be needed in future work to further understand why the all-cause mortality rate was higher in the group receiving rocuronium or vecuronium and whether those patients had increased risk of mortality from underlying disease at time of presentation.

Survival following intentional succinylcholine injection for self-harm

Succinylcholine is a short-acting depolarizing neuromuscular blocking agent. We describe a case where the above drug was employed for self-harm by a health-care worker. The patient, a 28-year-old female, was brought to the emergency department (ED) in impending respiratory arrest and altered mental status. On arrival, she had hypoxia, bradycardia, and hypotension. Although the cause for rapid deterioration in this patient was unknown, the ED physician still went ahead by resuscitating the patient's airway, breathing, and circulation. During the course of resuscitation, information was received that an empty ampoule of succinylcholine was recovered from her bathroom. Further clinical examination and laboratory investigations led the treating physicians to suspect deliberate intravenous injection of succinylcholine. She was mechanically ventilated and monitored in the critical care unit. Targeted temperature management was initiated in the ED and was continued for 24 h. The patient was discharged from the hospital without any neurological deficits after 4 days. Patients with acute poisoning are one of the major encounters in ED, and this case highlights the possibility of anesthetic drug misuse in any health-care workers coming to the ED with sudden cardiac arrest, altered sensorium, or abnormal vitals. This is the first report describing the survival of a patient following intentional succinylcholine injection for self-harm.

Pseudocholinesterase Deficiency - Is Succinylcholine Still Needed to Facilitate Endotracheal Intubation?

Pseudocholinesterase (butyrylcholinesterase) deficiency is an inherited or acquired condition in which the serum pseudocholinesterase levels are absent or lower than normal. The enzyme is produced by the liver; decreased levels of the enzyme in an individual cause increased sensitivity to anesthetic agents, like succinylcholine and mivacurium. Pseudocholinesterase deficiency is caused by butyrylcholinesterase (BCHE) gene mutation, a gene that provides instructions for making the pseudocholinesterase enzyme. Succinylcholine is a depolarizing muscle relaxant that provides a quicker onset and a brief duration of muscle relaxation during general anesthesia. In this article, we would like to discuss a case report of prolonged intubation and ventilation in a patient with pseudocholinesterase deficiency and the necessity of succinylcholine during intubation in comparison to possible alternatives (rocuronium). 

Postanesthetic skin erythema due to succinylcholine versus atracurium

Intraoperative anaphylactic reactions may range from mild, erythema-like to anaphylactic shock, with tension crash and bronchospasm. The substances considered to be most responsible for the occurrence of intraoperative allergic reactions are neuromuscular blocking agents, antibiotics and latex. Recent studies have identified a new receptor, Mas-Related G-Protein-coupled Receptor X2 (MRGPRX2), considered as a target for some neuromuscular blockers such as atracurium, rocuronium or fluoroquinolone, resulting in pseudoallergic or anaphylactoid reactions. Induction of anesthesia can use both depolarizing myorelaxants, useful especially in emergency situations, in the patient with gastric plenitude or at high risk of intubation, and non-depolarizing myorelaxants such as atracurium, cisatracurium and rocuronium. Succinylcholine has a short time of action and it is rapidly metabolized. Atracurium, although having a slightly longer time to action, has the benefit of a low risk of increased levels of potassium in blood, which is extremely important in patients with cardiac pathology or associated kidney diseases. The present study compared the side effects of systemic anesthesia with succinylcholine vs. atracurium.

Succinylcholine-Induced Masseter Muscle Rigidity Successfully Managed With Propofol and Laryngeal Mask Airway: A Case Report and Brief Review

Masseter muscle rigidity following administration of succinylcholine for induction of general anesthesia is considered an early warning sign for the possibility of an episode of dreaded complication i.e., malignant hyperthermia. This report describes a case of masseter muscle rigidity encountered at the start of an emergency surgical procedure. After succinylcholine administration, laryngoscopy and intubation were not possible due to the masseter muscle spasms. This led to the use of laryngeal mask airway and propofol for the successful conclusion of the procedure with no intraoperative or postoperative complications. Later, the patient was discharged with instructions to avoid the contributing triggers in the future and recommendations of caffeine-muscle biopsy.

A retrospective observational study of neuromuscular monitoring practice in 30,430 cases from six Danish hospitals

Timely application of objective neuromuscular monitoring can avoid residual neuromuscular blockade. We assessed the frequency of objective neuromuscular monitoring with acceleromyography and the last recorded train‐of‐four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving neuromuscular blocking agents, divided into non‐depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a neuromuscular blocking drug. Non‐depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non‐depolarising neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non‐depolarising drugs and from 3% to 79% for succinylcholine alone. The median (IQR [range]) of the last recorded train‐of‐four ratio before tracheal extubation was 0.97 (0.90–1.06 [0.01–2.20]) when non‐depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95%CI 2.33–2.70) p < 0.001] and non‐depolarising drugs [2.57 (95%CI 2.32–2.84) p < 0.001] as compared with cases where no neuromuscular blockade drug was used. In conclusion, acceleromyography was almost always used in cases where non‐depolarising neuromuscular blocking drugs were used, but a train‐of‐four ratio of 0.9 was not always achieved. Monitoring was used in less than 30% of cases where succinylcholine was the sole drug used.

Succinylcholine Administration and Resultant Pulseless Ventricular Tachycardia: A Case Report of Communication Breakdown During an Emergent Intubation

Poor communication continues to be one of the leading root causes of sentinel events in the United States annually. This case report documents a miscommunication that occurred during the management of a patient with Guillain-Barré syndrome (GBS) and acute respiratory failure requiring emergent intubation, which resulted in a transient hyperkalemia and subsequent cardiac arrest.

Study of Rocuronium-Sugammadex as an Alternative to Succinylcholine-Cisatracurium in Microlaryngeal Surgery

Microlaryngeal surgery (ML) is a short procedure that requires a deep neuromuscular blockade to provide optimum surgical conditions. Succinylcholine is a relaxant widely used but involves numerous complications. One valid alternative is rocuronium, with a specific antagonist, sugammadex. The primary objective was to assess the surgical conditions in ML according to the relaxant. The secondary objectives were to assess intubation conditions and intraoperative and immediate postoperative adverse events.

STUDY DESIGN

Prospective randomized study.

METHODS

This was a prospective study of patients scheduled for ML randomized into two groups according to relaxant. Neuromuscular blockade was recorded after administration and during ML surgery. Surgical conditions were assessed using the ML Rating Scale, intubation conditions, remifentanil doses, intraoperative complications, surgery time, emergence time, and complications in the postanesthesia care unit.

RESULTS

Two hundred five patients were included (rocuronium = 103, succinylcholine = 102). Train-of-four values were higher for rocuronium, though the otorhinolaryngology surgical conditions were significantly better in that group (rocuronium = 5.54 ± 1.39 points; succinylcholine = 9.13 ± 1.99 points). Intubation conditions were similar in both groups. Remifentanil doses were higher for succinylcholine (P < .001) (rocuronium = 0.102 ± 0.05 μg/kg/min; succinylcholine = 0.201 ± 0.05 μg/kg/min). There were no differences in the duration of surgery, but the time to awakening was significantly longer for succinylcholine (rocuronium = 3.82 ± 1.38 minutes, succinylcholine = 9.18 ± 2.04 minutes, P < .001).

CONCLUSIONS

Rocuronium provides better surgical conditions and allows for the use of lower doses of remifentanil as compared to succinylcholine and cisatracurium in ML. This makes it possible to decrease the time to awakening and the complications associated with high doses of remifentanil.

LEVEL OF EVIDENCE

1b Laryngoscope, 131:E212-E218, 2021.

Accidental injection of succinylcholine into epidural space as a test dose

Inadvertent injection of nonepidural drugs into the epidural space is a rare situation, which is under-reported, and can lead to serious complications, such as cardiovascular and respiratory complications, paraplegia, or quadriplegia, and can worsen the patients' outcome from surgery. Succinylcholine administered epidurally leads to the appearance of fasciculation and shortness of breath and can prolong neuromuscular blockade. We report a case of accidental administration of 100 mg of succinylcholine via an epidural catheter as a test dose instead of 2 ml 0.5% bupivacaine in a patient planned for major abdominal surgery. After 2 min, the patient complained of shortness of breath; dysarthria; and fasciculation in the trunk, upper limbs, and face. This was managed with induction to general anesthesia (GA). In the postoperative period, no neurological or cardiovascular complications were observed. There is no adequate drug as an antidote of accidentally given nonepidural drugs via an epidural catheter. Succinylcholine given via epidural catheter has been shown to prolong neuromuscular blockade. Proper labeling and storage of syringes are of utmost importance for avoiding these unpleasant situations.

The Effect of Pregabalin on the Prevention of Succinylcholine-Induced Fasciculation and Myalgia

PURPOSE

This study evaluates the effect of pregabalin on fasciculation and myalgia after using succinylcholine.

DESIGN

This randomized double-blind prospective study was conducted among 100 patients aged 20 to 60 years old.

METHODS

Pregabalin (300 mg) and placebo (in capsule form) were placed in similar containers. The results were analyzed by SPSS 23 software, and statistical analysis consisted of χ² test and t test, and a P value less than .05 was considered significant.

FINDINGS

The mean pain score in the group receiving pregabalin was lower than the placebo group. According to the χ² test, there was a significant difference between the two groups in the frequency of fasciculation (P = .003). Mean fasciculation severity in the pregabalin group was lower than placebo group. According to t test, there was a significant difference in the mean fasciculation severity between the two groups (P = .002).

CONCLUSIONS

This study showed that 300 mg of pregabalin was effective in reducing postoperative fasciculation and myalgia in patients treated with succinylcholine.

Supramolecular therapeutics to treat the side effects induced by a depolarizing neuromuscular blocking agent

Succinylcholine (Sch) is the only depolarizing neuromuscular blocking agent widely used for rapid sequence induction in emergency rooms. Unfortunately, a variety of (sometimes lethal) adverse effects, such as hyperkalemia and cardiac arrest, are associated with its use, and currently there are no specific antidotes to reverse Sch or to treat these side-effects. Methods: The binding behaviors of Sch and several synthetic receptors, including cucurbit[7]uril, sulfo-calix[4]arene and water-soluble carboxylatopillar[6]arene (WP[6]), were first investigated. With a mouse model, a leathal dose of Sch was selected for evaluation of the antidotal effects of these synthetic receptors on Sch induced mortality. The antidotal effects of a selected synthetic receptor, WP[6], on Sch induced cardiac arrhythmias, hyperkalemia, rhabdomyolysis and paralysis were subsequently evaluated with rat and mouse models. The reversal mechanism was also investigated at a cellular level. Results: All of these macrocyclic molecules exhibited relatively high binding affinities with Sch in vitro. In a Sch-overdosed mouse model, immediate injection of these synthetic receptors right after Sch administration increased the overall survival rate, with WP[6] standing out with the most effective antidotal effects. In addition, administration of WP[6] also reversed the paralysis induced by Sch in a mouse model. Moreover, infusion of WP[6] to Sch-overdosed rats reduced the incidence of cardiac arrhythmia, inhibited the otherwise abnormally high serum potassium levels, and relieved the muscular damage. At the cellular level, WP[6] reversed the Sch induced depolarization and reduced the efflux of intracellular potassium. Conclusion: Synthetic receptors, particularly WP[6], exhibited high binding affinities towards Sch, and presented a significant potential as supramolecular therapeutics to treat the various side effects of Sch by specifically sequestering Sch in vivo.

Medical alert tattoos-A pinch of style along with patient safety

The use of medical tattoos can potentially be life-saving. We present a 16-year-old patient who chose to tattoo a medical condition on her forearm. Her tattoo is more extensive than most medical tattoos and shows the measures a mother will take to ensure her daughter's safety. To our knowledge, there are no published guidelines recommending an ideal location or symbology for a medical tattoo. Such guidelines would be useful to artists, as well as to medical personnel in emergencies if the patient has a tattoo.

Prolonged neuromuscular block associated with cholinesterase deficiency

RATIONALE

Hereditary genetic mutations may cause congenital cholinesterase deficiency. When succinylcholine and mivacurium are applied on cholinesterase-deficient patients during general anesthesia, prolonged postoperative asphyxia occurs, which is an uncommon but very serious complication.

PATIENT CONCERNS

A previously healthy 30-year-old female presented prolonged spontaneous breathing recovery after general anesthesia.

DIAGNOSES

After the patient's postoperative spontaneous breathing recovery delayed, the plasma cholinesterase was found to be 27 U/L, which was far below the normal level (4000 U/L to 13500 U/L). This patient had no disease that can cause plasma cholinesterase deficiency and was therefore diagnosed as congenital cholinesterase deficiency.

INTERVENTIONS AND OUTCOMES

The patient was sent to the intensive care unit (ICU) intubated for mechanical ventilator support, and on the next day the tracheal tube was removed without any complications when her spontaneous respiration resumed.

LESSONS

Cholinesterase is an enzyme secreted by the liver involved in many physiological processes in human body. Plasma cholinesterase commonly contains acetylcholinesterase (AChE) and butyrylcholinesterase (BChE). When succinylcholine and mivacurium are applied on patients with cholinesterase-deficiency during general anesthesia, prolonged postoperative asphyxia occurs, which is an uncommon but very serious complication. Lately, new evidences have suggested that hereditary genetic mutations may be responsible for congenital cholinesterase deficiency.

Succinylcholine-Induced Rhabdomyolysis in Adults: Case Report and Review of the Literature

PURPOSE

A case of succinylcholine (SCh) and sevoflurane as a probable cause of rhabdomyolysis in an adult is presented, along with a review of the relevant literature and strategies for prevention.

SUMMARY

A nondiabetic, morbidly obese 32-year-old female developed rhabdomyolysis after administration of SCh and sevoflurane for diagnostic procedures of 30 minutes' duration. Thirty-three hours following anesthesia, the patient developed diffuse muscle tenderness and progressive weakness with a creatinine kinase (CK) of 4319 U/L. Urinalysis findings indicated contamination, a white blood cells of 12.1 × 10³/μL was stress induced, while all other labs were normal. Following 26 hours of intravenous fluids, the patient's CK decreased to 1243 U/L, with pain responsive to acetaminophen and improved mobility, resulting in discharge. With a lack of reasonable alternative causes and a temporal association of symptoms, procedural medication-induced rhabdomyolysis was suspected. Based on Naranjo scale evaluation, SCh and sevoflurane were probable causes of rhabdomyolysis. We reviewed the literature for SCh-induced rhabdomyolysis among adults and found 10 cases. The majority of patients received halogenated anesthesia (HA) and prophylaxis for SCh myopathy, with no known personal or family history of neuromuscular disorders (NMD) reported.

CONCLUSION

Rhabdomyolysis was observed in a woman following the administration of SCh and sevoflurane for diagnostic procedures lasting 30 minutes. While avoidance is possible in adults with histories of NMDs, a high index of suspicion for occurrence of rhabdomyolysis is needed whenever combining SCh with HA in all adults.

Rapid Sequence Intubation in Traumatic Brain-injured Adults

Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.

Low-dose Succinylcholine to Facilitate Laryngeal Mask Airway Insertion: A Comparison of Two Doses

Background and Aims:

Around the world, the use of the laryngeal mask airway (LMA) is becoming more common for different surgeries accounting for it being the dominant choice of airway in numerous surgeries. Although propofol is known to blunt the laryngeal reflexes often patient movement, coughing, and gagging occur on insertion. This study aims to identify the optimum dose of succinylcholine required to facilitate LMA insertion comparing placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. Further objectives were to compare (a) the overall insertion conditions of the LMA, (b) the number of insertion attempts, (c) the amount of propofol consumption, and (d) the hemodynamics in the three groups.

Setting and Design:

This is a prospective, double-blinded, randomized control trial of 283 patients randomized into three groups-placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. It was done in the day case theatres of a tertiary hospital in Southern India.

Subjects and Methods:

Patients were induced with 2 mg/kg of propofol, after 2 μg/kg of fentanyl. The study drug was given after loss of consciousness. After 60 s, a classic LMA was inserted by the standard method by a single investigator. Jaw relaxation, coughing, gagging, movement, laryngospasm, ease of insertion, number of attempts, propofol usage, and hemodynamics were assessed.

Statistical Analysis:

Statistical methods used were analysis of variance with Bonferroni's t-test, Chi-square test, and Fisher's test. P < 0.05 was considered statistically significant.

Results:

Jaw relaxation was significantly better in the 0.25 mg/kg succinylcholine group. There was no significant difference in coughing and gagging in the groups, but patient movement was more in the placebo group. Two patients in the placebo group experienced partial laryngospasm. Overall insertion conditions were significantly better in the 0.25 mg/kg group compared to the other two groups. Propofol consumption was significantly more in the placebo group.

Conclusions:

The study concludes that 0.25 mg/kg succinylcholine facilitates insertion of the LMA.

Spectroscopic determination of succinylcholine in dosage forms using eosin Y

Two simple and sensitive analytical assay methods using spectrophotometry and spectrofluorimetry techniques were developed for the estimation of succinylcholine chloride (SUC) in pharmaceutical preparations. The suggested methods are based on the formation of an ion pair complex formed between the drug and eosin Y spectrophotometrically (Method I), or the suppressive effect of succinylcholine on the native fluorescence property of eosin Y (Method II). The spectrophotometric method (Method I) involves measuring the absorbance of the complex between succinylcholine and eosin Y at 550 nm in Britton Robinson buffer of pH 3. However, the spectrofluorimetric method (Method II) involves measuring the quenching effect of the studied drug on the native fluorescence property of eosin Y at the same pH at 550 nm after excitation at 480 nm. The absorbance versus concentration of the drug is rectilinear over the range of 0.5 to 15 μg/ml. The formation constant was 3.5 × 10⁴ and the Gibb's free energy change was -2.5 × 10⁴  J/mol. In Method II, the relative fluorescence intensity was directly proportional to SUC concentration over the range of 0.05 to 1 μg/ml. The proposed methods allowed a successful application to the estimation of succinylcholine ampoules. An explanation of the reaction pathway was postulated.

Malignant Hyperthermia: A Review

Malignant hyperthermia is an uncommon, but potentially lethal condition that may be encountered during the perioperative period. There is wide variability in the manner in which malignant hyperthermia may manifest. For a patient to survive a malignant hyperthermia crisis, prompt recognition and treatment is of paramount importance. Perioperative nurses play a pivotal role in the successful management of malignant hyperthermia. The fictitious case study presented in this paper describes the identification, presentation, pathophysiology, and treatment of a general anesthesia patient with fulminant malignant hyperthermia.

Optimal dose of succinylcholine for laryngeal mask airway insertion: systematic review, meta-analysis and metaregression of randomised control trials

OBJECTIVES

To evaluate the optimal dose of succinylcholine for laryngeal mask airway (LMA) insertion and all related morbidities.

DESIGN

Systematic review, meta-analysis and metaregression of randomised controlled trials (RCTs).

DATA SOURCE AND STUDY ELIGIBILITY CRITERIA

A comprehensive search of RCTs in the PubMed, Embase, the Cochrane Library and the ClinicalTrials.gov registry up to July 2016 and articles that evaluated the use of succinylcholine chloride for LMA insertion were included in the analyses. The relative risk (RR) and the corresponding 95% CIs were determined.

INTERVENTION

Succinylcholine as the coinduction agent and the doses were divided into mini (≤0.3 mg/kg) and low (0.3-1.0 mg/kg) doses for dose-dependent effect analyses.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the first-attempt LMA insertion failure rate. Secondary outcomes included all related adverse events.

RESULTS

Data from 10 RCTs comprising 625 participants showed that succinylcholine reduced the first-attempt LMA insertion failure rate (RR, 0.22; 95% CI 0.12 to 0.43), coughing and gagging (RR, 0.26; 95% CI 0.15 to 0.45) and laryngospasm (RR, 0.14; 95% CI 0.05 to 0.39). The use of succinylcholine did not result in a significant increase of postoperative myalgia (RR, 2.58; 95% CI 0.79 to 8.44) and did not reduce the risk of postoperative sore throat (RR, 0.76; 95% CI 0.55 to 1.03). Subgroup analysis further showed that low-dose succinylcholine reduced the LMA insertion failure rate and its related coughing and gagging when compared with mini dose.

CONCLUSION

The use of succinylcholine compared with none can facilitate LMA insertion and reduce insertion-related reflexes without significant postoperative myalgia. However, additional prospective studies with a larger sample size are required to fully evaluate the dose-dependent effect and complications of succinylcholine for LMA insertion.

Comparison of atracurium and methocarbamol for preventing succinylcholine-induced muscle fasciculation: A randomized controlled trial

Fasciculation is a minor adverse effect of succinylcholine and may be an unpleasant experience for patient. The aim of this study was to compare the use of atracurium and methocarbamol to decrease the occurrence and severity of succinylcholine-induced muscle fasciculation. Fifty-nine adults with American Society of Anesthesiologists I or II hospitalized for elective surgery were randomly assigned to two groups: Group A (n = 29) who received succinylcholine 1 mg/kg body weight (BW) intravenously followed by 0.2–0.5 mg/kg BW atracurium and patients in Group B (n= 29) who received succinylcholine 1 mg/kg BW intravenously followed by methocarbamol 0.2–0.5 mg/kg BW. Anesthesia was induced in all patients with thiopental sodium 3–5 mg/kg. Fasciculation was scored on a four-point (0–4) Likert scale. There were no statistically significant differences in demographic variables between two groups, whereas in Group A, 27 patients (93.1%) suffered from mild fasciculation and two (6.9%) from moderate fasciculation. In Group B, twenty patients (68.9%) suffered from mild fasciculation, five (17.2%) from moderate fasciculation, and four (13.9%) from severe fasciculation. The difference between the groups was statistically significant (P < 0.05). Atracurium is more effective than methocarbamol in decreasing the occurrence and severity of succinylcholine-induced fasciculations. In addition, the use of methocarbamol before succinylcholine administration can decrease the incidence of severe fasciculation.

To Evaluate the Efficacy of Intravenous Infusion of Dexmedetomidine as Premedication in Attenuating the Rise of Intraocular Pressure Caused by Succinylcholine in Patients Undergoing Rapid Sequence Induction for General Anesthesia: A Randomized Study

Context:

Laryngoscopy and intubation performed during RSI lead to choroidal blood volume increase and an eventual rise in intraocular pressure (IOP). Use of succinylcholine (SCh) causes an undesirable rise in IOP which is further aggravated by laryngoscopy and endotracheal intubation. Dexmedetomidine is a highly selective centrally acting α₂ adrenergic agonist that has IOP lowering properties.

Aims:

This study aims to evaluate the efficacy of intravenous (i.v.) infusion of dexmedetomidine (0.5 μg/kg) as premedication in attenuating the rise of IOP and adverse effect if any caused by SCh in patients undergoing RSI for general anesthesia.

Settings and Design:

This was a double-blind, randomized trial.

Subjects and Methods:

Sixty adult patients in the age group of 20–50 years scheduled for elective surgeries under general anesthesia. Group I (dexmedetomidine group) (n = 30) received i.v. infusion of dexmedetomidine (0.5 μg/kg) and Group II (control group) (n = 30) received i.v. infusion of 50 ml normal saline as premedication

Statistical Analysis Used:

The analysis was done using Statistical Package for Social Sciences Version 15.0 statistical Analysis Software.

Results:

It was observed that Group I (dexmedetomidine group) had a better attenuating effect over the increases in IOP in patients undergoing RSI for general anesthesia using SCh. An increase in IOP was seen in Group II (control group) patients with RSI.

Conclusions:

The findings in the present study indicate that i.v. dexmedetomidine effectively attenuates the increases in IOP with an additional advantage of control on hemodynamic responses following RSI.

The Influence of Two Different Doses of Magnesium Sulfate on Intraocular Pressure Variations after Injection of Succinylcholine and Endotracheal Intubation: A Prospective, Randomized, Parallel Three-Arm, Double-blind, Placebo-controlled Clinical Trial

Background:

The use of succinylcholine for rapid sequence induction in patients with open globe injuries may be detrimental to the eye.

Aim:

The aim of this study is to determine if the premedication with magnesium sulfate (MgSO₄) could attenuate the increase in intraocular pressure (IOP) associated with succinylcholine injection and intubation.

Setting:

Operation theaters in a tertiary care University Hospital between December 2014 and July 215.

Design:

This was a prospective, randomized, parallel three-arm, double-blind, placebo-controlled clinical trial.

Participants:

One hundred and thirteen patients’ physical status ASA Classes I and II underwent elective cataract surgery under general anesthesia.

Patients and Methods:

These patients allocated into three groups: Group C (control group) received 100 ml normal saline, Group M1 received 30 mg/kg MgSO₄ in 100 ml normal saline, and Group M2 received 50 mg/kg MgSO₄ in 100 ml normal saline. IOP, mean arterial pressure (MAP), and heart rate (HR) reported at 5-time points related to study drug administration. In addition, any adverse effects related to MgSO₄ were recorded. Intragroup and between-groups differences were examined by analysis of variance test.

Results:

We noticed a significant decrease in IOP in M1 (n = 38) and M2 (n = 37) groups as compared with C group (n = 38) after study drugs infusion, 2 and 5 min after intubation, P < 0.001. While the difference between M1 and M2 groups was insignificant, P = 0.296 and P = 0.647, respectively. There was a significant decrease in MAP and HR in M1 and M2 groups as compared with C group 2 and 5 min after intubation, P = 0.01. While the difference between M1 and M2 groups was insignificant, P = 1.

Conclusion:

MgSO₄ 30 mg/kg as well as 50 mg/kg effectively prevented the rise in IOP, MAP, and HR associated with rapid sequence induction by succinylcholine and endotracheal intubation.

Effects of low-dose ketamine on succinylcholine-induced postoperative myalgia in outpatient surgeries: a randomized, double-blind study

Objective

Despite the many complications of succinylcholine, it is still widely used as a superior muscle relaxant for rapid sequence induction. One of these complications is postoperative myalgia (POM). The aim of this study was to investigate the prophylactic effect of low-dose ketamine on the incidence and severity of POM.

Materials and methods

In this double-blind clinical study, a total of 148 patients scheduled for general anesthesia were randomly divided into two equal groups. Initially, in Group K, 0.5 mg/kg of ketamine was injected intravenously, whereas in Group N, the same volume (5 mL) of normal saline was injected. Thereafter, anesthesia was induced in all patients, by injecting 1.5 mg/kg of fentanyl and 2 mg/kg of propofol intravenously. Following the loss of eyelid reflex, 1.5 mg/kg of succinylcholine was injected intravenously as a muscle relaxant and then the patients were intubated. POM was defined as a pain with no surgical interferences, and its intensity was graded based on a four-point scale. The incidence and severity of myalgia were assessed by a blinded observer 24 hours after surgery.

Results

In terms of demographic data, the results of this study showed that there is no significant difference between patients in both groups (P>0.05). Overall, the incidence of POM in Group K was significantly less, when compared with Group N (P<0.05), but both groups were comparable based on the grade 2 of POM. After the induction of anesthesia, the systolic and diastolic blood pressure values were found to reduce in both groups (P<0.05). However, the changes were somehow similar, and repeated measures of variance analysis showed no significant difference in the two study groups (P>0.05).

Conclusion

The addition of 0.5 mg/kg of ketamine to propofol for the induction of anesthesia can be effective in reducing the incidence of low-grade POM.

Malignant hyperthermia in a 6-month-old infant

Malignant hyperthermia (MH) is a rare hypermetabolic disorder of skeletal muscles that manifests as a life-threatening crisis in susceptible individuals, after exposure to triggering agents, most commonly halothane and succinylcholine. MH presents with multiple nonspecific signs and laboratory findings such as tachycardia, hyperthermia, hypercarbia, acidosis, and muscle rigidity. Caffeine halothane contracture test is not available at most centers in India. Larach et al. have described a clinical grading scale for determining the MH raw score based on clinical findings and biochemical tests. The high degree of suspicion, early recognition and aggressive treatment should commence immediately. It is imperative to avoid triggering agents, such as volatile anesthetics and succinylcholine, and promote the use of total intravenous anesthesia in MH susceptible patients. We report a case of 6-month-old child undergoing laparotomy under general anesthesia, who presented with signs and symptoms of MH, had MH rank 5 and raw score 36.

Comparison of rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries

Background:

The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia.

Materials and Methods:

Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared.

Statistical Analysis Used:

To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t-test were used.

Results:

The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg.

Conclusion:

Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated.

Endotracheal intubation without muscle relaxants in children using remifentanil and propofol: Comparative study

Introduction:

Endotracheal intubation is essential during general anesthesia and muscle relaxant drugs provide ideal conditions for this purpose. The objective of this study was to evaluate the intubating condition of remifentanil combined with propofol without muscle relaxant.

Materials and Methods:

In this prospective randomized study, 60 children aged 3-12 years, American Society of Anesthesiologists physical status I and II were included. All the children were premedicated with 0.05 mg/kg midazolam and 1.5 mg/kg lidocaine 5 min before the induction of anesthesia with 3 mg/kg propofol. Then, they were allocated randomly to receive either 2 μg/kg remifentanil (group R) or 1.5 mg/kg succinylcholine (group S). Tracheal intubation was attempted 90 s after the administration of propofol. The quality of intubation was assessed by using Copenhagen score based on jaw relaxation, ease of laryngoscopy, position of vocal cord, coughing and limb movement. Heart rate and blood pressure were recorded before and after induction, and 1, 3, 5 min after intubation.

Results:

There was no significant difference in intubating condition between the two groups (P = 0.11). Intubation condition was excellent in 26 of 30 (86.7%) patients in the group R compared with 30 (100%) patients in the group S. We observed significant difference in heart rate and systolic blood pressure over time between two groups (P = 0.02, P = 0.03 respectively). After intubation, we had higher heart rate and systolic blood pressure with a significant difference in group S compared with group R (P = 0.006, P = 0.018). None of the children had a chest rigidity, laryngospasm, and hypoxia.

Conclusions:

In premedicated children, propofol-remifentanil combination provides adequate conditions for tracheal intubation that is comparable with succinylcholine. Hemodynamic response to laryngoscopy and tracheal intubation was controlled better in group R.

Efficacy of alpha2 agonists in obtunding rise in intraocular pressure after succinylcholine and that following laryngoscopy and intubation

Context:

Elevation of intraocular pressure (IOP) is an inherent and inadvertent association with the use of succinylcholine and alpha₂ agonists can be used to obtund this effect.

Aims:

The study was aimed to assess the efficacy of intravenous dexmedetomidine and clonidine premedication in attenuating rise in IOP during laryngoscopy and intubation following administration of succinylcholine.

Settings and Design:

This prospective, observational study was conducted in 40 patients aged 20–60 years undergoing non ophthalmic surgical procedures.

Subjects and Methods:

For patients in Group D, dexmedetomidine 0.4 mcg/kg and in Group C clonidine 1 μg/kg over 10 min was administered before induction. All patients were induced with propofol. Laryngoscopy and intubation were performed 1 min after administration of succinylcholine 2 mg/kg.

Statistical Analysis Used:

Mann–Whitney, Chi-square and Wilcoxon tests.

Results:

Mean baseline IOP of both groups were comparable (15.4 ± 2.6 vs. 14.7 ± 2.3). Following premedication and induction, IOP decreased in both groups and the reduction was significantly more in Group D. Following administration of succinylcholine and 1 min after intubation IOP raised and exceeded the baseline value in Group C (16.0 ± 1.6 and 18.6 ± 2.2). Though there was an increase in IOP in Group D (12.0 ± 1.9 and 14.0 ± 2.1), it did not reach up to baseline values. Then there was a gradual reduction in IOP in both groups at 3, 5, and 10 min and Group D continued to have a significantly low IOP than Group C up to 10 min.

Conclusions:

Dexmedetomidine 0.4 μg/kg resulted in a reduction of IOP and blunted the increase in IOP, which followed administration of succinylcholine, laryngoscopy, and intubation. Though clonidine 1 μg/kg reduced IOP, it did not prevent rise in IOP following succinylcholine, laryngoscopy, and intubation.

Statins and succinylcholine interaction: A cause of concern for serious muscular damage in anesthesiology practice!

Statins are being extensively used in cardiac patient throughout the globe. Succinylcholine has been the mainstay of profound relaxation during induction and intubation of anesthesia for almost six decades now. The interactive properties of these drugs have been of major concern during routine anesthesiology practice in the last few years. However, no major research trial, prospective studies or meta-analysis are available, which can truly allay the fears of possible potential negative synergistic interactions between these two commonly used drugs. Whatever the evidence is available is hardly enough to support a positive outcome and the results have been drawn from observations of only few small studies. As a result, a continuous need among anesthesiologist fraternity is felt to arrive at a suitable inference, which can predict definite consequences of this synergistic interaction. The present article reviews some of the important observations of few handful studies which were carried out to observe any potential adverse interactions between succinylcholine and statins.

Management of malignant hyperthermia: diagnosis and treatment

Malignant hyperthermia is a potentially lethal inherited disorder characterized by disturbance of calcium homeostasis in skeletal muscle. Volatile anesthetics and/or the depolarizing muscle relaxant succinylcholine may induce this hypermetabolic muscular syndrome due to uncontrolled sarcoplasmic calcium release via functionally altered calcium release receptors, resulting in hypoxemia, hypercapnia, tachycardia, muscular rigidity, acidosis, hyperkalemia, and hyperthermia in susceptible individuals. Since the clinical presentation of malignant hyperthermia is highly variable, survival of affected patients depends largely on early recognition of the symptoms characteristic of malignant hyperthermia, and immediate action on the part of the attending anesthesiologist. Clinical symptoms of malignant hyperthermia, diagnostic criteria, and current therapeutic guidelines, as well as adequate management of anesthesia in patients susceptible to malignant hyperthermia, are discussed in this review.

Functional and genetic characterization of clinical malignant hyperthermia crises: a multi-centre study

BACKGROUND

Malignant hyperthermia (MH) is a rare pharmacogenetic disorder which is characterized by life-threatening metabolic crises during general anesthesia. Classical triggering substances are volatile anesthetics and succinylcholine (SCh). The molecular basis of MH is excessive release of Ca2+ in skeletal muscle principally by a mutated ryanodine receptor type 1 (RyR1). To identify factors explaining the variable phenotypic presentation and complex pathomechanism, we analyzed proven MH events in terms of clinical course, muscle contracture, genetic factors and pharmocological triggers.

METHODS

In a multi-centre study including seven European MH units, patients with a history of a clinical MH episode confirmed by susceptible (MHS) or equivocal (MHE) in vitro contracture tests (IVCT) were investigated. A test result is considered to be MHE if the muscle specimens develop pathological contractures in response to only one of the two test substances, halothane or caffeine. Crises were evaluated using a clinical grading scale (CGS), results of IVCT and genetic screening. The effects of SCh and volatile anesthetics on Ca2+ release from sarcoplasmic reticulum (SR) were studied in vitro.

RESULTS

A total of 200 patients met the inclusion criteria. Two MH crises (1%) were triggered by SCh (1 MHS, 1 MHE), 18% by volatile anesthetics and 81% by a combination of both. Patients were 70% male and 50% were younger than 12 years old. Overall, CGS was in accord with IVCT results. Crises triggered by enflurane had a significantly higher CGS compared to halothane, isoflurane and sevoflurane. Of the 200 patients, 103 carried RyR1 variants, of which 14 were novel. CGS varied depending on the location of the mutation within the RyR1 gene. In contrast to volatile anesthetics, SCh did not evoke Ca2+ release from isolated rat SR vesicles.

CONCLUSIONS

An MH event could depend on patient-related risk factors such as male gender, young age and causative RyR1 mutations as well as on the use of drugs lowering the threshold of myoplasmic Ca2+ release. SCh might act as an accelerant by promoting unspecific Ca2+ influx via the sarcolemma and indirect RyR1 activation. Most MH crises develop in response to the combined administration of SCh and volatile anesthetics.

Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures

BACKGROUND

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life-threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial.

OBJECTIVE

To review the perioperative outcomes of patients with DMD and BMD.

METHODS

We reviewed records of patients with DMD or BMD who underwent anesthetic management at our institution from January 1990 through December 2011.

RESULTS

We identified 47 patients (DMD, 37; BMD, 10) who underwent 117 anesthetic exposures (DMD, 101; BMD, 16). Volatile anesthetic agents were used 66 times (DMD, 59; BMD, 7). One patient with undiagnosed BMD received succinylcholine and developed acute rhabdomyolysis and hyperkalemic cardiac arrest. All other major complications were attributed to the procedure (i.e., large bleeding), to preexisting comorbidities (i.e., respiratory failure, cardiac disease), or to both.

CONCLUSIONS

Use of succinylcholine in children with dystrophinopathy is contraindicated. These patients have significant comorbidities and are frequently undergoing extensive operations; complications related to these factors can develop, as evidenced by our series. These complications may occur with use of volatile and nonvolatile anesthetics. However, because most of our patients were older than 8 years at the time of surgery, our observation cannot be generalized to younger dystrophin-deficient children.

Nurse induced respiratory depression by succinylcholine--the 'hero syndrome'

A nurse administered the neuromuscular blocking agent succinylcholine (SUX) to at least one patient and gave first aid in the therapy of unexpected respiratory depression. SUX is regarded as an undetectable and thus perfect poison due to its short half-life and degradation to the endogenous compounds choline and succinic acid. However, SUX and especially its metabolite succinylmonocholine (SMC) were found in plasma and urine a few hours after administration by means of high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Compared to clinical studies, the window of detection was sufficient to gain definite proof; in other cases no samples were collected. The nurse enjoyed high reputation with the doctors. According to the court she wanted to present herself spectacularly as the first and decisive rescuer to demonstrate her special abilities and capacities, perhaps to receive a better job in the hospital. Considering the actual case, the hero syndrome is not limited to fire-fighters.