Sux onset

[Reveler]

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I'm on an anesthesia elective and I worked with an attending today that had me intubating immediately after pushing sux. When I've worked with other attendings, I normally mask ventilate for ~60 seconds before intubating. I felt that I had to work a lot harder to get comparable views today and feel it might have been due to inadequate relaxation (also being a med student). When I asked my attending about it he said that he always intubates immediately after administering the sux without waiting.

What's the general thought about waiting for full onset? Do you intubate immediately after pushing sux? Caveat: there was a de-fasciculating dose of roc administered ~20 seconds prior.

 

[deleted162650]

Blade goes in when fasciculations stop. If I’m giving sux, it’s for a real no-sheet RSI, and I’m not ventilating.

 

[Onefellswoop87]

Agree with above. Blade goes in when fasiculations stop.
But if you are using a defasciulating dose of roc, you need to give it time to work. 20 sec is inadequate. It goes in a few minutes before succinylcholine, but that means that you need a higher dose of suc (and it’s gonna take a little longer for full effect). And defasciulating doses stop fasiculations not myalgias, just a point for you to keep in your back pocket, not to antagonize your attending over tomorrow.
You probably had to work harder cause the succinylcholine was still in the vasculature, and definitely not at the neuromuscular junction yet. But that just proves you don’t need paralysis to intubate haha

 

[anbuitachi]

I'm on an anesthesia elective and I worked with an attending today that had me intubating immediately after pushing sux. When I've worked with other attendings, I normally mask ventilate for ~60 seconds before intubating. I felt that I had to work a lot harder to get comparable views today and feel it might have been due to inadequate relaxation (also being a med student). When I asked my attending about it he said that he always intubates immediately after administering the sux without waiting.

What's the general thought about waiting for full onset? Do you intubate immediately after pushing sux? Caveat: there was a de-fasciculating dose of roc administered ~20 seconds prior.

you get paralysis pretty quick with sux. After sux is pushed i usually tape eyes, grab intubating stuff over, and by then the patient is almost ready. intubating conditions of course also depends on the dose of sux. I usually give a bit on the higher side because i know our sux often sucks. It often sits on the drug cart for a week, when storage is supposed to be in the fridge. though i dont have data on warm sux vs cold sux

 

[Dr.whom]

Your attending is smart! Make you struggle with the intubation, then takes over once pt fully relaxes and slides tube in easily to look like a hero.

 

[Aether2000]

Laryngeal adductor succinylcholine onset averages 34 seconds. (Onset and duration of rocuronium and succinylcholine at the adductor pollicis and laryngeal adductor muscles in anesthetized humans. - PubMed - NCBI)

 

[MirrorTodd]

Laryngeal adductor succinylcholine onset averages 34 seconds. (Onset and duration of rocuronium and succinylcholine at the adductor pollicis and laryngeal adductor muscles in anesthetized humans. - PubMed - NCBI)

What about the rest of the throat/mouth muscles though ? Does it hit adductors or masseters etc first? Kinda hard to intubate if one can’t open their mouth.

 

[Reveler]

This attending has been doing this for years, so he's obviously successful with it. But I seemed to be applying an inordinate amount of force for only minor improvements in the view. In one case, I could barely open the mouth wide enough to pass an 8.0 tube, much less manipulate it.

 

[deleted171991]

Bad teacher. He should be able to tell you exactly what you did wrong.

 

[Psai]

Inadequate relaxation?

What are you, a ****ty surgeon?

 

[OB1🤙]

Sux is myalgia-causing garbage and using it for elective cases is abhorrent in my opinion.

 

[deleted162650]

Bad teacher. He should be able to tell you exactly what you did wrong.

Not to mention using “Because that’s how I always do it” as an explanation is unacceptable.

 

[anbuitachi]

Sux is myalgia-causing garbage and using it for elective cases is abhorrent in my opinion.

No paralysis for the win.

 

[Aether2000]

Of course there are ways to significantly reduce myalgias: preop gabapentin or pregabalin, IV magnesium, ketamine, lidocaine, increasing the dosage of propofol to 3.5mg/kg, etc.

 

[coffeebythelake]

Of course there are ways to significantly reduce myalgias: preop gabapentin or pregabalin, IV magnesium, ketamine, lidocaine, increasing the dosage of propofol to 3.5mg/kg, etc.

can also give an NSAID if risk of bleeding is low

or INCREASING your dose of succinylcholine -- i usually do 1.2-1.5 mg/kg

"... higher doses of succinylcholine decrease the risk of myalgia compared with lower doses... "
Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

 

[deleted162650]

can also give an NSAID if risk of bleeding is low

or INCREASING your dose of succinylcholine -- i usually do 1.2-1.5 mg/kg

"... higher doses of succinylcholine decrease the risk of myalgia compared with lower doses... "
Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

Or try decreasing the dose - to zero.

 

[Noyac]

If I’m giving sux then I’m putting a tube in ASAP as many of you have said already. My timing is, once the pt starts to fasiculate then I grab the blade and start to dive in or at least before the fasiculations are done. I don’t wait for them to stop.

 

[dannyboy1]

Sux is myalgia-causing garbage and using it for elective cases is abhorrent in my opinion.

I have administered sux hundreds of times. Not once have I ever experienced myalgias

 

[Psai]

I have administered sux hundreds of times. Not once have I ever experienced myalgias

Well yeah of course, it's the patient getting the sux

 

[Noyac]

Well yeah of course, it's the patient getting the sux

 

[narcusprince]

I wait for fasciculations then dive in. I rarely use sux unless indicated. You know what rattles my feathers is those who give sux and give ventilations versus putting the tube in. Btw OP cuddos for putting your picture in your account.

 

[dhb]

Well yeah of course, it's the patient getting the sux

 

[coffeebythelake]

Or try decreasing the dose - to zero.

ok SaltyDog,
what a revelation, if you never give suxx then you never deal with suxx-associated myalgias!
good luck next time you decide to do an ECT without suxx.
one of many examples.

 

[dannyboy1]

Well yeah of course, it's the patient getting the sux

That’s the point
Myalgia= patients problem
Getting sued for an aspiration when I should have done proper RSI = my problem

 

[deleted162650]

ok SaltyDog,
what a revelation, if you never give suxx then you never deal with suxx-associated myalgias!
good luck next time you decide to do an ECT without suxx.
one of many examples.

I use sux when it’s indicated - true RSI scenarios which I mentioned earlier. Fortunately, that’s not really that often even at the Level 2 trauma center I work at. Especially now with Sugga - there’s just not a good reason to give sux to elective cases.

In the pre-Sugga days I did have an ECT patient with pseudocholinisterase deficiency. Low dose roc worked fine.

 

[dhb]

ok SaltyDog,
what a revelation, if you never give suxx then you never deal with suxx-associated myalgias!
good luck next time you decide to do an ECT without suxx.
one of many examples.

Way to put word in people's mouth!

I like sux, i think it's a good drug and i use it when indicated which as Salty says isn't that often.

I think it's nuts to use it routinely for GETA.

 

[Hoya11]

I'm on an anesthesia elective and I worked with an attending today that had me intubating immediately after pushing sux. When I've worked with other attendings, I normally mask ventilate for ~60 seconds before intubating. I felt that I had to work a lot harder to get comparable views today and feel it might have been due to inadequate relaxation (also being a med student). When I asked my attending about it he said that he always intubates immediately after administering the sux without waiting.

What's the general thought about waiting for full onset? Do you intubate immediately after pushing sux? Caveat: there was a de-fasciculating dose of roc administered ~20 seconds prior.

Not every intubation is under perfect conditions. As others have said, when you see fasciculations, you go. It may be a little bit tight but good technique can overcome this and its what the patient needs. I have seen many many students struggle with RSI intubations in an imperfect situation when they usually have no trouble after a slow roc induction. Its a higher level of difficulty that you did not possess the skills to successfully overcome.. your not a lone it takes practice, but don't blame your attending, understand that anesthesia skills can be hard to learn and respect those skills for not being able to be learned in one or two attempts... its your problem not the problem of the attending..

I use sux relatively often... RSIs for hiatial hernias, full stomach trauma situations, unit intubations, or a case where I am intubating but don't need long term muscle relaxation... For a period of time I did try the no paralytic approach, it works fine most times, sometimes though you do see some myoclonus or other patient movement before or during intubation that looks strange to the other staff.. sux covers this movement up nicely and give you nice intubating conditions and control... I'm not afraid of myalgias, I think it is overblown and in the course of all the fentanyl and other analgesics and with an appropriate dose of sux its nothing to fear..

 

[DrZzZz]

Just throwing this in the ring - Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

I also limit Sux use to situations where it's truly indicated. Probably use it once a month, aside from ECT. My hospital still doesn't have Sugga on formulary either.

How many of you give a defasciculating dose of Roc prior to Sux, knowing it doesn't really reduce myalgia anyway? I generally do, but I don't have full autonomy to do as I please for another couple months. If you do use it, why?

 

[deleted171991]

Just throwing this in the ring - Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

I also limit Sux use to situations where it's truly indicated. Probably use it once a month, aside from ECT. My hospital still doesn't have Sugga on formulary either.

How many of you give a defasciculating dose of Roc prior to Sux, knowing it doesn't really reduce myalgia anyway? I generally do, but I don't have full autonomy to do as I please for another couple months. If you do use it, why?

I don't. But since all my patients get lidocaine before propofol, and toradol and mag whenever possible, I am not surprised that no surgeon has ever complained to me about his patients' myalgias.

 

[IlDestriero]

This attending has been doing this for years, so he's obviously successful with it. But I seemed to be applying an inordinate amount of force for only minor improvements in the view. In one case, I could barely open the mouth wide enough to pass an 8.0 tube, much less manipulate it.

That’s because he wasn’t paralyzed yet. I rarely paralyze unless necessary and when I do I’m always aware of how much easier everything is.


--
Il Destriero

 

[pgg]

That’s the point
Myalgia= patients problem
Getting sued for an aspiration when I should have done proper RSI = my problem

Whoa, back up.

When an RSI is indicated you give an RSI dose of succ (or roc).

As a card-carrying member of the Succinylcholine Haters Club, I still use the stuff when it's indicated. What I don't do is use it routinely, because that's barbaric and cruel.

Also, defasciculation doses are dumb. If you're going to use succ, use it without compromising its only redeeming quality (onset time).

 

[coffeebythelake]

Way to put word in people's mouth!

I like sux, i think it's a good drug and i use it when indicated which as Salty says isn't that often.

I think it's nuts to use it routinely for GETA.

I wasn' putting words in his mouth. He wrote such words, that he would only use suxx for real deal RSI. Obviously he didn' think of ECT when he made that statement. Or perhaps of a large obese obstructing airway that you wouldnt want to mask for 2 minutes for your roc to kick in. instead of trying to explain strategies to prevent of suxx related myalgias when it is used, he replies to my post with his crusade on how you can prevent myalgias by not using suxx altogether and other pointless drivel.

And yes like you I only use suxx when I feel there is a compellng reason to use it. That should go without saying.

 

[OB1🤙]

It *should* go without saying, but all the time I see people give sux to intubate their fasted elective long case, then five minutes later give roc.

All the damn time, and it drives me f^cking bonkers.

 

[Psai]

It *should* go without saying, but all the time I see people give sux to intubate their fasted elective long case, then five minutes later give roc.

All the damn time, and it drives me f^cking bonkers.

Yes! They go nuts with cricoid pressure and rushing the intubation then they check twitches just in case there is pseudocholinesterase deficiency and I'm like we could have avoided all this bull**** by giving roc upfront.

 

[facted]

It *should* go without saying, but all the time I see people give sux to intubate their fasted elective long case, then five minutes later give roc.

All the damn time, and it drives me f^cking bonkers.

There are reasons to give sux to fasted patients. There are plenty of patients that I take one look at and decide that ventilation will be harder than intubating. Why not give sux, wait 20 seconds and then intubate the patient?

And checking twitches and giving roc later is fine. I used to but check until I had a patient who I'm pretty sure had pseudocholinesterase deficency.

Honestly not sure why people demonize sux. It surely has its side effects, but it's got it's uses.

 

[OB1🤙]

Why not just give a solid dose of roc upfront instead of sux?

Fwiw I mask ventilate before intubating almost never. It's probably 1-2% of patients.

If you've ever talked to someone who had experienced sux myalgias, they will tell you that they're MISERABLE.

Why expose someone to any risk of misery if you don't have to?

 

[Psai]

There are reasons to give sux to fasted patients. There are plenty of patients that I take one look at and decide that ventilation will be harder than intubating. Why not give sux, wait 20 seconds and then intubate the patient?

And checking twitches and giving roc later is fine. I used to but check until I had a patient who I'm pretty sure had pseudocholinesterase deficency.

Honestly not sure why people demonize sux. It surely has its side effects, but it's got it's uses.

Because if you preoxygenate properly, you should have more than enough time to intubate most nonfat people.

 

[pgg]

If you've ever talked to someone who had experienced sux myalgias, they will tell you that they're MISERABLE.

This is the truth.

I got them after my radius & ulna ORIF. I thought maybe they did chest compressions on me. It felt like someone took a baseball bat to me. Even breathing hurt.

 

[epidural man]

I once had an attending that I really respected tell me "most people need a reason to give sux. I think you need a reason NOT to use sux"

This of course was before glide scopes and NMB reversal agents that actually worked. The way we used to save airways was with that really crappy LMA Fast Track POS and light wands and bullard scopes, and a ton of other garbage that never worked.

So I liked his wisdom.

It probably makes no sense in today's environment.

 

[pgg]

I once had an attending that I really respected tell me "most people need a reason to give sux. I think you need a reason NOT to use sux"

This of course was before glide scopes and NMB reversal agents that actually worked. The way we used to save airways was with that really crappy LMA Fast Track POS and light wands and bullard scopes, and a ton of other garbage that never worked.

So I liked his wisdom.

It probably makes no sense in today's environment.

I'm not so sure it ever made sense.

When you first lay eyes on the patient, either the airway gives you pause, or it doesn't.

If it does, the very notion that succinylcholine lends some kind of safety to the induction of that patient and his dodgy airway is flawed. It's not going to wear off before an anoxic brain injury occurs. You shouldn't be inducing those patients pre-tube in the first place.

If it doesn't, and the airway turns out to be the one in a thousand or ten thousand that's a genuinely unexpected nightmare, the sux is still not going to wear off in time to save the patient's brain.

When you're moving down the can't intubate/ventilate algorithm, it doesn't really matter if the patient was paralyzed by succinylcholine or rocuronium. You either ventilate the patient via some mechanism, pronto, or you're both boned. That "wake the patient up" branch only works if you can ventilate the patient.

 

[epidural man]

I'm not so sure it ever made sense.

When you first lay eyes on the patient, either the airway gives you pause, or it doesn't.

If it does, the very notion that succinylcholine lends some kind of safety to the induction of that patient and his dodgy airway is flawed. It's not going to wear off before an anoxic brain injury occurs. You shouldn't be inducing those patients pre-tube in the first place.

If it doesn't, and the airway turns out to be the one in a thousand or ten thousand that's a genuinely unexpected nightmare, the sux is still not going to wear off in time to save the patient's brain.

When you're moving down the can't intubate/ventilate algorithm, it doesn't really matter if the patient was paralyzed by succinylcholine or rocuronium. You either ventilate the patient via some mechanism, pronto, or you're both boned. That "wake the patient up" branch only works if you can ventilate the patient.

How long does your sux last?

Mine doesn’t seem to last that long. Maybe I’m doing something wrong.

 

[pgg]

How long does your sux last?

Mine doesn’t seem to last that long. Maybe I’m doing something wrong.

A few minutes? Maybe five? Dose and patient dependent.

Hard to predict. I see some people induce with sux and then wait for twitches to give roc. Sometimes it takes a while. Longer than I'd want someone to be apneic.

I guess a preoxygenated lean & healthy 22 year old would probably recover in time to breathe. The obese patient who's desaturating before the fasciculations stop ... I don't think so.


The kind of patients who might recover in time to save themselves from the induction, aren't the ones with concerning airways and body habituses (habiti?) in the first place.

 

[dhb]

How long does your sux last?

4-12min is the range asuming competent pseudocholine esterase.

 

[anbuitachi]

It *should* go without saying, but all the time I see people give sux to intubate their fasted elective long case, then five minutes later give roc.

All the damn time, and it drives me f^cking bonkers.

the main advantage of sux over rocc in my opinion is no ventilation for sux. just push drug, fasiculate, and go. for roc you have to wait for it to work

 

[dhb]

the main advantage of sux over rocc in my opinion is no ventilation for sux. just push drug, fasiculate, and go. for roc you have to wait for it to work

Not if you go for 1.2mg/kg

 

[coffeebythelake]

Not if you go for 1.2mg/kg

Even at 1.2 mg/kg still takes longer to work

 

[parcus]

Yes, but Propofol/alfentanyl will be effective at around the same time of roc, so patient will be apneic for virtually the same amount of time.

 

[dhb]

Even at 1.2 mg/kg still takes longer to work

Not by much

 

[nimbus]

the main advantage of sux over rocc in my opinion is no ventilation for sux. just push drug, fasiculate, and go. for roc you have to wait for it to work

You don't have to wait. Just mix the roc in the same syringe with the prop and intubate when the patient stops breathing. I almost never ventilate and I almost never use sux. Really the only time I use sux is when I give 10-20mg to break laryngospasm after extubation. I do around 1000cases/year at an L1 trauma center and use sux maybe 3-4 times/year. In Mexico, sux is not even available and their anesthesiologists do just fine.

 

[dhb]

In Mexico

Do we really need to go there again 😉