Stability of suxamethonium in pharmaceutical solution for injection by validated stability-indicating chromatographic method.

STUDY OBJECTIVE: To assess the stability of pharmaceutical suxamethonium (succinylcholine) solution for injection by validated stability-indicating chromatographic method in vials stored at room temperature. METHODS: The chromatographic assay was achieved by using a detector wavelength set at 218 nm, a C18 column, and an isocratic mobile phase (100% of water) at a flow rate of 0.6 mL/min for 5 minutes. The method was validated according to the International Conference on Harmonization guidelines with respect to the stability-indicating capacity of the method including linearity, limits of detection and quantitation, precision, accuracy, system suitability, robustness, and forced degradations. RESULTS: Linearity was achieved in the concentration range of 5 to 40 mg/mL with a correlation coefficient higher than 0.999. The limits of detection and quantification were 0.8 and 0.9 mg/mL, respectively. The percentage relative standard deviation for intraday (1.3-1.7) and interday (0.1-2.0) precision was found to be less than 2.1%. Accuracy was assessed by the recovery test of suxamethonium from solution for injection (99.5%-101.2%). CONCLUSION: Storage of suxamethonium solution for injection vials at ambient temperature (22°C-26°C) for 17 days demonstrated that at least 95% of original suxamethonium concentration remained stable.

Stability of Drugs Used in Helicopter Air Medical Emergency Services: An Exploratory Study.

OBJECTIVE: Transportation by air exposes drugs used in emergency medical services to vibrations. The aim of the study was to determine whether or not vibrations caused by a helicopter induce the degradation of 5 drugs used in this setting. METHODS: A longitudinal study in an operating medical helicopter along with a worst case was conducted. The studied drugs were 3 drugs labeled for refrigeration (cisatracurium, lorazepam, and succinylcholine) and 2 albumin solutions (human albumin 4% and 20%). These drugs were stored for 4 months according to the following conditions: inside a helicopter, worst case with exposure to extreme vibrations, at room temperature, and according to manufacturers' recommendations. Samples were analyzed with validated high-performance liquid chromatography assay methods. A drug was considered stable if the remaining drug content was above 90% of the label claim. Except for the albumin solutions, visual inspection was used to determine instability by the formation of aggregates. RESULTS: Only the samples stored at room temperature became unstable after 4 months. No difference in extreme foaming was observed in the albumin solutions. CONCLUSIONS: These data suggest that the effect of degradation of drugs caused by vibrations is negligible. Temperature was observed as the main cause of drug degradation.

Real-time detection, classification, and quantification of apneic episodes using miniature surface motion sensors in rats.

BACKGROUND: Real-time detection and classification of apneic episodes remain significant challenges. This study explores the applicability of a novel method of monitoring the respiratory effort and dynamics for rapid detection and classification of apneic episodes. METHODS: Obstructive apnea (OA) and hypopnea/central apnea (CA) were induced in nine tracheostomized rats, by short-lived airway obstruction and administration of succinylcholine, respectively. Esophageal pressure (EP), EtCO2, arterial O2 saturation (SpO2), heart rate, and blood pressure were monitored. Respiratory dynamics were monitored utilizing three miniature motion sensors placed on the chest and epigastrium. Three indices were derived from these sensors: amplitude of the tidal chest wall displacement (TDi), breath time length (BTL), that included inspiration and rapid expiration phases, and amplitude time integral (ATI), the integral of breath amplitude over time. RESULTS: OA induced a progressive 6.42 ± 3.48-fold increase in EP from baseline, which paralleled a 3.04 ± 1.19-fold increase in TDi (P < 0.0012), a 1.39 ± 0.22-fold increase in BTL (P < 0.0002), and a 3.32 ± 1.40-fold rise in the ATI (P < 0.024). During central hypopneic/apneic episodes, each sensor revealed a gradual decrease in TDi, which culminated in absence of breathing attempts. CONCLUSION: Noninvasive monitoring of chest wall dynamics enables detection and classification of central and obstructive apneic episodes, which tightly correlates with the EP.

[Storing succinylcholine in prehospital settings following the recommendations of the French National Agency for the safety of medicines]. / Conservation de la succinylcholine en préhospitalier après recommandations de l'Agence nationale de santé et du médicament.

OBJECTIVE: The French National Pharmaceuticals Agency (ANSM) has recommanded in July 2012 not to break the cold chain before using succinylcholine (Celocurine®). RESEARCH OBJECTIVE: to understand the pre-clinical evolution of the conservation modes of this curare. RESEARCH TYPE: Descriptive study before (year 2011) and after (year 2012). PATIENTS AND METHOD: Online survey to French Samu/Smur. DATA COLLECTED: SMUR location, conservation method at clinical base, in the mobile unit (UMH) and at the patient. Principal decision criteria: evolution of the conservation modes before and after the recommendation (qualitatives variables compared with a Fisher test). RESULTS: Out of 101 SAMU/SMUR, 62 answered. Conservation modes of succinylcholine vials were significantly different (P<0.001). Proper conservation was observed in 26 % of the cases before and 43 % after. Mobile units (UMH) equipped with a fridge increased from one out of two to 77 %. The lack of conservation modes passive or active on UMH went from 31 % to 3.4 % with isotherms bags with ice when a fridge was not available. The destruction of capsules at current temperature in a 24-hour period increased: 22 % before, 47 % after (P=0.04). CONCLUSION: After recommendations from ANSM, conservation modes and destruction of succinylcholine in a prehospital environment were significantly impacted.

Malignant hyperthermia in Canada: characteristics of index anesthetics in 129 malignant hyperthermia susceptible probands.

BACKGROUND: Between 1992 and 2011, 373 Canadian individuals with adverse anesthetic reaction were referred to the Malignant Hyperthermia Unit in Toronto, Ontario, Canada for malignant hyperthermia (MH) diagnostic testing. We analyzed the epidemiologic characteristics of the index adverse anesthetics for those probands who were confirmed to be MH susceptible. METHODS: One hundred twenty-nine proband survivors of adverse anesthetic reactions, whose MH susceptible status was confirmed by caffeine-halothane contracture testing were selected. Individuals were excluded if the index anesthetic record was not available for review. Data regarding demographics, clinical signs, laboratory findings, treatment, and complications were retrospectively compiled and analyzed. A Fisher exact test and χ test were applied to compare categorical variables. The Wilcoxon rank-sum test was applied with continuous variables. RESULTS: Young males (61.2%) dominated among selected patients. Seventeen of 129 (13.2%) patients had prior unremarkable anesthesia. Anesthetic triggers were volatile-only (n = 58), succinylcholine-only (n = 20), or both volatile and succinylcholine (n = 51). Eight (6.2%) cases occurred in the postanesthetic care unit. There were no reactions after discharge from the postanesthetic care unit. The most frequent clinical signs were hyperthermia (66.7%), sinus tachycardia (62.0%), and hypercarbia (51.9%). Complications occurred in 20.1% of patients, the most common complication being renal dysfunction. When 20 or more minutes between the first adverse sign and dantrolene treatment elapsed, complication rates increased to ≥30%. CONCLUSIONS: This is the first Canadian study in 3 decades to report nationwide data on MH epidemiology. Features that differ from earlier reports include a 15.5% incidence of reactions triggered by succinylcholine alone and lower complication rates. In agreement with previously published studies, we confirmed in this independent dataset that increased complication rates were associated with an increased time interval between the first adverse clinical sign and dantrolene treatment. This underscores the need for early diagnosis and rapid dantrolene access and administration in anesthetizing locations using either succinylcholine or volatile anesthetic drugs.

Cellular membrane phospholipids act as a depository for quaternary amine containing drugs thus competing with the acetylcholine/nicotinic receptor.

We previously demonstrated that ammonium- or guanidinium-phosphate interactions are key to forming noncovalent complexes (NCXs) through salt bridge formation with G-protein coupled receptors (GPCR), which are immersed in the cell membrane's lipids. The present work highlights MALDI ion mobility coupled to orthogonal time-of-flight mass spectrometry (MALDI IM oTOF MS) as a method to determine qualitative and relative quantitative affinity of drugs to form NCXs with targeted GPCRs' epitopes in a model system using, bis-quaternary amine based drugs, α- and ß- subunit epitopes of the nicotinic acetylcholine receptor' (nAChR) and phospholipids. Bis-quaternary amines proved to have a strong affinity for all nAChR epitopes and negatively charged phospholipids, even in the presence of the physiological neurotransmitter acetylcholine. Ion mobility baseline separated isobaric phosphatidyl ethanolamine and a matrix cluster, providing an accurate estimate for phospholipid counts. Overall this technique is a powerful method for screening drugs' interactions with targeted lipids and protein respectively containing quaternary amines and guanidinium moieties.

A new polymorph of succinylcholinium diiodide: comparison of succinylcholinium structures.

The title compound {systematic name: trimethyl[2-({4-oxo-4-[2-(trimethylazaniumyl)ethoxy]butanoyl}oxy)ethyl]azanium diiodide}, C(14)H(30)N(2)O(4)(2+)·2I(-), is a salt of the succinylcholinium cation. There is one formula unit in the asymmetric unit, represented by two anions and two halves of two cations which lie on centres of inversion. The component species are stabilized by electrostatic interactions, and C-H···I and C-H···O hydrogen bonds are also present.

Evaluating degradation with fragment formation of prehospital succinylcholine by mass spectrometry.

OBJECTIVES: Pharmaceutical manufacturers recommend refrigerating succinylcholine at a temperature range of 2-8 degrees C. With widespread use of prehospital succinylcholine on ambulances without refrigeration, it is important to understand the stability of this drug. Using mass spectrometry, this study investigated the degradation of the succinylcholine compound before and after its exposure to ambulance cabin temperatures, while removing light exposure. A 10% degradation threshold was set as not appropriate for human use, in accordance with U.S. Food and Drug Administration guidelines. METHODS: The study used 17 vials of succinylcholine sealed with duct tape in light-resistant bags. The bags were placed in climate controlled compartments in two ambulances: one stationed in a garage and the other stationed outdoors. Mass spectrometry analysis was used to examine drug degradation at Time 0, the 14th day of the first month, and monthly from Time 0 to 7 months. RESULTS: The degradation products of succinyl monocholine (SMC) and choline are already present at Day 0. Ten percent degradation was achieved at approximately 90 days into the experiment. Temperature in the ambulance climate controlled compartment was 70 degrees F, with a range from 56 to 89 degrees F during the 6-month time period. CONCLUSIONS: Identifiable breakdown fragments of succinylcholine have been identified using mass spectrometry with fresh drug upon receipt from the manufacturer. Ten percent degradation was not observed until approximately 90 days after being placed on ambulances. Temperature variations did not significantly contribute to degradation of succinylcholine, and it is safe for injection until approximately 90 days in similar climates.

Goodbye suxamethonium!

No drugs in anaesthesia are more problematic than suxamethonium. Yet, no drugs have survived as suxamethonium does in spite of crisis after crisis, and attempt after attempt at its replacement. For decades, suxamethonium has taught us neuromuscular pharmacology and provided us with an encyclopaedia of side effects, while benefiting millions and millions of our anaesthetised patients. With the arrival of sugammadex, it finally appears that suxamethonium can be retired. Suxamethonium has done its job and seen its days! The present review is intended to offer a eulogy for suxamethonium.

Determination of suxamethonium in a pharmaceutical formulation by capillary electrophoresis with contactless conductivity detection (CE-C(4)D).

A simple method based on capillary electrophoresis with a capacitively coupled contactless conductivity detector (CE-C(4)D) was developed for the determination of suxamethonium (SUX) in a pharmaceutical formulation. A hydro-organic mixture, consisting of 100mM Tris-acetate buffer at pH 4.2 and acetonitrile (90:10, v/v), was selected as background electrolyte (BGE). The applied voltage was 30kV, and the sample injection was performed in the hydrodynamic mode. All analyses were carried out in a fused silica capillary with an internal diameter of 50 microm and a total length of 64.5cm. Under these conditions, a complete separation between SUX, sodium ions and the main degradation products (choline) was achieved in less than 4min. The presence of acetonitrile in the BGE allowed a reduction of SUX adsorption on the capillary wall. The CE-C(4)D method was validated, and trueness values between 98.8% and 101.1% were obtained with repeatability and intermediate precision values of 0.7-1.3% and 1.2-1.6%, respectively. Therefore, this method was found appropriate for controlling pharmaceutical formulations containing suxamethonium and degradation products.

Amazing stability of phosphate-quaternary amine interactions.

We have previously used MALDI mass spectrometry to highlight ammonium- or guanidinium-aromatic interactions via cation-pi bonding and ammonium- or guanidinium-phosphate interactions through salt bridge formation. In the present work, the gas-phase stability and dissociation pathways of the interaction between phosphorylated peptides and compounds containing quaternary amines are demonstrated using electrospray ionization mass spectrometry. The presence of one quaternary amine in a compound is enough to form a noncovalent complex with a phosphorylated residue. However, if two quaternary amines are present in one molecule, the electrostatic interactions of the quaternary amines with the phosphate results in a "covalent-like" stability, and these bonds can withstand fragmentation by collision-induced dissociation at energies similar to those that fragment covalent bonds. Such interactions are important in accounting for physiological, pathophysiological, and pharmacological effects of many therapeutic compounds and small molecules containing quaternary amines or phosphates.

Succinylmonocholine analytics as an example for selectivity problems in high-performance liquid chromatography/tandem mass spectrometry, and resulting implications for analytical toxicology.

The determination and quantitation of drugs in biological matrices using high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) is becoming increasingly popular in analytical toxicology, while at the same time a growing awareness for the limits of this technique can be observed. Our group previously developed a rapid HPLC/ESI-MS/MS method for the detection and quantitation of succinylcholine (SUX) and succinylmonocholine (SMC) using ion-pairing extraction of samples with subsequent separation by gradient chromatography on a Synergi Hydro RP C18 column (4 microm, 150 x 2 mm). Identification of analytes was achieved in the multiple reaction monitoring (MRM) mode, using two characteristic ion transitions each, the respective analytes' retention time as well as co-elution of stable isotopic analogues. In both native serum as well as urine an interference with the main MRM transition of SMC was found to co-elute with this analyte, thus severely compromising the identification and quantitation of this target analyte. The interference was further shown to be eliminated from serum and urine by exposure to alkaline conditions and hence proven to share a key physicochemical property with SMC. The observed absence of the second and third most intense ion transitions of SMC in the unknown substance was the only useful distinction between both compounds.The detailed presentation of selectivity problems encountered during method development is intended to initiate further discussion on this yet underrepresented issue in HPLC/MS/MS. The present work emphasizes the need to monitor more than just one ion transition to confidently rule out signal interferences, ensure correct analyte identification as well as quantitation, and thus avoid false-positive results. In this context, the employment of minor MRM transitions for the quantitation and identification of a given analyte is presented as a satisfactory solution to HPLC/MS/MS selectivity problems, and proposed as a possible alternative to previously published approaches.

Synthesis and characterization of succinylcholine-d18 and succinylmonocholine-d3 designed for simultaneous use as internal standards in mass spectrometric analyses.

Succinylcholine (SUX) is a routinely used yet potentially lethal depolarizing muscle relaxant, the detection of which poses severe problems to the clinical or forensic analyst: within a few minutes after its in vivo administration, SUX is broken down via succinylmonocholine (SMC) to yield the endogenous substances succinic acid and choline. For quantification of SUX and SMC in biological matrices using mass spectrometric detection, appropriate internal standards, i.e. deuterated analogs of the above substances, are indispensable but not commercially available. Internal standards for both substances were hence tailored to fit the analytical needs. The two-step synthesis and subsequent characterization of SUX-d(18) and SMC-d(3) using a combination of nuclear magnetic resonance (NMR) spectroscopy, fast atom bombardment mass spectroscopy (FAB-MS) and high-performance liquid chromatography/tandem mass spectrometry (HPLC-MS/MS) are described. SUX-d(18) was synthesized by reacting ethanolamine and iodomethane-d(3) in a first quaternization step to choline-d(9), which in turn was esterified with succinyldichloride to yield the final product. SMC-d(3) was produced by esterification of succinic acid anhydride with dimethylaminoethanol, yielding desmethyl-SMC as intermediate product. The latter was then reacted with iodomethane-d(3) to obtain SMC-d(3). (1)H- and (13)C-NMR data support the identity and purity as well as the designated deuteration of both preparations, findings which were further confirmed by FAB-MS as well as HPLC-MS/MS. Owing to a thoughtful design, the obtained substances SUX-d(18) and SMC-d(3) feature different deuteration patterns at their trimethylamine moieties, and thus finally offer the possibility to simultaneously quantify SUX and SMC in clinical as well as forensic samples using isotope dilution mass spectrometry.

Stability of succinylcholine solutions stored at room temperature studied by nuclear magnetic resonance spectroscopy.

The effect of storage temperature on the stability of two succinylcholine chloride solutions (20 and 50 mg/ml) was evaluated. Molecular composition was analysed using nuclear magnetic resonance spectroscopy. At room temperature, the degradation rate constant was 1.2%/month for the 20 mg/ml solution and 2.1%/month for the 50 mg/ml solution. The corresponding monthly degradation rates for the two solutions were 0.18% and 0.30% when stored at 4 degrees C, and 5.4% and 8.1% when stored at 37 degrees C. If a 10% loss of potency is considered acceptable, then the 20 and 50 mg/ml succinylcholine solutions can be stored in emergency resuscitation carts at room temperature for 8.3 and 4.8 months, respectively.

Substrate and product trafficking through the active center gorge of acetylcholinesterase analyzed by crystallography and equilibrium binding.

Hydrolysis of acetylcholine catalyzed by acetylcholinesterase (AChE), one of the most efficient enzymes in nature, occurs at the base of a deep and narrow active center gorge. At the entrance of the gorge, the peripheral anionic site provides a binding locus for allosteric ligands, including substrates. To date, no structural information on substrate entry to the active center from the peripheral site of AChE or its subsequent egress has been reported. Complementary crystal structures of mouse AChE and an inactive mouse AChE mutant with a substituted catalytic serine (S203A), in various complexes with four substrates (acetylcholine, acetylthiocholine, succinyldicholine, and butyrylthiocholine), two non-hydrolyzable substrate analogues (m-(N,N,N-trimethylammonio)-trifluoroacetophenone and 4-ketoamyltrimethylammonium), and one reaction product (choline) were solved in the 2.05-2.65-A resolution range. These structures, supported by binding and inhibition data obtained on the same complexes, reveal the successive positions and orientations of the substrates bound to the peripheral site and proceeding within the gorge toward the active site, the conformations of the presumed transition state for acylation and the acyl-enzyme intermediate, and the positions and orientations of the dissociating and egressing products. Moreover, the structures of the AChE mutant in complexes with acetylthiocholine and succinyldicholine reveal additional substrate binding sites on the enzyme surface, distal to the gorge entry. Hence, we provide a comprehensive set of structural snapshots of the steps leading to the intermediates of catalysis and the potential regulation by substrate binding to various allosteric sites at the enzyme surface.