Neuromuscular Blocking Agents for Rapid Sequence Intubation - Summary Table
(April 29, 2023)
RSI Rapid sequence intubation
AChR Acetylcholine receptor
⚠ Critical concerns about succinylcholine and hyperkalemia
Pathologic hyperkalemic response occurs by two distinct mechanisms: receptor upregulation and rhabdomyolysis. In either situation, potassium increase may approach 5 to 10 mEq per L within a few minutes and result in hyperkalemic dysrhythmias or cardiac arrest (3).
⚠ Succinylcholine absolute contraindications: situations that cause AChR upregulation (3):
Denervation: Spinal cord injury or stroke over 72 hours old
Present rhabdomyolysis or crush injuries >72 hours old
Burns over 72 hours old
Significant hyperkalemia (eg, suggested by characteristic changes on an electrocardiogram)
Black Box Warning
The US-FDA issued a black box warning regarding pediatric patients.
Text transcript: (7)
“WARNING: VENTRICULAR DYSRHYTHMIAS, CARDIAC ARREST, AND DEATH FROM HYPERKALEMIC RHABDOMYOLYSIS IN PEDIATRIC PATIENTS.
Acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death has occurred after the administration of succinylcholine to apparently healthy pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne muscular dystrophy.
When a healthy appearing pediatric patient develops cardiac arrest within minutes after administration of succinylcholine chloride injection, not felt to be due to inadequate ventilation, oxygenation or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. In the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.
Reserve the use of succinylcholine chloride injection in pediatric patients for emergency intubation or instances where immediate securing of the airway is necessary, e.g., laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible.
McManus MC. Neuromuscular blockers in surgery and intensive care, Part 2 [published correction appears in Am J Health Syst Pharm 2002 Jan 1;59(1):16]. Am J Health Syst Pharm. 2001;58(24):2381-2395. doi:10.1093/ajhp/58.24.2381
AJHP (Open Access)
Naguib M, Samarkandi AH, El-Din ME, Abdullah K, Khaled M, Alharby SW. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg. 2006;102(1):151-155. doi:10.1213/01.ANE.0000181320.88283.BE
Brown CA, Sakles JC, Mick NW. The Walls Manual of Emergency Airway Management. 5th edition. Philadelphia, PA. Wolters Kluwer; 2018.
NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Vecuronium bromide injection, powder, lyophilized, for solution. Updated in July 2018. Accessed April 12, 2023.
DailyMed 2018 - Vecuronium
Levin NM, Fix ML, April MD, Arana AA, Brown CA 3rd; NEAR Investigators. The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients. CJEM. 2021;23(4):518-527. doi:10.1007/s43678-021-00119-6
Springer (Open Access)
NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Rocuronium - rocuronium bromide injection, solution. Updated in October 2021. Accessed April 12, 2023.
DailyMed 2021 - Rocuronium
NIH-NLM (National Institutes of Health - National Library of Medicine). DailyMed. Label: Succinylcholine injection, solution. Updated in November 2022. Accessed April 12, 2023.
DailyMed 2023 - Succinylcholine
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