Succinylcholine born 1951 and still going faster. Matthias W. König, MD FAAP

Transcription

1 Succinylcholine born 1951 and still going faster Matthias W. König, MD FAAP

2 What kind of quack is he? Dr. Lupa never does this! OMG, you want to give SUX? I hope I don t get this question on the oral boards

3 We have combined results of 37 studies, with a total of 2690 patients, which compared the effects of succinylcholine versus rocuronium on intubation conditions. We have found that rocuronium is less effective than succinylcholine for creating excellent intubation conditions. Rocuronium should therefore only be used as an alternative to succinylcholine when it is known that succinylcholine should not be used. Perry JJ, Lee JS, Sillberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2008, Issue 2

4 On- and offset of succinylcholine 2mg/kg vs rocuronium 0.8 and 1.2mg/kg Sux high dose roc low dose roc Woolf et al.: Dose response of rocuronium bromide in children anesthetized with propofol: a comparison with succinylcholine, Anesthesiology 1997, 87(6):

5 On- and offset of succinylcholine 2mg/kg vs rocuronium 0.8 and 1.2mg/kg Sux high dose roc low dose roc Woolf et al.: Dose response of rocuronium bromide in children anesthetized with propofol: a comparison with succinylcholine, Anesthesiology 1997, 87(6):

6 Recovery of T1 after 0.6mg/kg rocuronium in infants and children Woelfel et al.: Effects of bolus administration of rocuronium in children during nitrous oxide-halothane anesthesia, Anesthesiology 1992, 76:

7 Laryngospasm is the #1 respiratory cause of cardiac arrests in children

8 Phase II block Pseudocholinesterase deficiency Hyperkalemia Bradycardia Myalgia Increased ICP Increased IOP Malignant Hyperthermia Masseter rigidity Malignant hyperthermia Anaphylaxis Rhabdomyolysis/myoglobinuria

9 mmh, it took them 43 years to notice this?

10 What really happened in the early 90 s? Case report in Anesthesiology 1992 FDA prepares label change to contain a warning Burroughs-Wellcome negotiates a contraindication Label change in effect November 1993

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12 Letters of concern published in Anesthesiology, Canadian Journal of Anaesthesia, and APSF Newsletter FDA meets with ASA, SPA and AAP representatives in June 1994 Dr Frederic Berry, UVA Dr Charles Coté, Children s Memorial Chicago Dr William Greeley, Duke & SPA Dr Steven Hall, SPA Dr Richard Kaplan, Children s National Medical Center Dr Robert Morell, Bowman Gray & APSF Dr William Ross, UVA Dr Theodore Striker, Cincinnati Children s & AAP Dr Thomas Wolfe, Riley Children s Indianapolis Dr Myron Yaster, Johns Hopkins & ASA Dr Marilyn Larach, Penn State Children s & North American Malignant Hyperthermia Association

13 Most cases reported in children < 8 years Many cases were poorly managed Muscle disease not always occult Halothane induction followed by succinylcholine Fewer cases in the UK & Canada

14 Complication Incidence per 10,000 Laryngospasm 175 Intraoperative awareness 80 Adverse effects from epidural 50 Aspiration 3.8 Cardiac arrest 1.5 Risk of being struck by lightning 1 Malignant hyperthermia Can t intubate, can t ventilate Hyperkalemic arrest after succinylcholine <0.02 HIV transmission through PRBC 0.02

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16 So what s the message? Succinylcholine still gives the best intubation conditions in the shortest time Rescue drug of first choice for laryngospasm without IV access The risk of hyperkalemia is exceedingly low when put into relevant clinical context

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18 Special thanks to Dr Berman, UNC, and Dr Striker, Cincinnati Children s Hospital, for their help with getting the historical facts straight