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trademark for preparations of succinylcholine, a neuromuscular blocking agent.
Pregnancy Category: C
ClassificationTherapeutic: neuromuscular blocking agents depolarizing
Used during surgical procedures to produce skeletal muscle paralysis after induction of anesthesia and provision of opioid analgesics.
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction.
Has agonist activity initially, producing fasciculation.
Causes the release of histamine.
Has no analgesic or anxiolytic effects.
Skeletal muscle paralysis.
Absorption: Well absorbed after deep IM administration.
Distribution: Widely distributed into extracellular fluid. Crosses the placenta in small amounts.
Metabolism and Excretion: 90% metabolized by pseudocholinesterase in plasma. 10% excreted unchanged by the kidneys.
Time/action profile (skeletal muscle paralysis)
|IM||up to 3 min||unknown||10–30 min|
|IV||0.5–1 min||1–2 min||4–10 min|
Contraindicated in: Hypersensitivity to succinylcholine or parabens; Plasma pseudocholinesterase deficiency; Pediatric: Children and neonates (continuous infusions); Personal history of malignant hyperthermia.
Use Cautiously in: History of anaphylaxis to other neuromuscular blockers; Familial history of malignant hyperthermia; History of pulmonary disease, renal or liver impairment; Major trauma, burns, or underlying myopathy (↑ risk of rhabdomyolysis and hyperkalemia, especially in children or adolescents); Glaucoma; Electrolyte disturbances; Receiving digoxin; Fractures or muscular spasm; Myasthenia gravis or myasthenic syndromes; Geriatric: Geriatric or debilitated patients; Obstetric: Has been used in pregnant women undergoing cesarean section; Pediatric: Children and neonates (↑ risk of malignant hyperthermia).
Adverse Reactions/Side EffectsMost adverse reactions to succinylcholine are extensions of pharmacologic effects
- apnea (life-threatening)
Fluid and Electrolyte
- hyperkalemia (life-threatening)
- rhabdomyolysis (life-threatening)
- muscle fasciculation
- anaphylaxis (life-threatening)
- malignant hyperthermia (life-threatening)
- myoglobinemia (↑ in children)
- myoglobinuria (↑ in children)
Drug-Drug interactionIntensity and/or duration of paralysis may be prolonged by pretreatment with general anesthesia, aminoglycosides, polymyxin B, colistin, clindamycin, lidocaine, quinidine, procainamide, beta blockers, lithium, cyclophosphamide, phenelzine, potassium-losing diuretics, and magnesium salts.↑ risk of adverse cardiovascular reactions with opioid analgesics or digoxin.
Route/DosageIV route is preferred, but deep IM injection may be used in children and patients without vascular accessTest Dose
Intravenous (Adults) 5–10 mg (0.1 mg/kg), then assess respiratory function.Short Procedures
Intravenous (Adults) 0.6 mg/kg (range 0.3–1.1 mg/kg) up to 150 mg total dose; additional doses depend on response, maintenance: 0.04–0.07 mg/kg q 5–10 min as needed.
Intravenous (Children) 1–2 mg/kg, up to 150 mg; additional doses depend on response, maintenance: 0.3–0.6 mg/kg q 5–10 min as needed, (continuous infusion not recommended in children or neonates because of the risk of malignant hyperthermia).Prolonged Procedures
Intravenous (Adults) 2.5 mg/min infusion (range 0.5–10 mg/min).Intramuscular Dosing
Intramuscular (Adults and Children) Up to 3—4 mg/kg (total dose not to exceed 150 mg).
Injection: 20 mg/mL, 100 mg/mL
- Assess respiratory status continuously throughout use of succinylcholine. Succinylcholine should be used only by individuals experienced in endotracheal intubation, and equipment for this procedure should be immediately available.
- Monitor neuromuscular response to succinylcholine with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs consecutively in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm.
- Monitor ECG, heart rate, and BP throughout use of succinylcholine.
- Assess patient for history of malignant hyperthermia before administration. Monitor for signs of malignant hyperthermia (tachycardia, tachypnea, hypercarbia, jaw muscle spasm, lack of laryngeal relaxation, hyperthermia) throughout administration.
- Observe patient for residual muscle weakness and respiratory distress during the recovery period.
- Lab Test Considerations: May cause hyperkalemia, especially in patients with severe trauma, burns, or neurologic disorders. If overdose occurs, use peripheral nerve stimulator to determine degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
Potential Nursing DiagnosesIneffective breathing pattern (Indications)
Impaired verbal communication (Side Effects)
- high alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication, or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Watch for packaging similarities and double check for correct medication and dose.
- Succinylcholine has no effect on consciousness or the pain threshold. Adequate anesthesia should always be used when succinylcholine is used as an adjunct to surgical procedures or when painful procedures are performed. To avoid patient distress, administer after unconsciousness has been achieved. Benzodiazepines and/or analgesics should be administered concurrently when prolonged succinylcholine therapy is used for ventilator patients because patient is awake and able to feel all sensations.
- If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
- To prevent excessive salivation, patients may be premedicated with atropine or scopolamine.
- A small dose of a nondepolarizing agent may be used before succinylcholine to decrease the severity of muscle fasciculations.
- When used prior to electroconvulsive therapy, shock should be administered 1 min after administration.
- Intramuscular: If IM route is used, administer deep into the deltoid muscle.
- Intravenous: A test dose of 5–10 mg or 0.1 mg/kg may be administered to determine patient’s sensitivity and recovery time.
- Diluent: May be administered undiluted.
- Rate: Usual adult dose is administered over 10–30 sec. Dose is titrated to patient response.
- Continuous Infusion: Diluent: Dilute as a 0.1–0.2% solution (1–2 mg/mL) in dextrose/Ringer’s or lactated Ringer’s combinations, dextrose/saline combinations, 0.45% NaCl, 0.9% NaCl, D5W, D10W, Ringer’s or lactated Ringer’s injection. Solution is stable for 24 hr at room temperature. Administer only clear solutions. Discard any unused solution.
- Rate: Administer at a rate of 0.5–10 mg/min; usual rate is 2.5–4.3 mg/min. Titrate dose to patient response and degree of paralysis required.
- Y-Site Compatibility: acyclovir, alfentanil, alemtuzumab, amikacin, aminocaproic acid, aminiophylline, amphotericin B lipid complex, anidulafungin, argatroban, asorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, caspofungin, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hetastarch, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, miconazole, midazolam, milrinone, minocycline, mitoxantrone, morphine, multivitamins, mycophenolate, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pantoprazole, papaverine, pemetrexed, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, sodium acetate, streptokinase, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, vitamin B complex with C, voriconazole, zoledronic acid
- Y-Site Incompatibility: amphotericin B colloidal, azathioprine, dantrolene, diazepam, diazoxide, ganciclovir, indomethacin, nafcillin, oxacillin, penicillin G, pentobarbital, phenobarbital, phenytoin, sodium bicarbonate, thiopental, trimethoprim/sulfamethoxazole
- Explain all procedures to patient receiving succinylcholine therapy without anesthesia, because consciousness is not affected by succinylcholine alone. Provide emotional support.
- Reassure patient that communication abilities will return as the medication wears off.
- Adequate suppression of the twitch response when tested with peripheral nerve stimulation, with subsequent muscle paralysis.