Succinycholine Myalgias

[narcusprince]

In my small practice I find myself using a large amount of succinycholine for intubations. I use the drug fairly often except obvious contraindiactions (Acute hyperkalemia, MH-succebtible patients, Renal failure, etc) I have found that my patients NEVER complain of myalgias afterward. I deal with a lot of young healthy muscular patients. Are the myalgia effects of succinycholine overblown? I know some providers at previous institutions whom would avoid?

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[pgg]

When are you asking them?

I very rarely use succ.

 

[Planktonmd]

In my small practice I find myself using a large amount of succinycholine for intubations. I use the drug fairly often except obvious contraindiactions (Acute hyperkalemia, MH-succebtible patients, Renal failure, etc) I have found that my patients NEVER complain of myalgias afterward. I deal with a lot of young healthy muscular patients. Are the myalgia effects of succinycholine overblown? I know some providers at previous institutions whom would avoid?

Yes... the myalgia is way over blown and Sux is a fantastic medication.
I use it everyday

 

[narcusprince]

PGG,
I ask them immediatly postop as well as 2-3 days after. As you well know I work and live around my patients so collecting postop data about their experiance is relatively easy.

 

[pgg]

Years ago I had an ORIF for comminuted radius/ulna fractures. The total body myalgias from the succ were worse than the surgical pain and near the injury/breaking pain. I thought maybe they'd done CPR on me and run over my legs with a forklift. Lasted a couple days. Hence my aversion to succ. I know that's anecdote and says nothing about either incidence or typical severity of the myalgias ...

I use succ when I have a solid indication for it ... but mostly just use roc. Even for short cases. If you give it a couple min to work, .3/kg gives good enough intubating conditions and usually only needs a reduced reversal dose, even for fast surgeons.

 

[dhb]

What situation prevents you from using any other muscle relaxant? Using sux everyday is kind of baffling.

 

[deleted171991]

What situation prevents you from using any other muscle relaxant? Using sux everyday is kind of baffling.

Short cases, maybe?

I also tend to use sux way more than roc. I don't really like residual muscle weakness in my patients, even the one that comes with 4 twitches and sustained tetany.

 

[dhb]

I don't really like residual muscle weakness in my patients, even the one that comes with 4 twitches and sustained tetany.

How do you objectify muscle weakness in a patient with four twitches and sustained tetany?

 

[pgg]

Short cases, maybe?

I also tend to use sux way more than roc. I don't really like residual muscle weakness in my patients, even the one that comes with 4 twitches and sustained tetany.

We've had a few threads about residual muscle weakness after nondepolarizers.

Just reverse when you've got 2+ twitches, and always* give at least a reduced dose of neostigmine even if they have 4 twitches and there's no residual weakness to worry about.


* I "always" reverse unless hours have passed since the last dose of NMBD and even then if I have any suspicion of weakness upon wakeup, I'll give some

 

[dhb]

I don't and i think it's ivy tower bs you don't need 100% recovery from nmb to do fine. Let's say i give 15 or 20mg of atracurium to a 60-70kg patient: that's 0.25mg/kg if the case lasts an hour i won't reverse. Now don't get me wrong if i have the slightest doubt i will but just not systematically

 

[chmd]

In my small practice I find myself using a large amount of succinycholine for intubations. I use the drug fairly often except obvious contraindiactions (Acute hyperkalemia, MH-succebtible patients, Renal failure, etc) I have found that my patients NEVER complain of myalgias afterward. I deal with a lot of young healthy muscular patients. Are the myalgia effects of succinycholine overblown? I know some providers at previous institutions whom would avoid?

Renal failure isn't a contraindication. I'm much more worried about the icu pt who hasn't moved in a week (regarding hyperK).

 

[narcusprince]

Relative contra indication for me. In patients in renal failure I try my best not to give anything that can cause a rapid increase in potassium their are different approaches to manage these patients versus giving Sux. Agreed on the ICU patient with possible increased extrajunctional receptors or patients whom have neuro injury resulting in denervated tissue.

 

[Planktonmd]

What situation prevents you from using any other muscle relaxant? Using sux everyday is kind of baffling.

Why is it baffling if you want to use a muscle relaxant that always works and always gives you excellent intubating conditions???

 

[chmd]

I like succ because it's speeds up the intubation. I get to leave the room for the next induction more quickly and secure that the airway is secure.

 

[dhb]

I use other drugs if i need to intubate but the case don't warrant muscle relaxation

 

[Ignatius J]

I use other drugs if i need to intubate but the case don't warrant muscle relaxation

I give one dose of non-depolarizer up front. Rarely redose. If they start over breathing the vent I will. Works fine. My former attendings and academic colleagues may be beside themselves but it works for me. Muscle relaxants are way overused. Give a dose to cover intubation and incision/exposure, but damn son, you should be able to keep a patient still without relaxants.

 

[deleted171991]

We've had a few threads about residual muscle weakness after nondepolarizers.

Just reverse when you've got 2+ twitches, and always* give at least a reduced dose of neostigmine even if they have 4 twitches and there's no residual weakness to worry about.


* I "always" reverse unless hours have passed since the last dose of NMBD and even then if I have any suspicion of weakness upon wakeup, I'll give some

I do the same, pgg, but I still worry. I want my patients to get the experience I would like to have if I had anesthesia, so I care about a bunch of things.

 

[pgg]

I do the same, pgg, but I still worry. I want my patients to get the experience I would like to have if I had anesthesia, so I care about a bunch of things.

Worry was probably the wrong word to use. I didn't mean to be dismissive of concern and care.

What I mean is that I'm confident that, absent unusual risk factors, a patient who gets a full neostigmine reversal with 2+ twitches back, or a reduced reversal with 4/ST back, will not have postop complications related to residual neuromuscular blockade. I still monitor the patients.

I have a reason, centered on patient comfort, to avoid succinylcholine when there's not a solid indication for it.

I see no reason to avoid nondepolarizers. I think it's pretty clear that they are routinely overdosed by many people. The ED95 of roc is 0.3 mg/kg; the typical intubating dose of 0.6 is a nod to faster onset, not a minimum for adequate relaxation. Surgeons don't need flat 0-twitch patients; when relaxation is helpful, NMBDs titrated to 1 twitch is more than adequate. I'm living with slow surgeons in academia now, but I wasn't burning myself with roc back when I was doing lap choles with 20 minute surgeons.

When I want the best intubating conditions the fastest, I use succinylcholine. There's no substitute for it in the desatting patient with laryngospasm. But these are not especially common occurrences.

I think succ is the 2nd-most overused drug in anesthesia, after midazolam. Just two of my biases.

 

[Ignatius J]

Pgg,

Can you talk a little more about Versed being overused? I happen to agree, but it's not a popular opinion. I think it can confuse the heck out of older patients and just isn't necessary a lot of the time.

 

[deleted171991]

How do you objectify muscle weakness in a patient with four twitches and sustained tetany?

I would expect that patient to not have any muscle weakness, but what do I know? The ulnar nerve territory might or might not recover after every other muscle in the body. I was just taking things to the extreme, to make a point.

My total number of weak postop patients ever is still 1 (and that was an early reversal, requested by an attending in residency), but it's an experience I don't wish to anyone. I know it's rare, but that doesn't make me less of a worrier. I have seen the complication only once, and that was one time too many. The patient was fine, but the image is still burnt in my memory.

Since then, I only reverse at 2+ clear twitches, and wake the patient up only when I have 4 strong twitches or sustained tetany after (half- or full-dose) reversal. Very similar to pgg.

 

[deleted171991]

I have a reason, centered on patient comfort, to avoid succinylcholine when there's not a solid indication for it.

I see no reason to avoid nondepolarizers. I think it's pretty clear that they are routinely overdosed by many people. The ED95 of roc is 0.3 mg/kg; the typical intubating dose of 0.6 is a nod to faster onset, not a minimum for adequate relaxation. Surgeons don't need flat 0-twitch patients; when relaxation is helpful, NMBDs titrated to 1 twitch is more than adequate. I'm living with slow surgeons in academia now, but I wasn't burning myself with roc back when I was doing lap choles with 20 minute surgeons.

I sometimes do the same (if I need muscle relaxation for the procedure, or the patient is overbreathing the vent despite adequate anesthesia). Typically 0.3 mg/kg of roc at the beginning of the surgery, less later. I never had an issue with that dose. But it's not always good/fast enough for intubations (at 0.3 mg/kg), while I find sux (at 0.6 mg/kg or even less) to always do a perfect job. I don't hear about myalgias either (but our PACU nurses don't ask specifically).

I tend to use sux for intubations, and roc for maintenance (when indicated). I use only roc if the surgery is expected to last over 60-90 minutes, so I can give 0.6 mg/kg for intubation. But I don't give muscle relaxant if I don't have to.

As a reminder/disclaimer: I use a ton of LMAs, so I don't need muscle relaxation for every patient, just to avoid bucking.

 

[GasEmDee]

What situation prevents you from using any other muscle relaxant? Using sux everyday is kind of baffling.

Relative speed of onset (and observable onset of effect). Avoiding the side effect and hassle of reversal. Resumption of spontaneous ventilation early in the case where appropriate, allowing titration of opioids and subsequent fast (and deep) extubation. The ED95 dose is something like 0.3mg/kg. I use maybe 0.6-0.7mg/kg. I don't robotically push 100mg. I haven't noticed any complaints of myalgias.

It's a great drug.

 

[psychbender]

I think succ is the 2nd-most overused drug in anesthesia, after midazolam. Just two of my biases.

This. We had a huge sux shortage for months during residency, and I remember having only two vials in the entire hospital. Those vials went to whoever was doing Peds that day, with the understanding that they would not be cracked unless absolutely necessary. As a result, I got used to not using sux, and still generally consider it an emergency-only drug. It annoys me that the SRNAs here each draw up a vial of it at the start of every day "just in case," and end up wasting it most of the time. It also annoys me when the CRNAs have healthy patients with perfect airways, who are NPO, undergoing procedures that "need relaxation," and they still intubate with 1mg/kg sux, then give roc when it wears off before incision. Where the hell is the logic in that? Since this is a military hospital, and several of the anesthetists have literally been doing this as long as I have been alive, I'm not going to be able to change their practices any time soon. Regarding the midaz...here, for non first start cases, the holding area is about 10 feet from the OR, and it doesn't get pushed until the patient is being wheeled to the room, why even bother?

 

[narcusprince]

I agree regarding midazolam. I rarely give Midazolam. Try this give 2-3ml of propofol mixed with 1ml of 2% lidocaine. This works well for patients with anxiolysis, and interestingly enough once they feel the effect of propofol they do not remember much after the medication was given. They are conscious and able to move themselves off the gurney. At my previous location the OR was maybe 30 feet from the PACU I would give the mix then wheel the patients off to the OR once we hit the OR doors the patients would feel the medication. This worked great until an OR nurse at a different location said I was inducing patients while the in the preop location...... I had to explain to her the concept of dosages, and that an OR nurse has no right to critique an anesthesiologist technique.

 

[fakin' the funk]

How do you objectify muscle weakness in a patient with four twitches and sustained tetany?

Um, exactly.

 

[fakin' the funk]

Relative speed of onset (and observable onset of effect). Avoiding the side effect and hassle of reversal. Resumption of spontaneous ventilation early in the case where appropriate, allowing titration of opioids and subsequent fast (and deep) extubation. The ED95 dose is something like 0.3mg/kg. I use maybe 0.6-0.7mg/kg. I don't robotically push 100mg. I haven't noticed any complaints of myalgias.

It's a great drug.

Agreed with all of your pro's above.

It's a very useful drug with lots of upside, and obviously some huge downside too, that's why you use it carefully.

1.5 mg/kg vs 1 mg/kg is associated with less myalgias.

So is concomitantly using lidocaine or an NSAID.

 

[fakin' the funk]

I agree regarding midazolam. I rarely give Midazolam. Try this give 2-3ml of propofol mixed with 1ml of 2% lidocaine. This works well for patients with anxiolysis, and interestingly enough once they feel the effect of propofol they do not remember much after the medication was given. They are conscious and able to move themselves off the gurney. At my previous location the OR was maybe 30 feet from the PACU I would give the mix then wheel the patients off to the OR once we hit the OR doors the patients would feel the medication. This worked great until an OR nurse at a different location said I was inducing patients while the in the preop location...... I had to explain to her the concept of dosages, and that an OR nurse has no right to critique an anesthesiologist technique.

I am quickly becoming a believer in minidose propofol for anxiolysis. Like 0.1-0.2 mg/kg.

 

[amyl]

Only time I use sux is rsi. Profopol is a wonder drug. It fixes everything but hypotension and bradycardia just kidding. But i use it for anxiolysis, Shivering, nausea, spinal placement in non-pregnant pts, when the versed makes them chatty....