Minimal Intubating Dose of Succinylcholine: A Comparative Study of 0.4, 0.5 and 0.6 mg/kg Dose

Muscle relaxants are integral part of modern balanced anesthesia and succinylcholine, a depolarizing drug, is in use despite its adverse effects. The excellent intubating condition, fastest onset and shortest duration of action make it an excellent choice for anesthesiologists. The conventional dose of 1.5-2 mg/kg is commonly used for obtaining relaxation for intubation. This study was conducted with much smaller dose of succinylcholine as 0.4, 0.5 and 0.6 mg/kg to evaluate the acceptable intubating dose at 60 seconds, which was unlikely to have any untoward/side effects.

Hipertermia maligna / Malignant hyperthermia

Resumen: La hipertermia maligna es un raro desorden farmacogenético potencialmente mortal, que se presenta como una respuesta hipermetabólica a los anestésicos volátiles y relajantes musculares despolarizantes en individuos susceptibles. Esta susceptibilidad se asocia a mutaciones en tres genes: RYR1, CACNA1S y STAC3. Puede manifestarse con síntomas leves o como una crisis fulminante, con rabdomiólisis severa, fibrilación ventricular e insuficiencia renal y circulatoria aguda, por lo tanto, el pronóstico depende de qué tan pronto se sospeche del diagnóstico y qué tan rápido se inicie el tratamiento. El diagnóstico definitivo se basa en una prueba de sensibilidad en biopsia muscular fresca y en pruebas genéticas. La mejor manera de prevenir un evento es la detección precoz de los pacientes susceptibles así como contar con el equipo para responder ante una crisis en cada centro donde se administren anestésicos volátiles y la capacitación del personal. Esta revisión sintetiza los conceptos actuales clínicos y biomédicos para detección, prevención, diagnóstico y manejo de la hipertermia maligna.

Abstract: Malignant hyperthermia is a rare, life-threatening pharmacogenetic disorder which presents as a hypermetabolic response to volatile anesthetics and depolarizing muscle relaxants in susceptible individuals. This susceptibility is associated with mutations in three genes: RYR1, CACNA1S and STAC3. Can manifest with mild symptoms or as a fulminant crisis, with severe rhabdomyolysis, ventricular fibrillation and acute renal and circulatory failure, therefore the prognosis depends on how soon the diagnosis is suspected and how fast treatment is started. The definitive diagnosis is based on a fresh muscle biopsy sensitivity test and genetic testing. The best way to prevent an event is the early detection of susceptible, as well as have equipment to respond to a crisis in each center where volatile anesthetics are administered and the training of staff. This review synthesizes current clinical and biomedical concepts for detection, prevention, diagnosis and management of malignant hyperthermia.

Deficiencia de butirilcolinesterasa: Una revisión narrativa de la literatura / Butirilcholinesterase Deficiency: A Narrative Review of Literature

RESUMEN La butirilcolinesterasa es una enzima que metaboliza relajantes neuromusculares despolarizantes como la succinilcolina, fármaco de elección para procedimientos que requieran parálisis muscular a corto plazo como facilitar la intubación endotraqueal en pacientes sometidos a procedimientos de emergencia. La deficiencia de butirilcolinesterasa se define como la reducción cuantitativa de dicha enzima y su actividad para hidrolizar moléculas, constituyéndose en la principal causa de bloqueo neuromuscular prolongado tras la administración de relajantes neuromusculares como la succinilcolina. Es una condición patológica que puede ser de origen hereditario o adquirido; siendo más común la deficiencia enzimática de origen genético y de carácter autosómico recesivo, la cual se presenta aproximadamente en una de cada 3200 a 5000 personas en todo el mundo. Su manifestación clínica se caracteriza por relajación muscular persistente, la cual puede producir insuficiencia respiratoria aguda. El diagnóstico debe estar orientado a la identificación de sus características clínicas, la cuantificación serológica y el monitoreo neuromuscular. Debido a que no existe cura para esta deficiencia, el manejo debe estar orientado a realizar ventilación mecánica del paciente hasta que el medicamento empleado se metabolice por completo. Este artículo tiene como objetivo realizar una revisión del estado del arte, describiendo su epidemiología, etiología, fisiopatología, manifestaciones clínicas y actualidades en su diagnóstico y tratamiento.

ABSTRACT Butyrylcholinesterase is an enzyme that metabolizes depolarizing neuromuscular relaxants, such as succinylcholine, a chosen medication for procedures that require short-term muscular paralysis, to facilitate endotracheal intubation in patients undergoing emergency procedures, for example. Butyrylcholinesterase deficiency can be defined as a quantitative reduction of the enzyme and its activity to hydrolyze molecules, becoming the main cause of prolonged neuromuscular blockade after the administration of neuromuscular relaxants such as succinylcholine. It is a pathological condition that can be of either hereditary or acquired origin; being more common the enzymatic deficiency of genetic origin and of auto-somal recessive character, occurring in approximately one in 3,200 to 5,000 people worldwide. Its clinical manifestation is characterized by persistent muscle relaxation which can lead to acute respiratory failure. The diagnosis must be oriented to the identification of its clinical characteristics, serological quantification, and neuromuscular monitoring. Because a cure does not exist for this deficiency, management should be directed to mechanical ventilation of the patient, until the used drug is fully metabolized. This article aims to review the state of the art, describing its epidemiology, etiology, pathophysiology, clinical manifestations, and updates in its diagnosis and treatment.

Desarrollo tecnológico e introducción del inyectable succinilcolina 50 mg/mL en el cuadro básico de medicamentos nacional de Cuba / Technological development and introduction of the injectable succinylcholine 50 mg/mL in the basic table of national medicines of Cuba / Desenvolvimento tecnológico e introdução da succinilcolina injetável 50 mg/mL na mesa da medicina básica de Cuba

RESUMEN Introducción: El inyectable succinilcolina 50 mg/mL se utiliza para intubaciones traqueales rápidas. Objetivo: Desarrollar e introducir el inyectable succinilcolina 50 mg/mL en el cuadro básico de medicamentos. Tres variantes de formulación fueron diseñadas: dos con preservantes antimicrobianos y presentación (bulbos 6R y 10R) y una sin preservantes (bulbos 6R). Metodología: Se validaron los métodos empleados para el control de calidad y estabilidad. A los lotes elaborados a escala de laboratorio, piloto e industrial con la fórmula seleccionada se les realizó estudio de estabilidad acelerada y vida útil. Las variantes diseñadas evidenciaron adecuada calidad, la no preservada fue seleccionada para realizar lotes a diferentes escalas. Las técnicas cromatográficas empleadas para la cuantificación de la succinilcolina cumplieron con los criterios de validación establecidos. Resultados: Se demostró el desempeño de las pruebas de esterilidad y ensayo de endotoxinas bacterianas. El producto en estudio de estabilidad indicó un adecuado comportamiento físico, químico y micro-biológico durante el período evaluado. Se comprobó la factibilidad del desarrollo tecnológico, con la fórmula seleccionada para el inyectable succinilcolina 50 mg/mL. Se introdujo el inyectable en el cuadro básico de medicamentos nacional.

SUMMARY Introduction: The injectable succinylcholine 50 mg/mL is used for rapid tracheal intubations. Aim: To develop and introduce the injectable succinylcholine 50 mg/mL into the basic drug table. Three formulation variants were designed: two with antimicrobial and presentation preservatives (6R and 10R bulbs) and one unpreserved (6R bulbs). Methodology: The methods used for quality control and stability were validated. Laboratory, pilot and industrial-scale batches with the selected formula were studied for accelerated stability and service life. The designed variants showed adequate quality, selecting the non-preserved, to make batches at different scales. Chromatographic techniques used for the quantification of succinylcholine met established validation criteria. Results: The performance of sterility tests and bacterial endotoxin testing was demonstrated. The product under stability study indicated adequate physical and chemical behavior during the period evaluated. The feasibility of technological development was verified, with the formula selected for the injectable succinylcholine 50 mg/mL. Injectable was introduced in the national medicines basic table.

RESUMO Introdução: A succinilcolina injetável 50 mg/mL é utilizada para intubações traqueais rápidas. Objetivo: Desenvolver e introduzir a succinilcolina injetável 50 mg/mL na tabela básica de medicamentos. Três variantes de formulação foram projetadas: duas com conservantes antimicrobianos e apresentação (lâmpadas 6R e 10R) e uma sem conservantes (lâmpadas 6R). Metodologia: Foram validados os métodos utilizados para o controle de qualidade e estabilidade. Estudos acelerados de estabilidade e vida de prateleira foram realizados nos lotes produzidos em escala laboratorial, piloto e industrial com a fórmula selecionada. As variantes projetadas apresentaram qualidade adequada, a não preservada foi selecionada para a realização de lotes em diferentes escalas. As técnicas cromatográficas utilizadas para a quantificação da succinilcolina atenderam aos critérios de validação estabelecidos. Resultados: Foi demonstrado o desempenho dos testes de esterilidade e do ensaio de endotoxinas bacterianas. O produto em estudo de estabilidade indicou comportamento físico, químico e microbiológico adequado durante o período avaliado. Foi verificada a viabilidade do desenvolvimento tecnológico, com a fórmula selecionada para a succinilcolina injetável 50 mg/mL. O injetável foi introduzido na tabela nacional de medicamentos básicos.

Study on distribution of succinylcholine chloride at poisoning dose in rats by UHPLC-MS/MS analysis / 中国药理学通报

Aim To determine the distribution of succinylcholine chloride (Suc) at toxic dose in rats by establishing UHPLC-MS/MS analysis. Methods The rats were subcutaneously injected with three doses of Suc, and 4 h later, rat serum and major organs were taken for acetonitrile protein precipitation and purified by solid phase extraction with WCX column. Luna NH2 column (2 mm × 100 mm, 3 μm) was used for chromatography. The mobile phase was 0. 1% formic acid-acetonitrile isoelution. Mass spectrometry was carried outwith positive ion scanning multi-reaction monitoring mode (MRM). Qualitative and quantitative analysis was conducted on the ion pairs of Suc (m/z 145. 1→93.3, m/z 145.1→115.4). Results The detection limit of Suc was 0.01 μg · L-1, the recovery rate was 89. 5% ∼ 95. 4%, and the intraday and mtraday RSD was less than 15%. Except in the untreated rat, Suc was detected in the serum, heart, liver, kidney and other major organs from Sue-administered rats, and Suc content in the kidney was the highest among organs. Conclusions Sucat poisoning dose is distributed in the serum, heart, liver, kidney and other tissues. The content in the kidney is the highest; UHPLC-MS/ MS analysis is an effective and reliable method for detecting the drug content in Sue-poisoned rats.

Study on Comparative Effects of Rocuronium and Succinylcholine During Rapid Sequence Intubation

Background: Patients frequently need a rapid sequenceinduction (RSI) endotracheal intubation technique duringemergencies or electively to protect against aspiration inconditions like pregnancy, abdominal pathologies especiallyobstruction or ileus, neurologic disease, or in difficult airway.Traditionally succinylcholine has been the most commonlyused muscle relaxant for this purpose because of its fast onsetand short duration; unfortunately, it can have serious sideeffects. Rocuronium has been suggested as an alternative tosuccinylcholine for intubation.Methods: This study was done at department of anesthesiaSMBT Institute of Medical Science and Research Center,Dhamangaon Tal. Igatpuri, Nashik, Maharashtra, India. Thepatients were systematically randomized into three groups oftwenty each. Group A: Succinylcholine 1.5 mg/kg, Group B:Rocuronium bromide 0.6 mg/kg &Group C: Rocuroniumbromide 0.9 mg/kg.Intubating conditions, onset of action andadverse effects were observed.Results: It was observed that group A & group C patients hadexcellent intubation conditions with faster onset of action forgroup A patients. Adverse effects were not seen in any of thethree groups.Conclusion: Our study concludes that Succinylcholine is anideal agent for intubation in all surgical procedures. Intubatingconditions of Rocuronium bromide at a dose of 0.9mg/kg(3xED95) is comparable to Succinylcholine 1.5mg/kgat1minute. Rocuronium bromide 0.9mg/kg can be used safelyin patients where succinylcholine is contraindicated.

Study to assess the effect of mini-dose Succinylcholine for ease of laryngeal mask airway insertion

Background: Propofol as sole induction agent is often insufficient for the laryngeal mask airway insertion and higher doses are at times required. The present study proposes to assess the effectiveness of 0.25mg/kg mini dose succinylcholine towards facilitation of laryngeal mask airway (LMA) insertion.Methods: In a single blinded randomized controlled trial, 68 patients posted for elective general and orthopaedic surgery were equally assigned to two groups during LMA insertion: Group S (Study group)- patients received a bolus of succinylcholine 0.25mg/kg diluted in 2 ml of 0.9% sodium chloride. Group C (Control group)-patients received a bolus dose of 2 ml of 0.9% sodium chloride. The number of attempts required and ease of LMA insertion, hemodynamic parameters and adverse responses were noted and compared between the groups.Results: The LMA was inserted in first attempt in 32 (94.11%) patients in group S and in 24 (70.58%) patients in group C. The control group had 67.62% grade 1, 32.38% grade 2 and 0% grade 3, while succinylcholine group had 73.53% grade 1, 26.47% grade 2 and 0% grade 3. Hemodynamic parameters didn’t differ significantly between the two groups at any point, but significant difference was observed between occurrence of fasciculation, head and limb movements, sore throat and coughing.Conclusions: Succinylcholine does seem to help in insertion of the laryngeal mask airway but the results could not gain the level of statistical significance, partly attributed to small sample size.

Eficacia de tres dosis de succinilcolina en la inducción de secuencia rápida / Effectiveness of three doses of succinylcholine in rapid sequence induction

Introducción: La intubación de secuencia de rápida es un procedimiento que minimiza el tiempo necesario para asegurar la vía respiratoria en pacientes con alto riesgo de broncoaspiración. Objetivo: Comparar la eficacia de tres dosis de succinilcolina en la inducción de secuencia rápida en pacientes con estómago y la calidad de la intubación, así como los efectos secundarios de dichos fármacos. Métodos: Se realizó un estudio observacional, de corte transversal para evaluar la calidad de la intubación con inducción de secuencia rápida en pacientes de urgencia, con estómago lleno. Se administraron 0,4 mg/kg de succinilcolina al grupo I, 0,6 mg/kg al grupo II y 1 mg/kg al grupo III. En todos los pacientes se evaluó la vía respiratoria. El estudio se realizó en el Hospital Clínico Quirúrgico "Hermanos Ameijeiras" entre agosto de 2013 y 2016. Resultados: El tiempo de visualización de las cuerdas vocales fue rápido en los tres grupos. Los mejores resultados se obtuvieron en el grupo III, seguido del grupo II. Las condiciones de intubación fueron excelentes en el grupo III (90 %), buenas en grupo II (80 %) y regulares en el grupo I (70 %). Las variables hemodinámicas mostraron diferencias significativas entre grupos (p=0,008). Conclusiones: Se determinó la eficacia del empleo de tres dosis de succinilcolina en la inducción de secuencia rápida, con intubación óptima y segura cuando se empleó la succinilcolina a dosis de 1 mg/kg; pero con mayor porcentaje de alteraciones hemodinámicas como efectos adversos(AU)

Introduction: Rapid sequence intubation is a procedure that minimizes the time required to guarantee the respiratory airway in patients with high risk of bronchoaspiration. Objectives: To compare the quality of intubation with three doses of succinylcholine in rapid sequence induction in patients with full stomach, as well as the side effects of such drugs. Methods: An observational, cross-sectional study was carried out to assess the quality of intubation with rapid sequence intubation in emergency patients and with full stomach. The group I was administered 0.4 mg/kg of succinylcholine; the group II, 0.6 mg/kg; and the group III 1 mg/kg. The respiratory airway was assessed in all patients. The study was carried out in Hermanos Ameijeiras Clinical Surgical Hospital, between August 2013 and 2016. Results: The time of visualization of the vocal folds was fast in the three groups. The best results were obtained in the group III, followed by the group II. The intubation conditions were excellent in the group III (90%), good in the group II (80%), and fair in the group I (70%). The hemodynamic variables showed significant differences among the three groups (p=0.008). Conclusions: The effectiveness was determined of using three doses of succinylcholine in rapid sequence intubation, with optimal and safe intubation when succinylcholine was used at doses of 1 mg/kg, but it had a higher percentage of hemodynamic alterations as adverse effects(AU)

Succinylcholine Induced Masseter Muscle Spasm during Rapid Sequence Induction in a Pregnant Patient with Kypho- Scoliosis: Case Report

Isolated masseter spasm is a rare entity encountered in patients with neuromuscular disorders and is frequently associated with use of succinylcholine or halogenated inhalational anaesthetic during induction. We present a case of 32-year old primigravida obstetric patient with kypho-scoliosis posted for lower segment caesarean section that developed masseter muscle spasm (MMS) following administration of a standard dose of succinylcholine. The episode resolved spontaneously after 6-7 min without progression to malignant hyperthermia. The report highlights that an event of masseter muscle spasm, though, rarely encountered in life-time practice of an anaesthesiologist, may be successfully managed by maintaining oxygenation and ventilation till the crisis is tided over

A Comparative Study Of Onset Time And Intubating Condition For Different Dose Of Rocuronium In Burn And Non-Burn Patients

An aberrant pharmacodynamics responses to neuromuscular blocking drugs(NMBD)in burn patients increases the potential for lethal hyperkalemia with the administration of depolarizing muscle relaxant eg:succinylcholine and 2.5–5 folds increase in the dose of plasma concentration requirement for non–depolarizing muscle relaxants like :D–tubocurarine,metacurine,pancuronium,atracurium,vecuronium.Therefore Rocuronium may be the drug of choice in burn patients.This study was planned to assess the onset time and intubating conditions with two different doses of rocuronium in patients with thermal injury.It was concluded that in non–burn patient onset time(loss of response to TOF) was 85.5�4.8 sec with a dose of 0.9 mg/kg as compared to 1.2 mg/kg it was 60.55�70.4,while in burn patients (more than 30% burn area) these values were 120.83�6.81 sec and 86.16�5.2 respectively.

Duración del bloqueo neuromuscular con succinilcolina y su relación con niveles de colinesterasa plasmática en pacientes sépticos: Hospital Central Universitario Dr. Antonio María Pineda / Neuromuscular blockade duration with succinylcholine and its correlation with levels of plasma cholinesterase in septic patients: Hospital Central Universitario Dr. Antonio María Pineda

La succinilcolina es un fármaco neuromuscular despolarizante generalmente utilizado en el contexto de protocolo de intubación de secuencia rápida indicada en pacientes en los cuales es necesario asegurar la vía aérea en menos de sesenta segundos. Se realizó un estudio descriptivo transversal con el objetivo de determinar la duración del bloqueo neuromuscular con succinilcolina y los niveles de colinesterasa plasmática en pacientes sépticos intervenidos en el Hospital Central Universitario Dr. Antonio María Pineda. Se incluyeron 30 pacientes con sepsis con un promedio de edad de 49,6 ± 17,4 años y predominio del sexo masculino (70%); la principal indicación de cirugía abdominal fue obstrucción intestinal (36,6%) y peritonitis secundaria (23,3%). Los valores de colinesterasa plasmática se registraron disminuidos en 42,8% de los hombres y 33,3% de las mujeres encontrándose valores promedios de 5554,1 ± 1220,5 U/L y 4770,1 ± 1627,4 U/L, respectivamente. La duración del bloqueo neuromuscular fue mayor de 14 minutos en 66,6% de las mujeres; el promedio de duración fue de 14,4 ± 5,1 min (mujeres) y 9,4 ± 4,3 min en hombres. Hubo una pobre correlación entre los niveles de colinesterasa plasmática y la duración así como el tiempo de recuperación del bloqueo neuromuscular. En conclusión, el bloqueo neuromuscular prolongado debido a la baja actividad de la colinesterasa después de la administración de succinilcolina se presenta en menos de la mitad de los pacientes sépticos estudiados(AU)

Succinylcholine is a depolarizing neuromuscular drug generally used in the context of rapid sequence intubation indicated in patients in whom it is necessary to secure the airway in less than sixty seconds. A descriptive cross-sectional study was conducted in order to determine the duration of neuromuscular blockade with succinylcholine and plasma cholinesterase levels in septic patients admitted at Hospital Central Universitario Dr. Antonio Maria Pineda. A sample of 30 patients with sepsis were studied, with a mean age of 49.6 ± 17.4 years, predominantly male (70%). The main indication for abdominal surgery was intestinal obstruction (36.6%) and secondary peritonitis (23.3%). Diminished values of plasma cholinesterase were recorded in 42.8% of men and 33.3% of women; mean plasma levels were 5554.1 ± 1220.5 U/L and 4770.1 ± 1627.4 U/L, respectively. Duration of neuromuscular blockade was longer in women (66.6%) with an average duration of 14.4 ± 5.1 min and 9.4 ± 4.3 min for men. A poor correlation between cholinesterase plasmatic levels and duration as well as time of recovery of neuromuscular blockage was found. Prolonged neuromuscular blockade is due to low cholinesterase activity after administration of succinylcholine and occurs in less than half of septic patients studied(AU)

Manejo anestésico en la enfermedad de Von Recklinghausen. Reporte de un caso / Von Recklinghausen syndrome: Case report and anesthesis management

La enfermedad de Von Recklinghausen o neurofibromatosis tipo I es una enfermedad caracterizada por tendencia a la formación de tumores de tejidos del ectodermo y mesodermo. Existen diversas implicaciones anestésicas que incluyen la sensibilidad alterada a la succinilcolina y a relajantes neuromusculares no-despolarizantes, además de alteraciones en la anatomía normal de la vía aérea; se presenta el caso de una paciente de 58 años programada para la resección de tumoración cutánea temporo-parietal derecha, se utilizó succinilcolina como relajante muscular en donde a pesar de la vida media corta de éste, no se requirió de dosis subsecuentes durante el tiempo de duración de la cirugía; por lo que se corroboro una sensibilidad alterada hacia los relajantes musculares de tipo despolarizantes en este tipo de pacientes.

Von Recklinghausen disease or neurofibromatosis type I is a disease characterized by the tendency to form tissue tumors of the ectoderm and mesoderm. There are several anesthetic implications that include altered sensitivity to succinylcholine and non-depolarizing neuromuscular relaxants, in addition to alterations in the normal anatomy of the airway; we present the case of a 58 year old patient scheduled for the resection of the right temporo-parietal cutaneous tumor. Succinylcholine was used as a muscle relaxant. Despite its short half-life, no subsequent doses were required during the treatment period duration of surgery; Therefore, an altered sensitivity towards muscle relaxants of depolarizing type was corroborated in this type of patients.

Deficiencia de butirilcolinesterasa identificada después de la administración de succinilcolina. Reporte del caso / Butyrylcholinesterase deficiency identified after succinylcholine administration. Case report

RESUMEN La función principal de la enzima butirilcolinesterasa es hidrolizar ésteres exógenos como los que están presentes en el relajante neuromuscular succinilcolina, que se utiliza con frecuencia en procedimientos quirúrgicos de corta duración. Se considera que la herencia de butirilcolinesterasa atípica o deficiencia de butirilcolinesterasa es un rasgo autosómico recesivo que se presenta aproximadamente en una de cada 3200 a 5000 personas. Dicha deficiencia puede tener consecuencias graves en pacientes anestesiados con dicho relajante porque en ocasiones causa prolongación de la parálisis o apnea posoperatoria. Se presenta el caso de una paciente de 73 años admitida al servicio de cirugía para una tiroidectomía subtotal. Finalizada la intervención, no emergió espontáneamente del anestésico, presentó signos de relajación con mal esfuerzo inspiratorio y sin recuperar la respuesta neuromuscular; por ello se procedió a revertir con neostigmina, previa aplicación de atropina. La reversión falló por lo que fue trasladada a la unidad de cuidados intensivos. En los exámenes se halló reducido el nivel de colinesterasa sérica, lo que indicó una deficiencia de butirilcolinesterasa compatible con sus síntomas. Tal situación está descrita en la literatura médica.

SUMMARY The main function of the enzyme butyrylcholinesterase is to hydrolyze exogenous esters such as those present in the neuromuscular blocking agent succinylcholine, which is frequently used in short surgical procedures. Inheritance of atypical butyrylcholinesterase or butyrylcholinesterase deficiency is considered an autosomal recessive characteristic and occurs worldwide in approximately one out of 3200 to 5000 people. Such deficiency may have serious consequences for patients anesthetized with that relaxant because sometimes it causes an extension of paralysis or postoperative apnea. We report the case of a 73-year-old woman submitted to subtotal thyroidectomy. After surgery, she did not spontaneously emerge from anesthesia, had signs of relaxation with poor inspiratory effort, and no recovery of neuromuscular response. After application of atropine, reversal was attempted with neostigmine, but it failed, and she was transferred to the ICU. Laboratory results revealed a reduced level of serum cholinesterase indicating a deficiency in butyrylcholinesterase consistent with her symptoms. Such situation has been described in medical literature.

Identification of Impurities in Succinylcholine Chloride Raw Material by Two-dimensional UPLC-QTOF-MS / 中国药房

OBJECTIVE:To establish the method for the identification of impurities in succinylcholine chloride raw material. METHODS:Two-dimensional UPLC-QTOF-MS was adopted. One dimension chromatographic condition was Hypersil GOLD C18 column using buffer solution(22 mmol/L sodium pentanesulfonate+50 mmol/L sodium chloride+5 mmol/L sulphuric acid)as mobile phase A and acetonitrile as mobile phase B,volume ratio of mobile phase A to mobile phase B 95:5,column temperature of 40 ℃,flow rate of 1.0 mL/min,detection wavelength of 214 nm. Two-dimension chromatographic condition was ACQUITY UPLC BEH C18column using 0.1% ammonia as mobile phase A and acetonitrile as mobile phase B(gradient elution)with column temperature of 30 ℃ at flow rate of 0.4 mL/min. Ionization mode was ESI+ with capillary voltage of 2.5 kV,source temperature of 120 ℃,temperature of atomizing gas at 450 ℃,flow rate of atomizing gas at 900 L/h,acquisition mode of MSE. RESULTS:The succinic acid,succinyl chloride(intermediate),pyridine(reagent)and other impurities were detected in succinylcholine chloride by one dimensional method of HPLC. Other 4 obvious unknown impurities were named impurity 1,impurity 2,impurity 3 and impurity 4,among which the apparent content of impurity 2 was the highest. Two-dimensional method of HPLC-QTOF-MS deduced that the impurity 2 was dehydrogenate succinylcholine chloride and impurity 4 was succinylcholine chloride. The impurity 1 and impurity 3 were not detected in mass spectrum. CONCLUSIONS:Establish method for the identification of impurity in succinylcholine chloride raw material,and the results of research are used for the evaluation of the quality of the succinylcholine chloride raw material.

Estimation of the effect-site equilibration rate constant using the time-to-peak effect of muscle relaxants measured by train-of-four stimulation during general anesthesia induction / 대한마취과학회지

BACKGROUND: The concept of the effect-site concentration of anesthetic agents is important. The effect compartment model can be explained using the concepts of effect-site concentration and effect-site equilibration rate constant (k e0). This study confirms that the time-to-peak effect (tpe ) can be measured easily in clinical practice by applying a priming dose and train-of-four (TOF) during general anesthesia induction, and k e0 can be calculated from the tpe of the four muscle relaxants that are commonly used in general anesthesia. METHODS: Eighty patients who received general anesthesia were divided into the succinylcholine, rocuronium, atracurium, or vecuronium groups. Priming doses of muscle relaxants were administered. The effects of muscle relaxants were quantified by recording the twitch response of the adductor pollicis muscle after stimulating the ulnar nerve. The tpe was measured at the lowest TOF value. k e0 was calculated from the measured tpe . RESULTS: The k e0 values of the succinylcholine, rocuronium, atracurium, and vecuronium groups were 0.076 (0.030)/min, 0.228 (0.122)/min, 0.062 (0.011)/min, and 0.077 (0.019)/min, respectively. CONCLUSIONS: It is possible to estimate k e0 from the tpe of muscle relaxants using a priming dose and TOF during general anesthesia induction.

Análisis costo-efectividad de rocuronio y succinilcolina en tiroidectomías programadas / Cost-effectiveness analisys ofrocuronium and succinylcholine in programmed thyroidectomy

RESUMEN En el presente trabajo se realiza un análisis costo-efectividad de la succinilcolina y del rocuronio utilizados en la intubación de pacientes sometidos a tiroidectomía programada, mediante un estudio descriptivo prospectivo, donde se tuvo en cuenta la calidad de intubación, los tiempos de latencia y de relajación muscular, necesidad de reversión farmacológica del bloqueo neuromuscular, parámetros hemodinámicos, reacciones adversas y costos directos e indirectos en 30 pacientes sometidos al procedimiento. El análisis económico evidenció la existencia de diferencias significativas entre los costos asociados al tiempo de latencia de la relajación muscular. En cuanto a los costos relacionados al bloqueo muscular, se observó que el grupo con succinilcolina presentó unos costos totales de 10972 ± 341,7 pesos colombianos, mientras que con rocuronio fueron de 63088 ± 1.184 con valor P < 0,0001. La succinilcolina mostró mayor costo-efectividad al presentar menor tiempo de latencia, mejores condiciones de intubación, no provocar cambios hemodinámicos clínicamente significativos y bajo costo al ser comparado con rocuronio.

SUMMARY The goal of this work was to perform a cost-effectiveness analysis of succinylcho-line and rocuronium used in the intubation of patients undergoing programmed thyroidectomy was compared by means of a prospective descriptive study, which included intubation quality, latency and muscle relaxation times, pharmacological reversion Neuromuscular blockade, hemodynamic parameters, adverse reactions and direct and indirect costs in 30 patients undergoing the procedure. The economic analysis evidenced the existence of significant differences between the costs associated with the latency time of muscle relaxation. Regarding the costs related to muscle blockade, it was observed that the succinylcholine group performed a total cost of 10972 ± 341.7 Colombian pesos, while with rocuronium it was 63088 ± 1184 with P value < 0.0001. Succinylcholine showed higher cost/effectiveness when presenting the shortest latency time, the best intubation conditions, no clinically significant cost changes and low cost when compared to rocuronium.

Inadvertent injection of succinylcholine as an epidural test dose / Injeção inadvertida de succinilcolina como uma dose teste epidural

Abstract Background and objectives: Epidural action of neuromuscular blocking agents could be explained under the light of their physicochemical characteristics and epidural space properties. In the literature there are few cases of accidental neuromuscular agent's epidural administration, manifesting mainly with neuromuscular blockade institution or fasciculations. Case report: We report a case of accidental succinylcholine administration as an epidural test dose, in a female patient undergoing scheduled laparotomy, under combined general and epidural anesthesia. Approximately 2 min after the succinylcholine injection the patient complained for shortness of breath, while mild fasciculations appeared in her trunk and face, managed by immediate general anesthesia institution. With the exception of a relatively longer duration of neuromuscular blockade compared with intravenous administration, no neurological or cardiovascular sequelae or other symptoms of local or systemic toxicity were observed. Conclusions: Oral administration of diazepam seems to lessen the adverse effects from accidental epidural administration of succinylcholine. The meticulous and discriminative labeling of syringes, as well as keeping persistent cautions during all anesthesia procedures remains of crucial importance.

Resumo Justificativa e objetivos: A ação epidural de agentes bloqueadores neuromusculares pode ser explicada à luz de suas características físico-químicas e propriedades do espaço epidural. Na literatura existem poucos casos sobre a administração acidental em espaço epidural de agente neuromuscular que se manifesta principalmente com a instituição de bloqueio neuromuscular ou fasciculações. Relato de caso: Relatamos um caso de administração acidental de succinilcolina como uma dose teste epidural em uma paciente submetida à laparotomia programada, sob anestesia combinada geral e peridural. Aproximadamente dois minutos após a injeção de succinilcolina, a paciente queixou-se de falta de ar, enquanto fasciculações leves apareceram em seu tronco e rosto, tratadas com a instituição imediata de anestesia geral. Exceto pela duração relativamente longa do bloqueio neuromuscular em comparação com a administração intravenosa, sequelas neurológicas ou cardiovasculares ou outros sintomas de toxicidade local ou sistêmica não foram observados. Conclusões: A administração oral de diazepam parece diminuir os efeitos adversos da administração epidural acidental de succinilcolina. A meticulosidade e discriminação dos rótulos das seringas, bem como os cuidados persistentes mantidos durante todos os procedimentos de anestesia, continuam a ser de importância crucial.

Comparative evaluation of the effects of succinylcholine and rocuronium bromide in intraocular pressure

Background: Abdominal masses are often incidentally discovered by a parent while bathing the child, palpated unexpectedly on routine physical examination, or detected on abdominal imaging. Aim: The objective of the present study was to observe intra-abdominal tumors in children less than 12 year. Materials and methods: Total 17 intra-abdominal tumors of both sexes under 12 years of age was collected and analyzes to determine the various types of intra-abdominal tumors in relation to age and sex. Study was done for a period of 4 years. Results: 1 to 5 years are more common pediatric age group with tumors in abdomen with 52.7%. Age under 5 years age group with 70.6%. Males are most commonly observed with pediatric tumors with 58.8% of total subjects. Male: female ratio is 1.2:1. Neuroblastoma was the most common tumor constituting 41.18 % of all cases, followed by Wilms’ tumor (23.53%), hepatoblastoma (11.76%), teratoma and granulosa cell tumor (11.76%). Conclusion: Neuroblastoma was the most common tumor. Most of the tumors were noted in children less than 5 years of age.

Therapeutic Analysis of Two Kinds of Muscular Relaxation in Airway Foreign Body Removal Operation in Children / 中山大学学报(医学科学版)

[Objective] To observe the muscle relaxation clinical effect and the occurrence of intraoperative and postoperative complications,and the postoperative extubation and muscle strength recovery of Rocuronium and Succinylcholine in children during airway foreign body removal operation.[Methods] 80 cases of children (ASA I) with airway foreign body,among them,30 cases were older than 3 years old,were agreed to be on electively airway foreign body removal surgery.According to anesthesia induction,intravenous injection muscle relaxants were randomly divided into two groups (n =40):Rocuronium group (Group R) 0.9 mg/kg,Succinylcholine group (Group S) 1.5 mg/kg.According to the degree of muscle relaxation and operation time,if necessary,patients in Group R were added intravenous injection with Rocuronium 0.3 mg/kg,patients in Group S were added intravenous injection with Succinylcholine 0.5 mg/kg,the other drugs were consistent.Observation items included:the bronchoscopy conditions,the degree of muscle relaxation during operation,the numbers of intravenous injection muscle relaxant and atropine,the times of tracheal extubation,the dynamic observation about vital sign and hemodynamic intraoperative and postoperative,and the occurrence situation of complications,the incidence rate of muscle soreness in children older than 3 years old 24 h after operation.[Results] (1) There was no significant statistics difference between the two groups in the condition of bronchoscopy (P ＞ 0.05).(2)The patients in Group R were not required to add muscle relaxants and atropine,but all patients in Group S were required to add muscle relaxants and atropine (P ＜ 0.01).(3)The complications such as body movement,hypoxemia,restlessness during recovery period were happened in Group S,and in Group R,there were only 1 case of laryngeal spasm and restlessness during recovery period,there was statistically significant difference between the two groups (P ＜ 0.05).(4)The muscle strength recovery of 15 min in Group S was significantly higher than the Group R (P ＜ 0.01).(5) The time of tracheal cannula extubation was extended after the operation in Group R,there was statistically significant difference between the two groups (P ＜ 0.05).(6)30 cases patients older than 3 years old were followed up 24 h after operation,14 cases in Group S were found with the muscle soreness of trunk and limb,but none was found in 16 cases in Group R,there was statistically significant difference between the two groups (P ＜ 0.01).[Conclusions] The muscle relaxant effect was well during the removal of forcign body in children with Rocuronium and Succinylcholine,but the former provided a more security anesthesia condition,the muscle soreness of trunk and limb was not found in patient 24 h after operation;and the latter must continue to add drugs in operation,and the complications were found during and after the operation,the muscle soreness of trunk and limb was found in patient 24 h after operation.

Prophylactic use of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia: a randomized, double-blinded, placebo-controlled study / Uso profilático de pregabalina para prevenção de mialgia e fasciculação induzidas por succinilcolina: estudo randômico, duplo-cego e controlado por placebo

ABSTRACT BACKGROUND: Succinylcholine is commonly used to achieve profound neuromuscular blockade of rapid onset and short duration. OBJECTIVE: The present study compared the efficacy of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia. DESIGN: Prospective, randomized, placebo controlled, double blinded study. MATERIALS AND METHODS: Patients of both genders undergoing elective spine surgery were randomly assigned to two groups. Patients in Group P (pregabalin group) received 150 mg of pregabalin orally 1 h prior to induction of anesthesia with sips of water and patients in Group C (control group) received placebo. Anesthesia was induced with fentanyl 1.5 mcg/kg, propofol 1.5-2.0 mg/kg followed by succinylcholine 1.5 mg/kg. The intensity of fasciculations was assessed by an observer blinded to the group allotment of the patient on a 4-point scale. A blinded observer recorded postoperative myalgia grade after 24 h of surgery. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. RESULTS: Demographic data of both groups were comparable (p > 0.05). The incidence of muscle fasciculation's was not significant between two groups (p = 0.707), while more patients in group C had moderate to severe fasciculation's compared to group P (p = 0.028). The incidence and severity of myalgia were significantly lower in group P (p < 0.05). CONCLUSION: Pregabalin 150 mg prevents succinylcholine-induced fasciculations and myalgia and also decreases the fentanyl consumption in elective sine surgery.

RESUMO JUSTIFICATIVA: A succinilcolina é comumente usada para atingir um bloqueio neuromuscular profundo, de início rápido e de curta duração. OBJETIVO: Comparar a eficácia de pregabalina na prevenção de mialgia e fasciculação induzidas por succinilcolina. DESENHO: Estudo prospectivo, randômico, duplo-cego e controlado por placebo. MATERIAIS E MÉTODOS: Pacientes de ambos os sexos submetidos a cirurgia eletiva de coluna foram aleatoriamente divididos em dois grupos. Os pacientes do Grupo P (pregabalina) receberam 150 mg de pregabalina oral uma hora antes da indução da anestesia e os pacientes do Grupo C (controle) receberam placebo. A anestesia foi induzida com fentanil (1,5 mcg/kg) e propofol (1,5-2,0 mg/kg), seguidos de succinilcolina 1,5 mg/kg. A intensidade da fasciculação foi avaliada por um observador, cego para a alocação dos grupos, com uma escala de 4 pontos. Um observador cego registrou o grau pós-operatório de mialgia após 24 horas de cirurgia. Para o alívio da dor no pós-operatório, fentanil foi usado em sistema de analgesia controlada pelo paciente. RESULTADOS: Os dados demográficos de ambos os grupos eram comparáveis (p > 0,05). A incidência de fasciculação muscular não foi significativa entre os dois grupos (p = 0,707), enquanto mais pacientes do Grupo C apresentaram fasciculação de moderada a grave em relação ao Grupo P (p = 0,028). A incidência e a gravidade da mialgia foram significativamente menores no grupo P (p < 0,05). CONCLUSÃO: Pregabalina (150 mg) previne mialgia e fasciculação induzidas por succinilcolina, além de diminur o consumo de fentanil em cirurgia eletiva de coluna.