Sux or not to Sux? A clinical opinion question...

[OldManDave]

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I wanted to take an informal poll & solicit folks thoughts on an a drug that is highly polarizing (pun not intended) around Dartmouth.

Succinycholine


For some of our faculty, they view it as a cheap, effective & relatively low-risk all-around paralytic. Others generally steer the residents away from its use unless specifically indicated, for example: full-blown RSI. Another subset of faculty act as if Sux was IV injected Draconian death-syrup that should be avoided at all costs - they generally substitute Rocuronium to avoid the rare, but very serious SEs of Sux.

So, what I would like to see is for everyone to express their own experiences with faculty bias & their practice patterns. It would be even better if you took a few moments to substantiate the "why" behind your choices. I will refrain from expressing my own point of view so as not to skew the conversation.

If this works as I hope it will, I plan to make topics like this a frequent feature of this forum. So, take a moment to 'chew' upon the concept & let your clinical wisdom be known. Who knows, you may provide some critical piece of info to someone else here in the forum?

 

[CremeSickle]

In would say its controversial where i am.

90% of people use Suxx for the obvious emergent RSI situation and about 10% have stopped using it for even that and now use Rocc. I often wonder how that would play out in court since rocc is certainly slower onset.

About 20% of people use suxx for every single induction with an ETT. I have asked why and they simply felt that it was the fastest and cheapest option in patients where there were no obvious risk factors. Hard to argue that logic really.

The other 80% use vecc or rocc (mostly vecc) because they just dont want to have to think about the issues with suxxs.

100% of our institution does not use suxx for peds < 10 yrs old per policy. These have to be rocc inductions (lawsuit terrified).

Personally, i could go either way. I hate the idea of allowing the fear of liability to dictate my anesthetic but then, i know its a serious consideration. All things being equal I currently use suxx only for adult RSIs with full stomachs and laryngospasm.

 

[Skrubz]

i can't think of an adult attending that won't use sux when clinically indicated... but outside of that, it's a crapshoot. some avoid it like the plague other than when needed for a "real" RSI, most tend to prefer using vec and roc in everyday practice. there is one attending that uses sux on everybody, unless specifically contraindicated - rumor has it that there was a bad outcome many years ago due to an inability to intubate/ventilate after giving a longer-acting relaxant.

we're taught to draw it up on pedi as an emergency drug, but it's rarely, if ever, actually used.

i personally use it for RSI, to break laryngospasm, ECT, or when the patient looks like he'll be a challenging mask (my hands are admittedly not the biggest in the world and i hate meeting up with patients that have big, flesh-encased mandibles). i've also used it for really short cases or when a brief period of relaxation is required - like a quick ENT DL and bx.

 

[Planktonmd]

There is no muscle relaxant better than Sux, but you need to avoid it when it's contraindicated.
I still use it very frequently.

 

[VolatileAgent]

europeans hate sux for some reason. if you use roc or vec, you better get the damn tube in (or be able to ventilate). otherwise, you'll be reaching for the cric kit.

 

[VentdependenT]

A true RSI we'll use SUX or ROC. Short case = sux. Longer case = Roc.

Thats about the only time I'll use it besides Laryngospasm, ECT, and the need for a quick burst of muscle relaxation during certain cases (like a bronch in a sick patient where cranking up gas or blasting propofol might be devastating to the pressure).

Occasionally we'll use it for an induction in a phattie who has a good airway that we thing we can tube but may experience difficulty ventilating. In this case NO NArCs. No Versed.

I don't agree with its use in that situation for the simple reason that If you think you may not be able to ventilate, or anticipate difficult DL, then you shouldn't even bother inducing the patient. I like Jets breath down technique but haven't used it yet. In our institution its an awake FOI in these situations. OR LMA open next to you.

 

[Intubate]

I use it all the time, more than any other NMB agent. Most of my patients get no other relaxant, and therefore need no reversal. I obviously avoid it in kids (they get no relaxant unless needed- I intubate them with deep gas plus a slug of propofol) and when contraindicated (which really isn't that often). Its a little dirty, but its a great drug. I almost never used it in residency, but in private practice, you get hosed if you give anything close to an intubating dose of any other relaxant (since the departure of miva-cough), and small doses of relaxant (.2-.3 /kg of roc for example) usually still give you a patient that coughs on the tube, and I still feel obligated to reverse them.

 

[Noyac]

I rarely use it unless the case is very short and requires an ETT. I do use it from time to time to place an LMA but very small doses (30 mg).

I almost never use it on kids.

I have a question for everyone though. If you are doing a pyloric stenosis case, do you use suxx or something else assuming you are not doing an awake intubation for this case? I don't use suxx. I know the literature supports suxx use in the very young but I rarely use it.

 

[BLADEMDA]

I rarely use it unless the case is very short and requires an ETT. I do use it from time to time to place an LMA but very small doses (30 mg).

I almost never use it on kids.

I have a question for everyone though. If you are doing a pyloric stenosis case, do you use suxx or something else assuming you are not doing an awake intubation for this case? I don't use suxx. I know the literature supports suxx use in the very young but I rarely use it.

Rocuronium.

Blade

 

[leaverus]

I use it all the time, more than any other NMB agent. Most of my patients get no other relaxant, and therefore need no reversal. I obviously avoid it in kids (they get no relaxant unless needed- I intubate them with deep gas plus a slug of propofol) and when contraindicated (which really isn't that often). Its a little dirty, but its a great drug. I almost never used it in residency, but in private practice, you get hosed if you give anything close to an intubating dose of any other relaxant (since the departure of miva-cough), and small doses of relaxant (.2-.3 /kg of roc for example) usually still give you a patient that coughs on the tube, and I still feel obligated to reverse them.

?? How do you provide surgical relaxation w/o any other NMB?

 

[epidural man]

?? How do you provide surgical relaxation w/o any other NMB?

There have been some pretty compelling studies with propofol/alfentanil vs propofol/sux - and the intubator was blinded to which drug was given and in the end the anesthesiologist could not tell a difference.

I showed one of the articles to an attending who said (just as most of you are probably thinking as you read this) "that's a bunch of crap! NO WAY." Anyway, after that, he tried alfentanil and thought it was neato.

I also had an attending that would say that he had to come up with a good reason NOT to use sux, rather than what most of us do, that is, come up with a justification for its use.

 

[rmh149]

?? How do you provide surgical relaxation w/o any other NMB?

Or...Deep with agent (if you can). I intubate with ScH for short cases. Since Mivacron is gone, which was great for short cases, carry them deep with agent (sevo is better IMO to avoid tachycardia) and the surgeon gets the relaxation they need....and the patient benefits from not requiring a reversal.

 

[fval28]

i only use sux when i absolutely have to- any drug with a side effect list longer than its therapeutic use list is not one i want in my body or in my patient's. although i have to admit i agree with plankton, there is no better relaxant , and in those few cases where it is absolutely needed, it is indispensible

 

[Intubate]

i only use sux when i absolutely have to- any drug with a side effect list longer than its therapeutic use list is not one i want in my body or in my patient's. although i have to admit i agree with plankton, there is no better relaxant , and in those few cases where it is absolutely needed, it is indispensible

Most drugs have dozens of side effects listed in the insert. This is a nonsense reason to avoid a drug. Its incredibly safe and has a long record of safety. Serious side effects are mostly predictable by patient history.

 

[fval28]

Most drugs have dozens of side effects listed in the insert. This is a nonsense reason to avoid a drug. Its incredibly safe and has a long record of safety. Serious side effects are mostly predictable by patient history.

Sorry dude, in training I saw 2 cases of sux related myalgias requiring readmission to the hospital, one guy progressed to rhabdo- and was otherwise healthy- and his tox screen was negative... also saw what I think was a case of sux induced hyperkalemia leading to cardiac arrest -not my case and no follow up was initiated (surprise). I have learned from what I think are other's misfortunes/ mistakes and come to my own conclusions- say what you want about my reason for avoiding the drug but this crap has NEVER happened with roc, or vec, or miv, or trac, or pavulon... I use it only when necessary and even then I use much smaller doses than I was trained to use- Glad to hear your experiences have been different, or maybe you're just not looking hard enough😉

 

[Noyac]

Rocuronium.

Blade

Exactly

 

[Noyac]

Most drugs have dozens of side effects listed in the insert. This is a nonsense reason to avoid a drug. Its incredibly safe and has a long record of safety. Serious side effects are mostly predictable by patient history.

Most side effects don't usually include DEATH.

 

[The_Sensei]

Yeah.....I only use sux when clinically indicated, and that is pretty rarely.

See that obese patient you are about to induce who hasn't exercised since the Reagan administration? Give them sux.......see those whole body fasciculations? Yeah........that represents the most intense exercise these fatties have had in a LONG time. Guess what? They call the hospital the next day and bitch mightily. Had it happen to me twice on cases I supervised.

There was a study in Anesthesiology that showed that giving like 100mg of Lidocaine was really the only effective means to decrease the incidence of post succinylcholine induced myalgias. I do that every time prior to giving sux. If I have some patient as big as the state of NJ that I think is going to give me one iota of trouble during induction, though.....they gets the sux and hopefully aren't sore as hell the next day. Better some temporary pain than the more permanent death.

 

[amyl]

The anesthesiologists at my hospital use sux VERY rarely. A few years ago an intern used it for RSI and then couldn't get it -- was the middle of the night. patient died. no sux.

 

[Planktonmd]

The anesthesiologists at my hospital use sux VERY rarely. A few years ago an intern used it for RSI and then couldn't get it -- was the middle of the night. patient died. no sux.

It's funny that you keep seeing this over and over again:
A single incident caused by some unfortunate situation, triggering a new institutional policy, based on reaction rather than logic!
So let's say for the sake of argument that he had used Rocuronium, would they have banned it as well?
Every drug we use is by definition a poison, and muscle relaxants particularly have a therapeutic index that equals 1, meaning your lethal dose and therapeutic dose are the same! The reason why every patient that gets these drugs doesn't die is that they are usually given by trained and knowledgeable people who can prevent that from happening.
So, in other words, the problem is usually not in the drug but in the provider.

 

[rmh149]

The anesthesiologists at my hospital use sux VERY rarely. A few years ago an intern used it for RSI and then couldn't get it -- was the middle of the night. patient died. no sux.

Dont know if I am understanding you correctly. Did the intern use ScH or no? Or did he use a NDNMB (vec or roc) and couldnt intubate or ventilate?

Or are you saying they dont use ScH anymore because of this incedent? If so, how did ScH lead to death?

 

[Intubate]

Most side effects don't usually include DEATH.

You couldn't be more wrong... death is a possible side effect of every drug.

 

[CremeSickle]

I think its best to say that every drug is dangerous or perfect when used by a good clinician (or bad) in the right situation (or wrong).

 

[bubalus]

There was a study in Anesthesiology that showed that giving like 100mg of Lidocaine was really the only effective means to decrease the incidence of post succinylcholine induced myalgias. I do that every time prior to giving sux. If I have some patient as big as the state of NJ that I think is going to give me one iota of trouble during induction, though.....they gets the sux and hopefully aren't sore as hell the next day. Better some temporary pain than the more permanent death.

1: Anesthesiology. 2005 Oct;103(4):877-84.
Comment in:
Anesthesiology. 2006 Jul;105(1):222-3; author reply 223.
Anesthesiology. 2006 Jul;105(1):222; author reply 223.
Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials.Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MR.
Department of Anesthesiology and Critical Care Medicine, University Hospital of the Saarland, Homburg, Germany.

Fifty-two randomized trials (5,318 patients) were included in this meta-analysis. In controls, the incidence of fasciculation was 95%, and the incidence of myalgia at 24 h was 50%. Nondepolarizing muscle relaxants, lidocaine, or magnesium prevented fasciculation (number needed to treat, 1.2-2.5). Best prevention of myalgia was with nonsteroidal antiinflammatory drugs (number needed to treat, 2.5) and with rocuronium or lidocaine (number needed to treat, 3). There was a dose-dependent risk of blurred vision, diplopia, voice disorders, and difficulty in breathing and swallowing (number needed to harm, < 3.5) with muscle relaxants. There was evidence of less myalgia with 1.5 mg/kg succinylcholine (compared with 1 mg/kg). Opioids had no impact. Succinylcholine-induced fasciculation may best be prevented with muscle relaxants, lidocaine, or magnesium. Myalgia may best be prevented with muscle relaxants, lidocaine, or nonsteroidal antiinflammatory drugs. The risk of potentially serious adverse events with muscle relaxants is not negligible. Data that allow for a risk-benefit assessment are lacking for other drugs.

 

[MTGas2B]

My first choice, in the OR, is to use the drug I know my attending prefers. 🙂 Usually makes the day go better if I don't argue with them. I have intubated without NMBs. I've done it with a sevo mask induction. Oto patient, nasty peritonsilar tumor scary airway. The other drug that works nice for non-NMB intubations in remi.

When I intubate on my own (floor intubations) I only use two drugs, Roc and etomidate. That's all I keep in my pocket, along with an eschmann. RT shows up with the rest. If I really need sux (that is I need really fast offset) at this stage in my training, I probably need my attending near by. Plus, at our trauma center many of the patients needing to be intubated in the floor or the unit are burn patients, neuro injuries, been sitting in bed for who knows how long.

I've been burned by propofol during urgent intubations, but that's a whole seperate topic.

 

[BlackSails]

You couldn't be more wrong... death is a possible side effect of every drug.

Several (3 or 4) anesthesiologists who worked on cases that ive watched made a point of showing me all the nice drugs in their drawers, and telling me that they could kill a man with any of them.

 

[OldManDave]

It's funny that you keep seeing this over and over again:
A single incident caused by some unfortunate situation, triggering a new institutional policy, based on reaction rather than logic!
So let's say for the sake of argument that he had used Rocuronium, would they have banned it as well?
Every drug we use is by definition a poison, and muscle relaxants particularly have a therapeutic index that equals 1, meaning your lethal dose and therapeutic dose are the same! The reason why every patient that gets these drugs doesn't die is that they are usually given by trained and knowledgeable people who can prevent that from happening.
So, in other words, the problem is usually not in the drug but in the provider.

Plankton,

You hit upon a chilling point that I think many of us forget once we survive our CA-1 year. In essence, EVERYTIME we induce someone, we are, in effect, delivering a letahl injection. Were it not for our knowledge, training & equipment - pts would be dropping like flies. That is not to make us sound grandiose, but to give food for thought & hopefully make all of us at least have this in the periphery of our minds every time we care for a patient. Our responsibilities are immense & the implications of errors even greater.

I was told during my 3rd or 4th day as a CA-1 that, "Anesth is the only specialty where you can take a young, healthy patient & kill them in under 3 minutes by simply f-ing up!"

 

[Arch Guillotti]

My first choice, in the OR, is to use the drug I know my attending prefers. 🙂 Usually makes the day go better if I don't argue with them. I have intubated without NMBs. I've done it with a sevo mask induction. Oto patient, nasty peritonsilar tumor scary airway. The other drug that works nice for non-NMB intubations in remi.

When I intubate on my own (floor intubations) I only use two drugs, Roc and etomidate. That's all I keep in my pocket, along with an eschmann. RT shows up with the rest. If I really need sux (that is I need really fast offset) at this stage in my training, I probably need my attending near by. Plus, at our trauma center many of the patients needing to be intubated in the floor or the unit are burn patients, neuro injuries, been sitting in bed for who knows how long.

I've been burned by propofol during urgent intubations, but that's a whole seperate topic.

Interesting. I have never used roc for a floor intubation. Usually I just give etomidate in order to try and keep them breathing. I have used sux twice and each time successfully intubated afterward unfortunately I think everyone has heard a story of somebody somewhere who gave sux and then could't intubate or ventilate. I find myself always carrying propofol as well. I think it helps in loosening up the jaw musculature sometimes when pts. are "clamped down". I will usually chase it with a little neo as well.