TOPIC OUTLINE
U.S. BRAND NAMES
PHARMACOLOGIC CATEGORY
DOSING: ADULTS
DOSING: PEDIATRIC
DOSING: ELDERLY
DOSING: HEPATIC IMPAIRMENT
DOSAGE FORMS
DOSAGE FORMS: CONCISE
GENERIC EQUIVALENT AVAILABLE
ADMINISTRATION
COMPATIBILITY
USE
ADVERSE REACTIONS SIGNIFICANT
CONTRAINDICATIONS
WARNINGS / PRECAUTIONS
DRUG INTERACTIONS
PREGNANCY RISK FACTOR
PREGNANCY IMPLICATIONS
LACTATION
MONITORING PARAMETERS
CANADIAN BRAND NAMES
INTERNATIONAL BRAND NAMES
MECHANISM OF ACTION
PHARMACODYNAMICS / KINETICS
REFERENCES
GRAPHICS
TABLES
Drug ratings in pregnancy
RELATED TOPICS
Succinylcholine: Patient drug information
Succinylcholine: Pediatric drug information
Succinylcholine: Drug information
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(For additional information see "Succinylcholine: Patient drug information" and see "Succinylcholine: Pediatric drug information")
DOSING: ADULTS — Neuromuscular blockade: I.M., I.V.: Dose to effect; doses will vary due to interpatient variability; use ideal body weight for obese patients
I.M.: Up to 3-4 mg/kg, total dose should not exceed 150 mg
I.V.: Initial:
Short surgical procedures: 0.6 mg/kg (range 0.3-1.1 mg/kg)
Long surgical procedures:
Continuous infusion: 2.5-4.3 mg/minute; adjust dose based on response
Intermittent: Initial: 0.3-1.1 mg/kg; maintenance: 0.04-0.07 mg/kg/dose as required
Note: Initial dose of succinylcholine must be increased when nondepolarizing agent pretreatment used because of the antagonism between succinylcholine and nondepolarizing neuromuscular-blocking agents.
Dose adjustment with reduced plasma cholinesterase activity: Administer a test dose of 5-10 mg to evaluate sensitivity, or cautiously administer 1 mg/mL by slow I.V. infusion to produce neuromuscular blockade
DOSING: PEDIATRIC — Neuromuscular blockade: I.M., I.V.: Dose to effect; doses will vary due to interpatient variability; use ideal body weight for obese patients
(For additional information see "Succinylcholine: Pediatric drug information")
I.M.: Children: Refer to adult dosing.
I.V.: Children: Note: Because of the risk of malignant hyperthermia, use of continuous infusions is not recommended in infants and children
Smaller Children: Intermittent: Initial: 2 mg/kg/dose one time; maintenance: 0.3-0.6 mg/kg/ dose every 5-10 minutes as needed
Older Children and Adolescents: Intermittent: Initial: 1 mg/kg/dose one time; maintenance: 0.3-0.6 mg/kg every 5-10 minutes as needed
Note: Initial dose of succinylcholine must be increased when nondepolarizing agent pretreatment used because of the antagonism between succinylcholine and nondepolarizing neuromuscular-blocking agents.
DOSING: ELDERLY — Refer to adult dosing.
DOSING: HEPATIC IMPAIRMENT — Dose should be reduced in patients with severe liver disease.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
ADMINISTRATION — May be administered by rapid I.V. injection without further dilution. I.M. injections should be made deeply, preferably high into deltoid muscle; use only when I.V. access is not available.
COMPATIBILITY — Stable in dextran 6% in dextrose, dextran 6% in NS, D5LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS.
Y-site administration: Compatible: Etomidate, heparin with hydrocortisone sodium succinate, potassium chloride, propofol, vitamin B complex with C. Incompatible: Thiopental.
USE — Adjunct to general anesthesia to facilitate both rapid sequence and routine endotracheal intubation and to relax skeletal muscles during surgery; to reduce the intensity of muscle contractions of pharmacologically- or electrically-induced convulsions; does not relieve pain or produce sedation
ADVERSE REACTIONS SIGNIFICANT
Frequency not defined.
Cardiovascular: Arrhythmias, bradycardia (higher with second dose, more frequent in children), cardiac arrest, hyper-/hypotension, tachycardia
CONTRAINDICATIONS — Hypersensitivity to succinylcholine or any component of the formulation; personal or familial history of malignant hyperthermia; myopathies associated with elevated serum creatine phosphokinase (CPK) values; acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle or upper motor neuron injury
WARNINGS / PRECAUTIONS
Boxed warnings:
Pediatrics: See "Special populations" below.
Concerns related to adverse effects:
Bradycardia: Risk of bradycardia may be increased with second dose and may occur more in children. Occurrence may be reduced by pretreating with atropine
Increased intraocular pressure (IOP): May increase IOP; use caution with narrow-angle glaucoma or penetrating eye injuries
Malignant hyperthermia: Use may be associated with acute onset of malignant hyperthermia; risk may be increased with concomitant administration of volatile anesthetics.
Vagal tone: May increase vagal tone.
Disease-related concerns:
Burn injury: Use with caution in patients with extensive or severe burns; risk of hyperkalemia is increased following injury. Onset of time and duration of risk are variable, but risk is generally greatest 7-10 days after injury.
Conditions which may antagonize neuromuscular blockade: Alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, infection, muscle trauma, and diabetes mellitus may result in antagonism of neuromuscular blockade.
Conditions which may potentiate neuromuscular blockade: Electrolyte abnormalities, severe hyponatremia, severe hypocalcemia, severe hypokalemia, hypermagnesemia, neuromuscular diseases, acidosis, acute intermittent porphyria, Eaton-Lambert syndrome, myasthenia gravis, renal failure, and hepatic failure may result in potentiation of neuromuscular blockade.
Hyperkalemia: Use with caution in patients with pre-existing hyperkalemia. Severe hyperkalemia may develop in patients with chronic abdominal infections, burn injuries, children with skeletal muscle myopathy, subarachnoid hemorrhage, or conditions which cause degeneration of the nervous system.
Plasma pseudocholinesterase disorders: Metabolized by plasma cholinesterase; use with caution (if at all) in patients suspected of being homozygous for the atypical plasma cholinesterase gene. Plasma cholinesterase activity may also be reduced by burns, decompensated heart disease, infections, malignant tumors, myxedema, pregnancy, severe hepatic or renal dysfunction, ulcer, and certain medications and chemicals
Special populations:
Elderly: Use with caution in the elderly, effects and duration are more variable.
Pediatrics: [U.S. Boxed Warning]: Use caution in children and adolescents. Acute rhabdomyolysis with hyperkalemia, ventricular arrhythmias and cardiac arrest have been reported (rarely) in children with undiagnosed skeletal muscle myopathy; occurs soon after administration and requires immediate treatment of hyperkalemia. Prolonged resuscitation may be required. Use in children should be reserved for emergency intubation or where immediate airway control is necessary.
Other warnings/precautions:
Appropriate use: Maintenance of an adequate airway and respiratory support is critical.
Experienced personnel: Should be administered by adequately trained individuals familiar with its use.
DRUG INTERACTIONS
Acetylcholinesterase inhibitors: Acetylcholinesterase inhibitors may enhance the neuromuscular-blocking effect of succinylcholine. Monitor for increased effects of succinylcholine if used concomitantly.
(For additional information: Launch Lexi-Interact™ Drug Interactions Program )
Aminoglycosides: Aminoglycosides may enhance the respiratory depressant effect of neuromuscular-blocking agents.
Cardiac glycosides (eg, digitoxin, digoxin): Neuromuscular-blocking agents may enhance the arrhythmogenic effect of cardiac glycosides. Monitor for the development of cardiac arrhythmias.
Colistin: Colistin may enhance the neuromuscular-blocking effect of neuromuscular-blocking agents. If possible, avoid concomitant use of these products. Monitor for deeper, prolonged neuromuscular-blocking effects (respiratory paralysis).
Cyclophosphamide: Cyclophosphamide may decrease the metabolism of succinylcholine. Consider using an alternative neuromuscular-blocking agent. Monitor for increased therapeutic effects of succinylcholine.
Echothiophate iodide: Echothiophate iodide may decrease the metabolism of succinylcholine. Consider using a neuromuscular-blocking agent other than succinylcholine.
Lincosamide antibiotics (eg, clindamycin, lincomycin): Lincosamide antibiotics may enhance the neuromuscular-blocking effect of neuromuscular-blocking agents.
Loop diuretics: The therapeutic effects of neuromuscular blockers may be altered by coadministration of loop diuretics. Low doses of the diuretic appear to enhance blockade, whereas higher doses may diminish blockade.
Magnesium salts: May enhance the neuromuscular-blocking effect of neuromuscular-blocking agents. Only of concern in patients with increased serum magnesium concentrations. Monitor for prolonged effects of neuromuscular blocking agents in patients with elevated serum magnesium concentrations.
Phenelzine: Phenelzine may enhance the neuromuscular-blocking effect of succinylcholine. Consider a lower initial dose of succinylcholine in patients who are receiving, or have recently received (within last 2 weeks) phenelzine. Monitor for increased therapeutic effects.
Polymyxin B: Polymyxin B may enhance the neuromuscular-blocking effect of neuromuscular-blocking agents. If possible, avoid concomitant use of these products. Monitor for deeper, prolonged neuromuscular-blocking effects (respiratory paralysis).
Quinidine: Quinidine may enhance the neuromuscular-blocking effect of neuromuscular-blocking agents. Monitor for increased/revitalized therapeutic effects
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reproduction studies have not been conducted. Small amounts cross the placenta. Sensitivity to succinylcholine may be increased due to a ~24% decrease in plasma cholinesterase activity during pregnancy and several days postpartum.
LACTATION — Excretion in breast milk unknown/use caution
MONITORING PARAMETERS — Monitor cardiac, blood pressure, and oxygenation during administration; temperature, serum potassium and calcium, assisted ventilator status; neuromuscular function with a peripheral nerve stimulator
MECHANISM OF ACTION — Acts similar to acetylcholine, produces depolarization of the motor endplate at the myoneural junction which causes sustained flaccid skeletal muscle paralysis produced by state of accommodation that developes in adjacent excitable muscle membranes
Duration: I.M.: 10-30 minutes; I.V.: 4-6 minutes with single administration
Metabolism: Rapidly hydrolyzed by plasma pseudocholinesterase
Excretion: Urine
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REFERENCES
Murray, MJ, Cowen, J, DeBlock, H, et al. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians. Crit Care Med 2002; 30(1):142-56. Available at: http://www.sccm.org/pdf/NeuromuscularBlockade.pdf. Accessed August 6, 2003.
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