Our love-hate relationship with succinylcholine: Is sugammadex any better?

Abstract

Some years ago, a colleague provided anesthesia care to a healthy young adult male for an emergency open appendectomy. Standard of care at that time was a rapidsequence induction and intubation (RSI). Following denitrogenation, general anesthesia and muscle relaxation were achieved with fentanyl, thiopental, and succinylcholine. While maintaining cricoid pressure, tracheal intubation was successfully achieved using direct laryngoscopy. The appendectomy proceeded uneventfully. As the surgeon was closing the abdominal wound, he requested additional muscle relaxation, and accordingly, a small dose of intravenous succinylcholine (20 mg) was administered. Within one minute, asystole was witnessed on the electrocardiogram monitor and no carotid pulse was detected. Help was summoned and chest compressions were initiated. Cardiac rhythm, carotid pulse, and oxygen saturation quickly returned to normal after the administration of atropine. At the conclusion of the surgery and after tracheal extubation, the patient was taken to the recovery room awake in stable condition. The patient was informed that cardiac arrest had occurred in the operating room. Despite no apparent long-term postoperative sequelae, medicolegal action was pursued. Many meetings with the patient and his legal team subsequently followed, and although the case did not proceed to trial, all involved were left with a bad memory of the ugly side effects of succinylcholine.

Rapid Sequence Induction: Succinylcholin gegen Rocuronium – 3:0 für Succi?

“…Sie verweisen auf die geringeren Nebenwirkungen von Rocuronium, ggf. in Kombination mit Sugammadex [3,4]. Argumente wie "bei einer ,Can't intubate, can't ventilate'-Situation kann man mit Succinylcholin schneller zur Spontanatmung zurück" sind eher historisch, denn die neuen Leitlinien fordern sogar eine Vertiefung der Relaxierung in solchen Situationen [5].…”

In defense of succinylcholine

“…To the Editor, I was intrigued by the recent editorial in the Journal by Drs Hung, McKeen, and Huitink, 1 especially their prediction that, with the arrival of sugammadex, succinylcholine (Sux) ''will fade into obscurity.'' Like all great editorials, theirs is erudite, topical, and provocative.…”