succinylcholine (Rx)

Brand and Other Names:Anectine, suxamethonium
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 20mg/mL
  • 100mg/mL
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Neuromuscular Blockade

Load

  • 0.3-1.1 mg/kg IV x1 dose, OR 
  • 3-4 mg/kg IM x1 dose
  • Short Procedures: usually 0.6 mg/kg IV injection

Maintenance for Prolonged Procedures

  • 0.04-0.07 mg/kg IV q5-10min PRN OR
  • 2.5 mg/min IV infusion

Administration

Dose should be calculated based on ideal body weight

Pretreatment: Atropine may reduce vagally mediated bradycardia/hypotension/drooling

Solution contains 1% benzyl alcohol

Prior administration of "defasciculating" dose of nondepolarizing neuromuscular blocker (such as 0.01 mg/kg IV vecuronium) will prevent muscular fasciculations that may increase ICP/IOP

Adequate ventilatory support mandatory, may experience increased sensitivity with electrolyte disorders (hyperMg, hypoK, hypoCa)

Dosage Forms & Strengths

injectable solution

  • 20mg/mL
  • 100mg/mL
more...

Neuromuscular Blockade

Load

  • Infants and small children: 2 mg/kg IV x1 dose 
  • Older children and adolescents: 1 mg/kg IV x1 dose
  • 3-4 mg/kg deep IM x1 dose; not to exceed 150 mg total dose (no adequate IV)

Maintenance

  • 0.3-0.6 mg/kg IV q5-10min PRN
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Interactions

Interaction Checker

and succinylcholine

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    Contraindicated

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          Minor

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            Adverse Effects

            Frequency Not Defined

            Muscle fasciculation which may result in postoperative pain

            Jaw rigidity

            Apnea

            Respiratory depression

            Bradycardia

            Hypotension

            Cardiac arrhythmias

            Sinus tachycardia

            Increased IOP

            Salivary gland enlargement

            Excessive salivation

            Rash

            Hypersensitivity reactions

            Malignant hyperthermia

            Myoglobinuria/myoglobinemia (rare)

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            Warnings

            Black Box Warnings

            Rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death after the administration of succinylcholine to apparently healthy children have been reported in children and adolescents. The children were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. It occurs soon after administration and requires immediate treatment of hyperkalemia. Prolonged resuscitation may be required.

            Reserve for use in children for emergency intubation or in instances when immediate securing of airway is necessary. It should be administered by trained personnel with a facility equipped to monitor, assist, and control respiration.

            Contraindications

            Hypersensitivity to drug or component; malignant hyperthermia, lack of ventilatory support, ocular surgery, penetrating eye injuries, closed-angle glaucoma, genetically determined disorders of plasma pseudocholinesterase, history of malignant hyperthermia, myopathies associated with elevated serum creatine kinase, acute phase of injury following major burns (hyperkalemia may occur), multiple trauma, extensive denervation of skeletal muscle or upper motor neuron injury

            Cautions

            Severe anaphylactic reactions to neuromuscular blocking agents have been reported; these reactions have, in some cases, been life threatening and fatal; because of the potential severity of these reactions, the necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken

            Chronic abdominal infection, subarachnoid hemorrhage, degenerative or dystrophic neuromuscular disease, conditions that may cause degeneration of central & peripheral nervous systems, upper motor neuron injury, multiple trauma, extensive denervation of skeletal muscle, electrolyte imbalance, glaucoma/eye injury (increases IOP)

            Patients with atypical or deficient pseudocholinesterase will have prolonged paralysis (such as organophosphate/carbamate poisoning, hyperthermia, burn patient, collagen-vascular disease)

            Additive/synergistic effects if administered with or following an opioid, sedative or anesthetic agent

            Acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, & death have been reported rarely in apparently healthy children & adolescents

            Repeated fractional doses or (to a lesser extent) continuous infusion may lead to tachyphylaxis

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            Pregnancy & Lactation

            Pregnancy Category: C

            Lactation: not known if excreted in breast milk; effect on nursing infant not known

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Depolarizing skeletal muscle relaxant; depolarizes motor endplate at myoneural junction, which causes sustained flaccid skeletal muscle paralysis; no effect on consciousness, pain

            Pharmacokinetics

            Onset: 30-60 sec (IV); 2-3 min (IM)

            Duration: 4-6 min (IV); 10-30 min (IM)

            Metabolism: Rapid, by plasma pseudocholinesterase to weakly active metabolite

            Metabolites: Succinylmonocholine & choline

            Excretion: Urine

            Pharmacogenomics

            Increased incidence of malignant hyperthermia with use of volatile anesthetics or depolarizing neuromuscular blockers in patients with gene mutations in ryanodine receptor (RYR1) or calcium channel alpha (1S)- subunit gene (CACNA1S)

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            Administration

            IV Incompatibilities

            Additive: methohexital, nafcillin, pentobarbital, sodium bicarbonate, thiopental

            Y-site: methohexital, thiopental

            IV Compatibilities

            Solution: compatible with most common solvents

            Additive: amikacin, isoproterenol, meperidine, methyldopate, morphine, norepinephrine, scopolamine

            Syringe: heparin

            Y-site: etomidate, heparin/hydrocortisone, Hextend, KCl, propofol, vit B/C

            IV Preparation

            Cont Infusion: dilute to 1-2 mg/mL w/ D5W, D5/NS, NS or Na-lactate 1/6M

            IV/IM Administration

            IM: IM injections should be made deeply, preferably high into deltoid muscle

            IV: may be given by rapid IV injection (10-30 sec) without further dilution

            Cont IV infusion: 2.5 mg/min (range: 0.5-10 mg/min)

            Storage

            Refrigerate at 2-8°C (36-46°F)

            Powder form does not require refrigeration

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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