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ALERT: U.S. Boxed Warning
The FDA-approved labeling includes a boxed warning. See Warnings/Precautions section and/or refer to product labeling for additional detail.
Medication Safety Issues
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Pronunciation
(suks in il KOE leen)
U.S. Brand Names
Index Terms
Generic Available
No
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
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
Pregnancy Risk Factor
C
Pregnancy Considerations
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
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.
Adverse Reactions
Frequency not defined.
Cardiovascular: Arrhythmias, bradycardia (higher with 2nd dose, more frequent in children), cardiac arrest, hyper-/hypotension, tachycardia
Dermatologic: Rash
Endocrine & metabolic: Hyperkalemia
Gastrointestinal: Salivation (excessive)
Neuromuscular & skeletal: Jaw rigidity, muscle fasciculation, postoperative muscle pain, rhabdomyolysis (with possible myoglobinuric acute renal failure)
Ocular: Intraocular pressure increased
Renal: Acute renal failure (secondary to rhabdomyolysis)
Respiratory: Apnea, respiratory depression (prolonged)
Miscellaneous: Anaphylaxis, malignant hyperthermia
Postmarketing and/or case reports: Acute quadriplegic myopathy syndrome (prolonged use), myositis ossificans (prolonged use)
Causes of prolonged neuromuscular blockade: Excessive drug administration; cumulative drug effect, decreased metabolism/excretion (hepatic and/or renal impairment); accumulation of active metabolites; electrolyte imbalance (hypokalemia, hypocalcemia, hypermagnesemia, hypernatremia); hypothermia; drug interactions; increased sensitivity to muscle relaxants (eg, neuromuscular disorders such as myasthenia gravis or polymyositis)
Drug Interactions
Acetylcholinesterase Inhibitors: May enhance the neuromuscular-blocking effect of Succinylcholine. Risk C: Monitor therapy
Aminoglycosides: May enhance the respiratory depressant effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Analgesics (Opioid): Succinylcholine may enhance the bradycardic effect of Analgesics (Opioid). Risk C: Monitor therapy
Botulinum Toxin Type A: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of Botulinum Toxin Type A. Risk C: Monitor therapy
Botulinum Toxin Type B: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of Botulinum Toxin Type B. Risk C: Monitor therapy
Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk D: Consider therapy modification
Cyclophosphamide: May decrease the metabolism of Succinylcholine. Risk D: Consider therapy modification
Echothiophate Iodide: May decrease the metabolism of Succinylcholine. Risk D: Consider therapy modification
Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Only of concern in patients with increased serum magnesium concentrations. Risk C: Monitor therapy
Phenelzine: May enhance the neuromuscular-blocking effect of Succinylcholine. Risk D: Consider therapy modification
Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk D: Consider therapy modification
QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Storage
Refrigerate at 2°C to 8°C (36°F to 46°F); however, stable for ?3 months unrefrigerated (25°C). Stability of parenteral admixture (1-2 mg/mL) at refrigeration temperature (4°C) is 24 hours in D5W or NS.
Reconstitution
May dilute to a final concentration of 1-2 mg/mL. Do not mix with alkaline solutions (pH >8.5).
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.
Compatibility in syringe: Compatible: Heparin.
Compatibility when admixed: Compatible: Amikacin, isoproterenol, meperidine, methyldopate, morphine, norepinephrine, scopolamine. Incompatible: Methohexital, nafcillin, sodium bicarbonate, thiopental. Variable (consult detailed reference): Pentobarbital.
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
Pharmacodynamics/Kinetics
Onset of action: I.M.: 2-3 minutes; I.V.: Complete muscular relaxation: 30-60 seconds
Duration: I.M.: 10-30 minutes; I.V.: 4-6 minutes with single administration
Metabolism: Rapidly hydrolyzed by plasma pseudocholinesterase
Excretion: Urine
Dosage
I.M., I.V.: Dose to effect; doses will vary due to interpatient variability; use ideal body weight for obese patients
I.M.: Children and Adults: Up to 3-4 mg/kg, total dose should not exceed 150 mg
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
Adults: 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 adjustment in hepatic impairment: Dose should be decreased in patients with severe liver disease
Administration: I.M.
I.M. injections should be made deeply, preferably high into deltoid muscle. Use only when I.V. access is not available.
Administration: I.V.
May be given by rapid I.V. injection without further dilution.
Administration: I.V. Detail
pH: 3.0-4.5
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
Patient Education
Patient will usually be unconscious prior to administration. Education should be appropriate to individual situation. Reassurance of constant monitoring and emotional support to reduce fear and anxiety should precede and follow administration. Following return of muscle tone, do not attempt to change position or rise from bed without assistance. Report immediately any skin rash or hives, pounding heartbeat, respiratory difficulty, or muscle tremors. Pregnancy/breast-feeding precautions: Inform prescriber if you are pregnant. Consult prescriber if breast-feeding.
Anesthesia and Critical Care Concerns/Other Considerations
Classified as an ultra-short duration neuromuscular-blocking agent; some formulations may contain benzyl alcohol.
Critically-Ill Adult Patients: The 2002 ACCM/SCCM/ASHP clinical practice guidelines for sustained neuromuscular blockade in the adult critically-ill patient recommend:
Optimize sedatives and analgesics prior to initiation and monitor and adjust accordingly during course. Neuromuscular blockers do not relieve pain or produce sedation.
Protect patient's eyes from development of keratitis and corneal abrasion by administering ophthalmic ointment and taping eyelids closed or using eye patches. Reposition patient routinely to protect pressure points from breakdown. Address DVT prophylaxis.
Concurrent use of a neuromuscular blocker and corticosteroids appear to increase the risk of certain ICU myopathies; avoid or administer the corticosteroid at the lowest dose possible. Reassess need for neuromuscular blocker daily.
Using daily drug holidays (stopping neuromuscular-blocking agent until patient requires it again) may decrease the incidence of acute quadriplegic myopathy syndrome.
Tachyphylaxis can develop; switch to another neuromuscular blocker (taking into consideration the patient's organ function) if paralysis is still necessary.
Atracurium or cisatracurium is recommended for patients with significant hepatic or renal disease, due to organ-independent Hofmann elimination.
Monitor patients clinically and via “Train of Four” (TOF) testing with a goal of adjusting the degree of blockade to 1-2 twitches or based upon the patient's clinical condition.
Dental Health: Effects on Dental Treatment
No significant effects or complications reported
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
None reported
Mental Health: Effects on Psychiatric Treatment
MAO inhibitors may prolong the effects of succinylcholine
Nursing: Physical Assessment/Monitoring
Only clinicians experienced in the use of neuromuscular-blocking drugs should administer and/or manage the use of succinylcholine. Dosage and rate of administration should be individualized and titrated to the desired effect, according to relevant clinical factors, premedication, concomitant medications, age, and general condition of patient. Ventilatory support must be instituted and maintained until adequate respiratory muscle function and/or airway protection are assured. Assess other medications for effectiveness and safety. Other drugs that affect neuromuscular activity may increase/decrease neuromuscular block induced by succinylcholine. This drug does not cause anesthesia or analgesia; pain must be treated with appropriate analgesic agents. Continuous monitoring of vital signs, cardiac status, respiratory status, and degree of neuromuscular block (objective assessment with external nerve stimulator) is mandatory during infusion and until full muscle tone has returned. Muscle tone returns in a predictable pattern, starting with limbs, abdomen, chest diaphragm, intercostals, and finally muscles of the neck, face, and eyes. Safety precautions must be maintained until full muscle tone has returned. Provide appropriate patient teaching/support prior to and following administration.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution, as chloride:
Anectine®: 20 mg/mL (10 mL)
Quelicin®: 20 mg/mL (10 mL)
Injection, solution, as chloride [preservative free]:
Quelicin®: 100 mg/mL (10 mL)
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.
International Brand Names
Lexi-Comp.com
Last full review/revision August 2008
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