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1
Gertler, Ralph. Intubationsbedingungen und Wirkprofil nach Org 9487 im Vergleich zu Succinylcholin bei Blitz-Narkoseeinleitung von Erwachsenen. [s.l.]: [s.n.], 1999.
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2
Kayla, Carl. Anectine (succinylcholine Chloride) Injection, Usp. Independently Published, 2018.
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3
HARRIS, Kayla. Anectine (succinylcholine Chloride) Injection, Usp. Independently Published, 2018.
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4
BRIGHT, James. Anectine (succinylcholine Chloride) Injection, Usp. Independently Published, 2018.
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5
The Effect of Rapacuronium or Succinylcholine on the Duration of Action of Rocuronium. Storming Media, 2001.
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6
Pollard, Brian J. Muscle relaxants in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0047.
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The place of neuromuscular blocking agents in the intensive care unit (ICU) has changed markedly over the last 20 years. Originally regarded as a mainstay of the process of ‘sedation’, they are now only used for specific indications. The principal disadvantage is probably the difficulty in neurological assessment when a muscle relaxant is used coupled with the increased risk of awareness, because inadequate sedation will be masked. Of the available agents, the intermediate acting ones are the most popular. The degree of relaxation can be readily controlled and they have few side effects. In the presence of renal and/or hepatic disease atracurium or cisatracurium are preferred. Succinylcholine is only used for securing the airway due to its very rapid onset of action. Rocuronium given in a higher dose also possesses a rapid onset in situations when succinylcholine might be contraindicated. When using a muscle relaxant, its effect should always be monitored with a simple train of four pattern of stimulation from a hand-held nerve stimulator. This will ensure that an adequate and not excessive block is secured. If a more rapid reversal is required then a dose of neostigmine with glycopyrrolate may be used. Alternatively, if rocuronium is the relaxant in use then the new agent sugammadex is effective.
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Kreeger, Renee, and James P. Spaeth. Muscular Dystrophy. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0058.
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Duchenne muscular dystrophy (DMD) is a complex disease characterized by multiple physiologic perturbations, progressively leading to cardiomyopathy, respiratory failure, and, eventually, death. Patients with DMD create unique challenges for the anesthesia team, including management of a difficult airway, avoidance of volatile anesthetics and succinylcholine, the need for respiratory support, and discussion of advance directives. A thorough and multidisciplinary collaborative approach must be utilized in the care of these patients for the entire perioperative period. This chapter uses a case example of a 17-year-old boy with DMD who presents for preoperative anesthesia consultation in anticipation of percutaneous endoscopic gastrostomy tube placement.
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Hunter, Jennifer M., and Thomas Fuchs-Buder. Neuromuscular blockade and reversal. Edited by Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0016.
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Over the past 70 years since the introduction of d-tubocurarine, the search for an ideal neuromuscular blocking agent has led to the development of the depolarizing drug, succinylcholine (suxamethonium), with its rapid onset of action and plasma metabolism, and a series of non-depolarizing agents of which there are two groups: benzylisoquinoliniums (e.g. atracurium, cisatracurium and mivacurium) and aminosteroidal agents (e.g. pancuronium, vecuronium and rocuronium). The need to monitor neuromuscular block perioperatively to ensure the appropriate dose of any neuromuscular blocking drug is given has led to the development of several nerve stimulation techniques. Particularly useful clinically are the train-of-four twitch response, double-burst stimulation, and the post-tetanic count. Their benefits and limitations are considered in this chapter. The most suitable equipment to monitor neuromuscular block and the appropriate anatomical sites for stimulation are discussed. To prevent residual block with its pathophysiological consequences such as upper airway and pharyngeal dysfunction and potential respiratory failure at the end of surgery, antagonizing agents are used. These are of two types: anticholinesterases such as neostigmine and edrophonium, and the γ-cyclodextrin, sugammadex. The pharmacodynamics and pharmacokinetics of neuromuscular blocking drugs and their antagonists are altered by the extremes of age, obesity, and several disease states including renal and hepatic failure, neuromuscular disorders, and critical illness. The altered response to all these drugs in these pathologies, which is related to their metabolism and excretion, is considered in detail, together with their other side-effects including the particular disadvantages to the use of succinylcholine.
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Heine, Christopher L. Malignant Hyperthermia. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0025.
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In this chapter we discuss the pathophysiology of malignant hyperthermia, identify those who are known to be susceptible to MH, delineate how best to prepare the operating for those patients, and provide step by step treatment recommendations for patients that develop MH. Malignant hyperthermia (MH) is a pharmacogenetic disease. When susceptible individuals are exposed to a triggering agent, a hypermetabolic response develops. Succinylcholine and halogenated, inhaled anesthetics are triggers of MH. The MH reaction is initiated by a rapid influx of calcium ions into the myoplasm that triggers uncontrolled muscle contraction. Prompt recognition and treatment of the reaction is critical to a successful outcome.
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Levy, David M., and Ieva Saule. General anaesthesia for caesarean delivery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0022.
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General anaesthesia (GA) is most often indicated for category 1 (immediate threat to life of mother or baby) caesarean delivery (CD) or when neuraxial anaesthesia has failed or is contraindicated. Secure intravenous access is essential. Jugular venous cannulation (with ultrasound guidance) is required if peripheral access is inadequate. A World Health Organization surgical safety checklist must be used. The shoulders and upper back should be ramped. Left lateral table tilt or other means of uterine displacement are essential to minimize aortocaval compression, and a head-up position is recommended to improve the efficiency of preoxygenation and reduce the likelihood of gastric contents reaching the oropharynx. Cricoid pressure is controversial. In the United Kingdom, thiopental remains the induction agent of choice, although there is scant evidence upon which to avoid propofol. In pre-eclampsia, it is essential to obtund the pressor response to laryngoscopy with remifentanil or alfentanil. Rocuronium is an acceptable alternative to succinylcholine for neuromuscular blockade. Sugammadex offers the possibility of swifter reversal of rocuronium than spontaneous recovery from succinylcholine. Management of difficult tracheal intubation is focused on ‘oxygenation without aspiration’ and prevention of airway trauma. The Classic™ laryngeal mask airway is the most commonly used rescue airway in the United Kingdom. There is a large set of data from fasted women of low body mass index who have undergone elective CD safely with a Proseal™ or Supreme™ laryngeal mask airway. Sevoflurane is the most popular volatile agent for maintenance of GA. The role of electroencephalography-based depth of anaesthesia monitors at CD remains to be established. Intraoperative end-tidal carbon dioxide tension should be maintained below 4.0 kPa.
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Felberg, Mary A. Mitochondrial Disease and Anesthesia. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0042.
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Mitochondrial disease is a genetically, biochemically, and clinically heterogeneous group of disorders that arise from defects in cellular oxidative phosphorylation, most commonly within the electron transport chain. All mitochondrial diseases involve disruption in energy production; clinical symptoms usually manifest in tissues with high energy demands although all organs may be affected. The extent of disease depends not only on the mitochondrial defect but on the numbers of dysfunctional mitochondria present in each tissue. Despite in vitro evidence that almost every anesthetic agent studied has been shown to decrease mitochondrial function, all anesthetic agents have been used safely. Discussion of the implications of mitochondrial disease for anesthetic management includes preoperative preparation, volatile and intravenous anesthetic agents, avoidance of succinylcholine, risk of malignant hyperthermia, perioperative fluids, and postoperative management.
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Dierdorf, Stephen F. Hyperkalemia/Hypokalemia. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0036.
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Disorders of potassium regulation (hyperkalemia/hypokalemia) are common in clinical medicine. Patients with neuromuscular disorders may develop hyperkalemia in response to inhaled, halogenated anesthetics and/or succinylcholine. This is most likely to occur in patients with occult myopathies. Potassium abnormalities have a wide range of potential implications for patient outcome. For instance, acute hyperkalemia has profound effects on the cardiac action potential that can lead to life-threatening dysrhythmias. In contrast is chronic hypokalemia, which occurs in 10% to 40% of patients receiving thiazide diuretics. In most cases, chronic hypokalemia does not cause perioperative complications unless intraoperative management alters potassium balance. In this chapter we present two clinical case scenarios which center around the underlying processes, detection, and treatment of each of these disorders.
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Thaisetthawatkul, Pariwat, and Eric Logigian. Guillain-Barré Syndrome and Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Pregnancy. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190667351.003.0026.
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Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are both immune-mediated diseases of the peripheral nervous system that typically present with symmetric, progressive muscle weakness, areflexia, and sensory symptoms or signs. GBS evolves rapidly with a nadir at 2–4 weeks usually with an antecedent viral illness, while CIDP progresses more slowly over months to years. GBS is sometimes complicated by life-threatening respiratory failure or dysautonomia. Onset of GBS and relapse of CIDP can occur during pregnancy or postpartum. But with appropriate supportive care and immunotherapy, maternal and fetal outcome in both conditions is typically excellent. The exception is fetal outcome in GBS triggered by maternal CMV or Zika infection transmitted to the fetus. Full-term vaginal delivery and regional anesthesia are preferred in maternal GBS and CIDP, but if C-section and general anesthesia are indicated, non-depolarizing agents such as succinylcholine should be avoided.
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Schakett, Brent, and Kathleen Chen. Laryngospasm. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0013.
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Laryngospasm is a complication that all pediatric anesthesia providers must be able to successfully diagnosis and treat. The risk factors include but are not limited to recent upper respiratory infection, history of asthma, preschool-age child, airway surgery, and light anesthesia. Laryngospasm can be defined as either partial laryngospasm with residual opening of the glottis or complete laryngospasm where there is no air movement. Prevention is obtained by limiting risk factors; waiting 6 to 8 weeks after upper respiratory infection symptoms have resolved if possible, smoking cessation, suctioning of residual secretions, and maintaining an adequate depth of anesthesia during crucial times like intubation and extubation. Treatment includes jaw thrust with positive pressure and 100% oxygen, followed by a subhypnotic dose of propofol if the laryngospasm does not break, then finally succinylcholine if all other methods have failed. With treatments that depress respiratory drive, delirium can result and must be diagnosed correctly.
15
Lin, Michael, and Erin S. Williams. Open Globe Repair. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0030.
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Penetrating eye injury in the pediatric patient is an emergency that requires careful management by the anesthesiologist to prevent further eye damage by the potential extrusion of vitreous fluid. Additionally, since these injuries are due to trauma, the patients typically are not adequately fasted for surgery. Thus prevention of aspiration of gastric contents must also be considered during the perioperative management of the child with an open globe injury. Depending on the risk of aspiration, the anesthesiologist must determine whether to use succinylcholine, a nondepoloarizing muscle relaxant, or no muscle relaxant at all, prior to laryngoscopy. A delicate balance must exist to achieve a smooth induction of anesthesia, blunted response to airway stimulation during laryngoscopy and intubation, and prevention of aspiration. During the perioperative period, the pediatric anesthesiologist can employ a variety of methods to limit the potential for increased intraocular pressure in the patient with penetrating eye trauma.
16
Thornton, Kevin, and Michael Gropper. Diagnosis, assessment, and management of hyperthermic crises. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0247.
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Malignant hyperthermia, the neuroleptic malignant syndrome (NMS), and the serotonin syndrome are the principal disorders associated with life-threatening hyperthermia in the intensive care unit. While each is a clinically unique entity, all can progress to multisystem organ dysfunction with acidosis, shock, and death. MH usually results from exposure to halogenated volatile anaesthetics and/or succinylcholine and symptoms of increased CO2 production and respiratory acidosis progress rapidly without prompt intervention, including the administration of dantrolene. NMS is a syndrome of rigidity and altered mental status seen most commonly in patients being treated with antipsychotic medications. The serotonin syndrome is seen in patients treated with serotonergic agents including selective serotonin reuptake or monoamine oxidase inhibitors and tricyclic antidepressants. The salient clinical finding is clonus, but agitation, altered mental status and autonomic dysfunction are common. Recognizing the non-specific features of these syndromes presents a challenge as they are life-threatening if not treated promptly and correctly with specific therapies.
17
Servin, Frédérique S., and Valérie Billard. Anaesthesia for the obese patient. Edited by Philip M. Hopkins. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0087.
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Obesity is becoming an epidemic health problem, and the number of surgical patients with a body mass index of more than 50 kg m−2 requiring anaesthesia is increasing. Obesity is associated with physiopathological changes such as metabolic syndrome, cardiovascular disorders, or sleep apnoea syndrome, most of which improve with weight loss. Regarding pharmacokinetics, volumes of distribution are increased for both lipophilic and hydrophilic drugs. Consequently, doses should be adjusted to total body weight (propofol for maintenance, succinylcholine, vancomycin), or lean body mass (remifentanil, non-depolarizing neuromuscular blocking agent). For all drugs, titration based on monitoring of effects is recommended. To minimize recovery delays, drugs with a rapid offset of action such as remifentanil and desflurane are preferable. Poor tolerance to apnoea with early hypoxaemia and atelectasis warrant rapid sequence induction and protective ventilation. Careful positioning will prevent pressure injuries and minimize rhabdomyolysis which are frequent. Because of an increased risk of pulmonary embolism, multimodal prevention is mandatory. Regional anaesthesia, albeit technically difficult, is beneficial in obese patients to treat postoperative pain and improve rehabilitation. Maximizing the safety of anaesthesia for morbidly obese patients requires a good knowledge of the physiopathology of obesity and great attention to detail in planning and executing anaesthetic management. Even in elective surgery, many cases can be technical challenges and only a step-by-step approach to the avoidance of potential adverse events will result in the optimal outcome.
18
Keienburg, Thomas. Der Einfluss einer Praecurarisierung mit Vecuronium, Pancuronium oder Atracurium auf das Wirkungsprofil von Succinylcholin. 1999.
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19
Gill, Steven J., and Michael H. Nathanson. Central nervous system pathologies and anaesthesia. Edited by Philip M. Hopkins. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0081.
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Anaesthesia induces changes in many organ systems within the body, though clearly none more so than the central nervous system. The physiology of the normal central nervous system is complex and the addition of chronic pathology and polypharmacy creates a significant challenge for the anaesthetist. This chapter demonstrates a common approach for the anaesthetist and specific considerations for a wide range of neurological conditions. Detailed preoperative assessment is essential to gain understanding of the current symptomatology and neurological deficit, including at times restrictions on movement and position. Some conditions may pose challenges relating to communication, capacity, and consent. As part of the consent process, patients may worry that an anaesthetic may aggravate or worsen their neurological disease. There is little evidence to support this understandable concern; however, the risks and benefits must be considered on an individual patient basis. The conduct of anaesthesia may involve a preference for general or regional anaesthesia and requires careful consideration of the pharmacological and physiological impact on the patient and their disease. Interactions between regular medications and anaesthetic drugs are common. Chronically denervated muscle may induce hyperkalaemia after administration of succinylcholine. Other patients may have an altered response to non-depolarizing agents, such as those suffering from myasthenia gravis. The most common neurological condition encountered is epilepsy. This requires consideration of the patient’s antiepileptic drugs, often relating to hepatic enzyme induction or less commonly inhibition and competition for protein binding, and the effect of the anaesthetic technique and drugs on the patient’s seizure risk. Postoperative care may need to take place in a high dependency unit, especially in those with limited preoperative reserve or markers of frailty, and where the gastrointestinal tract has been compromised, alternative routes of drug delivery need to be considered. Overall, patients with chronic neurological conditions require careful assessment and preparation, a considered technique with attention to detail, and often higher levels of care during their immediate postoperative period.
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Latorre, Federico. Atropin in der Pramadikation von Risikopatienten: Wirkung auf Herz-Kreislaufverhalten und Salivation bei Intubationsnarkosen mit Succinylcholin. 1989.
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21
Aschhoff, Susanne. Nachweis und Charakterisierung der aktivierenden und hemmenden Effekte von Succinylcholin, Butyrylcholin, Decamethonium und Hexamethonium auf die menschliche Acetylcholinesterase aus Erythrozyten und Basalganglien. 1998.
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