Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks

Abstract

Background: Neuromuscular blocking agents (NMBAs) with a non-depolarising mechanism of action carry the risk of postoperative residual paralysis and are associated with postoperative pulmonary complications (POPC). Owing to the shorter duration of action, the depolarising NMBA succinylcholine may be associated with less postoperative residual paralysis, and hence fewer POPC. We tested the association of succinylcholine administration during anaesthesia and POPC. Methods: In a retrospective cohort study of registry data from two large US academic medical centres, 244 850 adult noncardiac surgical patients undergoing general anaesthesia were included. The primary outcome was POPC, defined as post-extubation haemoglobin oxygen de-saturation to <90%, or re-intubation requiring intensive care unit admission within 7 days after surgery. The association between succinylcholine and POPC and its dose-dependency were tested in a hierarchical fashion using a multivariable logistic regression model. Results: A total of 13 206 patients (5.4%) experienced POPC. Use of succinylcholine was associated with increased risk of POPC (adjusted odds ratio [OR Adj ]¼1.11; 95% confidence interval [CI], 1.06e1.16; P<0.001; adjusted risk¼5.18%; 95% CI, 5.06e5.30 without and 5.69%; 95% CI, 5.53e5.85 with succinylcholine), with a dose-dependent relationship (OR Adj ¼1.08; 95% CI, 1.05e1.11 per mg kg À1 ; P<0.001). In patients receiving non-depolarising NMBAs, succinylcholine further increased the risk of POPC (ORAdj¼1.08; 95% CI, 1.03e1.14; P¼0.001). The association between succinylcholine and POPC was modified (P¼0.03 for interaction) by the duration of surgery with higher odds of POPC in patients undergoing surgeries of <2 vs !2 h (OR Adj ¼1.24; 95% CI, 1.15e1.33 and 1.05; 95% CI, 1.00e1.10, respectively). Conclusions: In contrast to our prediction, succinylcholine administration was associated with an increased risk of POPC. This association was dose-dependent and magnified in surgeries of shorter duration.

Not another requiem for succinylcholine. Comment on Br J Anaesth 2020; 125: 423–5

“…The similarity in the incidence of POPC between patients who received succinylcholine and those who received nondepolarising neuromuscular blocking agents could therefore be attributable to the definition of POPC used by Sch€ afer and colleagues. 2 This observation does not strike us as 'another nail in the coffin of succinylcholine. '…”

“…EditordWe read the recent editorial in British Journal of Anaesthesia 1 entitled 'Another nail in the coffin of succinylcholine' with considerable interest. The authors' analysis of the observations of Sch€ afer and colleagues 2 on the association between succinylcholine administration and postoperative pulmonary complications (POPC) 2 was scholarly, as expected from these well-regarded experts. But despite their cogent arguments, we are not yet ready to accept their conclusion that there is no role for succinylcholine in modern anaesthesia practice.…”

Another nail in the coffin of succinylcholine?

“…In complete contrast, Sch€ afer and colleagues report in the British Journal of Anaesthesia a surprisingly high frequency of succinylcholine use in two distinguished university hospitals in the USA over a 12 year period between 2006 and 2017. 15 This latest contribution from the "Eikermann team", recognised for their thorough analysis of hospital registries, found that 14.2% of surgical patients had been treated with succinylcholine as the only neuromuscular blocking drug. 15 This rate is more than six-fold higher than the 2.3% observed in the European POPULAR study in 2014 and 2015.…”

“…15 This latest contribution from the "Eikermann team", recognised for their thorough analysis of hospital registries, found that 14.2% of surgical patients had been treated with succinylcholine as the only neuromuscular blocking drug. 15 This rate is more than six-fold higher than the 2.3% observed in the European POPULAR study in 2014 and 2015. 16 Another 23.8% of the patients were treated with a combination of succinylcholine and a non-depolarising neuromuscular blocking drug, resulting in 38.0% of anaesthetised patients receiving at least one dose of succinylcholine.…”

“…This frequent use of succinylcholine allowed Sch€ afer and colleagues 15 to address one of the hottest topics in the field of DOI of original article: 10.1016/j.bja.2020.05.059. Editorials -423 neuromuscular pharmacology from a very different perspective.…”