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 rapid-sequence 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. For decades, we have loved to hate succinylcholine. While most of us love the rapid onset and brief duration of action of succinylcholine at critical moments in airway management, such as RSI, we hate the array of adverse effects it produces—including its potential for cardiac arrest with repeat administration. Hunt and Taveau discovered suxamethonium, the international non-proprietary name for succinylcholine, in 1906 1 , but it was not introduced into clinical practice until the early 1950s. 2,3 Because of its unique characteristics of rapid onset and short duration of muscle paralysis, succinylcholine enjoyed superiority over other muscle relaxants as the ''gold standard'' 4 for RSI by clinicians for more than half a century. 5 According to a survey conducted in several European countries and the United States, 6 the most desirable features of succinylcholine reported were rapid onset (88%), short duration (64%), and effective relaxation (61%). The thousands of succinylcholine-related papers published since the 1950s have generated an expansive body of literature, including discoveries extending beyond its immediate effects of muscle relaxation. Indeed, it was research into the genetics of inactivation of succinylcholine by plasma cholinesterase that led to the development of the field of pharmacogenetics in the 1950s. 7 By 1957, succinylcholine had its own subject heading in Index Medicus! 8