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Suxamethonium: A Lifesaver in Critical Situations

Discover the importance of suxamethonium in managing laryngospasm and its efficacy compared to alternative medications. Explore the potential benefits of intramuscular and intra-osseous administration. Vote to preserve suxamethonium from obsolescence!

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Suxamethonium: A Lifesaver in Critical Situations

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  1. “This house believes that suxamethonium should not be consigned to the pharmacological graveyard” Mike Copp Cheltenham General Hospital

  2. What about suxamethoniun compared with rocuronium for RSI ?

  3. Professor Mirakhur’s work ‘Comparison of intubating conditions after administration of Org 9426 (rocuronium) and suxamethonium’ Cooper R, Mirakhur RK et al, BJA 1992

  4. Cooper R, Mirakhur RK et al, BJA 1992

  5. Cochrane Review Rocuronium versus succinylcholine for rapid sequence induction intubation Perry JJ, lee JS, Sillberg VAH, Wells GA Cochrane Database of Systematic Reviews 2008; Issue 2: CD002788

  6. “Overall, succinylcholine was superior to rocuronium, RR 0.86 (95%CI 0.80 to 0.92)”

  7. “...we found no difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium...”

  8. Succinylcholine better then rocuronium whether propofol or thiopental used

  9. ‘Succinylcholine or rocuronium? A meta-analysis of the effects on intubation conditions’ Suxamethonium 1-1.5 mg/kg compared with rocuronium 0.6-1.2 mg/kg Suxamethonium associated with 17.7% (95 C.I. 13 to 22) increase in excellent conditions and 5.1% (-7.3 to -2.9) reduction in unacceptable conditions Subgroup: excellent conditions in 84% of those receiving 1.5 mg/kg of suxamethonium vs 66% in those receiving 1-1.2 mg/kg rocuronium (Diff = 18.4% (C.I. 8.4-28.4)). Karcioglu et al, Int J Clin Pract 2006

  10. Laryngospasm • Clear role for a rapid onset, short duration agent for immediate ‘release’ of tight, life-threatening laryngospasm • Ease of use essential: high-pressure situation • Proven efficacy and clinical experience • Only a small dose needed • Vocal cords may be more sensitive to suxamethonium than other muscles?

  11. Laryngospasm • Two cases of layrngospasm during laryngeal surgery • Managed with 0.1 mg/kg suxamethonium • Relaxation of vocal cords seen by direct visualisation • Relaxation lasted about 2 min • Spontaneous ventilation preserved Chung and Rowbotham, Anaesthesia 1993

  12. Laryngospasm without IV access ‘Severe laryngospasm without intravenousaccess - a case report and literature review of the non-intravenous routes of administration of suxamethonium’ Seah and Chin, Sinagapore Medical Journal 1998 ‘Which port in a storm? Use of suxamethonium without intravenous access for severe larnygospasm’ (editorial) Walker and Sutton, Anaesthesia 2007

  13. Summary • Suxamethonium retains a clear role for certain situations, e.g. laryngospasm • Less complicated than alternatives for short procedures, e.g. ECT • Intramuscular use – an unusual but definite indication • Role of rocuronium for RSI does not (yet) have a long, proven track record

  14. Other routes of suxamethonium administration • Intramuscular • 1.5 – 4 mg/kg • Peak effect at 4 min (after 4 mg/kg) • Intubation possible after ~1-2 min in most patients • May be faster if mixed with hyaluronidase • Intra-osseous – onset as fast as intravenous, similar dosing

  15. Pharmacological The ^ Graveyard We’ve already lost: methohexitone, enflurane, cyclopropane, droperidol What’s next: etomidate, halothane, vecuronium, suxamethonium?

  16. You are about to vote: Think ahead to your next list - An elective patient, but... Perhaps a potentially reactive airway, or a difficult airway, or a child, or planning to use an LMA in a case with stimulation? Are you going to vote to lose the suxamethonium in the fridge next to you (or, perhaps even, already drawn up)?

  17. “This house understands that we CANNOT afford to let suxamethonium be consigned to the pharmacological graveyard”

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