Succinylcholine

• It is used to calm muscles during surgery.
• It is used to calm muscles while on a breathing machine.

• Tell all of your health care providers that you take succinylcholine. This includes your doctors, nurses, pharmacists, and dentists.
• Very bad and sometimes deadly allergic side effects have rarely happened. Talk with your doctor.
• Use with care in children. Talk with the doctor.
• Tell your doctor if you are pregnant or plan on getting pregnant. You will need to talk about the benefits and risks of using this medicine while you are pregnant.
• Tell your doctor if you are breast-feeding. You will need to talk about any risks to your baby.

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
• Signs of a high potassium level like a heartbeat that does not feel normal; change in thinking clearly and with logic; feeling weak, lightheaded, or dizzy; feel like passing out; numbness or tingling; or shortness of breath.
• Slow heartbeat.
• Very bad dizziness or passing out.
• Very bad headache.
• Muscle pain.
• Twitching.
• Not able to pass urine or change in how much urine is passed.
• A heartbeat that does not feel normal.
• Chest pain or pressure.
• More eye pressure.
• Trouble breathing, slow breathing, or shallow breathing.
• This medicine may cause a very bad and sometimes deadly problem called malignant hyperthermia. Call your doctor right away if you have a fast heartbeat, fast breathing, fever, or spasm or stiffness of the jaw muscles.

(suks in il KOE leen)

• Neuromuscular Blocker Agent, Depolarizing

Hypersensitivity to succinylcholine or any component of the formulation; personal or familial history of malignant hyperthermia; skeletal muscle myopathies; use after the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury.

Documentation of allergenic cross-reactivity for neuromuscular blockers is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Neuromuscular blockade: Dose to effect; doses will vary due to interpatient variability. Use carefully and/or consider dose reduction in patients with reduced plasma cholinesterase activity due to genetic abnormalities of plasma cholinesterase or when associated with other conditions (eg, electrolyte abnormalities, neuromuscular disease); prolonged neuromuscular blockade may occur.

IM: Up to 3 to 4 mg/kg, maximum total dose: 150 mg

IV:

Intubation: 0.6 mg/kg (range: 0.3 to 1.1 mg/kg)

Intubation (rapid sequence) (off-label dosing): 1 to 1.5 mg/kg (Sluga 2005; Weiss 1997)

Long surgical procedures (intermittent administration): Initial: 0.3 to 1.1 mg/kg; administer 0.04 to 0.07 mg/kg at appropriate intervals as needed.

Note: Pretreatment with atropine may reduce occurrence of bradycardia. Initial dose of succinylcholine must be increased when nondepolarizing agent pretreatment is used because of the antagonism between succinylcholine and nondepolarizing neuromuscular-blocking agents (Miller 2010). When the cumulative dose of succinylcholine exceeds 2 to 4 mg/kg under general anesthesia or succinylcholine is administered by continuous infusion, transition from a phase I to a phase II block may occur. If phase II block is suspected, diagnosis should be confirmed by peripheral nerve stimulation prior to administration of an anticholinesterase drug (Hilgenberg 1981).

There are no dosage adjustments provided in the manufacturer's labeling.

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 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, such as laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible.

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Have patient report immediately to prescriber bradycardia, severe dizziness, passing out, severe headache, muscle pain, twitching, urinary retention, change in amount of urine passed, abnormal heartbeat, angina, ocular pressure, difficulty breathing, slow breathing, shallow breathing, signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling), or signs of malignant hyperthermia (tachycardia, fast breathing, fever, spasm of jaw muscles, or stiffness of jaw muscles) (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.