PDR MEMBER LOGIN:
  • PDR Search

    Required field
  • Advertisement
  • CLASSES

    Muscle Relaxants, Peripherally Acting

    BOXED WARNING

    Burns, digitalis toxicity, Guillain-Barre syndrome, hyperkalemia, trauma

    Succinylcholine is contraindicated in patients after the acute phase of injury after major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury. In such individuals, succinylcholine can cause severe hyperkalemia, which can result in serious cardiac arrhythmias and cardiac arrest. Risk of hyperkalemia increases over time and usually peaks 7 to 10 days after the injury; however, risk is dependent on the extent and location of injury, and the precise onset and duration of the risk period are unknown.[42039] Consider avoiding succinylcholine use or verify the patient's serum potassium concentration is within normal range before use in patients with electrolyte abnormalities, digitalis toxicity, chronic abdominal infections, subarachnoid hemorrhage, tetanus, disuse atrophy, Guillain-Barre syndrome, and degenerative nervous system disorders due to increased risk of developing severe hyperkalemia after succinylcholine administration in these patients.[42039] [52486] Do not use succinylcholine in any patient with a serum potassium of more than 5.5 mEq/L.[54427]

    Children, infants, malignant hyperthermia, myopathy, neonates, rhabdomyolysis

    Succinylcholine is contraindicated in persons with skeletal muscle myopathy or known or suspected genetic susceptibility to malignant hyperthermia. Succinylcholine can induce malignant hyperthermia in persons with known or suspected susceptibility based on genetic factors or family history, including those with certain inherited ryanodine receptor (RYR1) or dihydropyridine receptor (CACNA1S) variants. Multiple pathogenic variants of RYR1 and CACNA1S genes have been associated with malignant hyperthermia susceptibility in persons receiving succinylcholine. Assess variant pathogenicity based on prior clinical experience, functional studies, prevalence information, or other evidence. Concomitant use of volatile anesthetics may further increase the risk of malignant hyperthermia. In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute immediate treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspected, initiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.[42039]

    DEA CLASS

    Rx

    DESCRIPTION

    Parenteral, short-acting, depolarizing neuromuscular blocking agent (NMBA)
    Used for an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation
    Associated with histamine release and vagal stimulation

    COMMON BRAND NAMES

    Anectine, Quelicin

    HOW SUPPLIED

    Anectine/Quelicin/Succinylcholine/Succinylcholine Chloride Intramuscular Inj Sol: 1mL, 20mg
    Anectine/Quelicin/Succinylcholine/Succinylcholine Chloride Intravenous Inj Sol: 1mL, 20mg

    DOSAGE & INDICATIONS

    For muscular relaxation during non-emergent endotracheal intubation.
    NOTE: Limit the use of succinylcholine in pediatric patients for emergency intubation or when immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach) or for intramuscular use when a suitable vein is inaccessible.
    Intravenous dosage
    Adults

    0.6 mg/kg/dose IV. Dosage range: 0.3 to 1.1 mg/kg. Onset of intubating conditions is about 1 minute.

    Intramuscular dosage
    Adults

    3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 3 minutes.[42039]

    Adolescents

    3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Infants and Children 6 months to 12 years

    4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Infants 1 to 5 months

    4 to 5 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Neonates

    2 to 4 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [54427] [64934]

    For muscular relaxation during rapid-sequence intubation.
    Intravenous dosage
    Adults

    1.5 mg/kg/dose IV. Onset of intubating conditions is about 1 minute.

    Children and Adolescents 2 to 17 years

    1 to 1.5 mg/kg/dose IV. Onset of intubating conditions is 30 to 60 seconds.[42039] [44771] [54428]

    Infants and Children 6 to 23 months

    1 to 2 mg/kg/dose IV. Onset of intubating conditions is 30 to 60 seconds.

    Infants 1 to 5 months

    2 mg/kg/dose IV. Dosage range: 1 to 3 mg/kg/dose. Onset of intubating conditions is usually 30 to 60 seconds. May repeat 1 mg/kg/dose IV if intubating conditions are not attained within an adequate period (1 to 5 minutes). Max: 4 mg/kg per intubation attempt.

    Neonates

    2 mg/kg/dose IV. Dosage range: 1 to 3 mg/kg/dose. Onset of intubating conditions is usually 30 to 60 seconds. May repeat 1 mg/kg/dose IV if intubating conditions are not attained within an adequate period (1 to 5 minutes). Max: 4 mg/kg per intubation attempt.

    Intramuscular dosage
    Adults

    3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 3 minutes. [44868]

    Adolescents

    3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Infants and Children 6 months to 12 years

    4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Infants 1 to 5 months

    4 to 5 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [64934]

    Neonates

    2 to 4 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.[42039] [44872] [54427] [64934]

    For neuromuscular blockade during surgery.
    Intermittent Intravenous dosage
    Adults

    0.3 to 1.1 mg/kg/dose IV once, followed by 0.04 to 0.07 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response.

    Continuous Intravenous Infusion dosage
    Adults

    0.5 to 10 mg/minute continuous IV infusion; titrate to patient's twitch response. Usual dosage range: 2.5 to 4.3 mg/minute.

    For muscular relaxation during electroconvulsive therapy (ECT)†.
    Intravenous dosage
    Adults

    0.5 to 1.5 mg/kg/dose IV.

    †Indicates off-label use

    MAXIMUM DOSAGE

    Adults

    1.5 mg/kg/dose IV; 150 mg/dose IM.

    Geriatric

    1.5 mg/kg/dose IV; 150 mg/dose IM.

    Adolescents

    1.5 mg/kg/dose IV; 4 mg/kg/dose (Max: 150 mg/dose) IM.

    Children

    2 to 12 years: 1.5 mg/kg/dose IV; 4 mg/kg/dose (Max: 150 mg/dose) IM.
    1 year: 2 mg/kg/dose IV; 4 mg/kg/dose IM.

    Infants

    6 to 11 months: 2 mg/kg/dose IV; 4 mg/kg/dose IM.
    1 to 5 months: 3 mg/kg/dose IV (Max: 4 mg/kg IV per intubation attempt); 5 mg/kg/dose IM.

    Neonates

    3 mg/kg/dose IV (Max: 4 mg/kg IV per intubation attempt); 4 mg/kg/dose IM.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    ADMINISTRATION

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
    Do not mix succinylcholine with alkaline solutions; succinylcholine is acidic (pH 3 to 4.5) and may not be compatible with alkaline solutions having a pH more than 8.5 (e.g., barbiturate solutions).
    Accidental administration of neuromuscular blocking agents can be fatal. Store succinylcholine with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.
    Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of succinylcholine. Adequacy of respiration must be assured through assisted or controlled ventilation.
    To avoid distress to the patient, administer succinylcholine after unconsciousness has been induced; in emergent life-threatening situations, it may be necessary to administer succinylcholine before unconsciousness. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.
    Pretreatment with anticholinergic agents (e.g., atropine) may reduce the occurrence of bradyarrhythmias.[42039]
    Monitor heart rate, blood pressure, and oxygen saturation during neuromuscular blockade. Continuously monitor temperature and expired carbon dioxide to aid in early recognition of malignant hyperthermia. Monitor ECG; peaked T-waves are an early sign of cardiac arrest secondary to rhabdomyolysis and hyperkalemia.[42039] [44872]
    Storage: Store in refrigerator at 2 to 8 degrees C (36 to 46 degrees F) until vial expiration date. Multi-dose vials (20 mg/mL) and prefilled syringes (20 mg/mL) are stable for up to 14 days at room temperature without significant loss of potency.[42039] Independent studies have produced inconsistent results, but generally, the drug appears to be stable in unopened vials for 2 months or more at room temperature. Succinylcholine 20 mg/mL and 50 mg/mL products from various manufacturers have been shown to retain at least 90% potency when stored unopened at room temperature for periods ranging from 2 to 8.3 months, depending on the specific product.[58491] [58492] [58495] These results should not be extrapolated to environments with variable temperatures (e.g., emergency transport vehicles), where 10% degradation times have been reported to be shorter (1 to 3 months).[58495] [58496] Undiluted succinylcholine chloride (20 mg/mL) was stable for 45 days at room temperature (25 degrees C) and 90 days refrigerated (4 degrees C) in 12 mL polypropylene syringes.[58493]
    Updates for coronavirus disease 2019 (COVID-19): The FDA is allowing succinylcholine 20 mg/mL to be used beyond the labeled in-use time to help ensure access during COVID-related drug shortages. This period should be as short as possible, and for a maximum of 2 hours at room temperature or 4 hours when refrigerated. In-use time is defined as the maximum amount of time allowed to elapse between penetration of a closed-container system or after reconstitution of a lyophilized drug before patient administration.[65833]

    Intravenous Administration

    Due to the risk for rhabdomyolysis and life-threatening hyperkalemia that has occurred in pediatric patients with unidentified myopathies, reserve succinylcholine use in pediatric patients for emergent situations when immediate securing of the airway is needed; intermittent IV infusions and continuous IV infusions are generally not recommended in pediatric patients.[42039]
     
    Dilution
    Succinylcholine supplied in single-dose vials (100 mg/mL) must be diluted before use. Succinylcholine supplied in multiple-dose vials (20 mg/mL) or prefilled syringes (20 mg/mL) do not require dilution before use.
    Succinylcholine may be diluted to 1 mg/mL or 2 mg/mL in a solution such as 5% Dextrose Injection or 0.9% Sodium Chloride Injection.
    Prepare diluted solution for single patient use only.
    Storage: Store diluted solution in refrigerator at 2 to 8 degrees C (36 to 46 degrees F) and use within 24 hours of preparation. Discard unused portion.[42039]
     
    IV Push
    Administer via IV push.
     
    Continuous IV Infusion
    Monitor neuromuscular function with a peripheral nerve stimulator.[42039] [58502]

    Intramuscular Administration

    If necessary, succinylcholine may be administered intramuscularly to infants, older pediatric patients, or adults when intravenous access cannot be secured.
    In patients with laryngospasm, relief of the spasm sufficient for effective bag-valve-mask ventilation should occur within 30 seconds of administration to allow for adequate ventilation until intubating conditions are achieved.
    Inject deeply into a large muscle mass. Some experts recommend administration into the deltoid because the time to onset is typically more rapid than with administration into the quadriceps.

    STORAGE

    Anectine:
    - Avoid exposure to heat
    - Diluted product if not used immediately can be stored at 36 to 46 degrees F for up to 24 hours
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Protect from direct sunlight
    - Store in a dry, well ventilated place
    - Store in original container
    - Store in refrigerator at 2 to 8 degrees C (36 to 46 degrees F)
    - Syringe can be stored at room temperature up to 77 degrees F (25 degrees C) up to 14 days
    Quelicin:
    - Avoid exposure to heat
    - Diluted product if not used immediately can be stored at 36 to 46 degrees F for up to 24 hours
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Protect from direct sunlight
    - Store in a dry, well ventilated place
    - Store in original container
    - Store in refrigerator at 2 to 8 degrees C (36 to 46 degrees F)
    - Syringe can be stored at room temperature up to 77 degrees F (25 degrees C) up to 14 days

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    In emergent life-threatening situations, it may be necessary to administer succinylcholine before unconsciousness. Otherwise, administer succinylcholine only after unconsciousness has been induced; maintain adequate amnesia and analgesia throughout paralyzation. Neuromuscular blocking agents do not cause sedation or analgesia. Individualize succinylcholine doses. Use of a peripheral nerve stimulator will permit the most advantageous use of succinylcholine, minimize the possibility of overdosage or underdosage, and assist in the evaluation of recovery.[42039]
     
    Evaluate patients at risk for aspiration and regurgitation and monitor patients during anesthesia induction for clinical signs of vomiting and/or aspiration. Succinylcholine may increase intragastric pressure, resulting in regurgitation and possible aspiration of stomach contents.[42039]

    Accidental exposure, requires a specialized care setting, requires an experienced clinician

    Succinylcholine administration requires an experienced clinician who is familiar with its actions and the possible complications that may occur after its use as well as requires a specialized care setting where facilities for intubation, artificial respiration, oxygen therapy, and reversal agents are immediately available. Accidental exposure to a neuromuscular blocking agent may be fatal in a patient for whom it is not intended. Store succinylcholine with cap and ferrule intact and in a manner that minimizes the possibility of selecting the wrong product. Confirm proper medication selection and clearly communicate the intended dose.

    Neuromuscular blocking agent hypersensitivity

    Succinylcholine is contraindicated in patients with a known hypersensitivity to the drug. Assess patients for previous neuromuscular blocking agent hypersensitivity before administering succinylcholine, as cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported. Severe anaphylactic reactions, in some cases life-threatening and fatal, have been reported with neuromuscular blocking agents, including succinylcholine. Ensure the necessary precautions, such as the immediate availability of appropriate emergency treatment, are taken before administration.

    Burns, digitalis toxicity, Guillain-Barre syndrome, hyperkalemia, trauma

    Succinylcholine is contraindicated in patients after the acute phase of injury after major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury. In such individuals, succinylcholine can cause severe hyperkalemia, which can result in serious cardiac arrhythmias and cardiac arrest. Risk of hyperkalemia increases over time and usually peaks 7 to 10 days after the injury; however, risk is dependent on the extent and location of injury, and the precise onset and duration of the risk period are unknown.[42039] Consider avoiding succinylcholine use or verify the patient's serum potassium concentration is within normal range before use in patients with electrolyte abnormalities, digitalis toxicity, chronic abdominal infections, subarachnoid hemorrhage, tetanus, disuse atrophy, Guillain-Barre syndrome, and degenerative nervous system disorders due to increased risk of developing severe hyperkalemia after succinylcholine administration in these patients.[42039] [52486] Do not use succinylcholine in any patient with a serum potassium of more than 5.5 mEq/L.[54427]

    Acid/base imbalance, adrenal insufficiency, dehydration, electrolyte imbalance, hypercalcemia, hypermagnesemia, hypocalcemia, hypokalemia, hypothermia, metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis

    Various physiologic states can alter the expected effects of succinylcholine; carefully consider each patient's clinical condition when dosing succinylcholine and monitoring the patient. Cachectic and debilitated patients are more sensitive to neuromuscular blocking agents (NMBAs). Electrolyte imbalance can alter a patient's sensitivity to NMBAs. Hypercalcemia can decrease sensitivity to NMBAs, while most other electrolyte disturbances increase sensitivity (e.g., hypokalemia, hypocalcemia, hypermagnesemia). Correct electrolyte imbalance before administration and monitor neuromuscular transmission throughout use. Use succinylcholine cautiously in patients with conditions that may lead to electrolyte imbalances, such as adrenal insufficiency, severe vomiting or diarrhea, or massive transfusion. Severe acid/base imbalance may alter a patient's sensitivity to NMBAs: metabolic alkalosis, metabolic acidosis, and respiratory acidosis may enhance neuromuscular blockade and/or prolong recovery time, while respiratory alkalosis reduces the potency of the drug. Dehydration and hypothermia can also increase a patient's sensitivity to NMBAs.

    Asthma, chronic lung disease (CLD), chronic obstructive pulmonary disease (COPD), pulmonary disease

    Use neuromuscular blocking agents (NMBAs), including succinylcholine, with caution in patients with asthma or other pulmonary conditions. NMBAs stimulate histamine release, which could exacerbate asthma. Histamine-mediated effects (e.g., flushing, hypotension, bronchoconstriction) are uncommon in normal clinical usage of succinylcholine; however, use succinylcholine with caution in patients with any condition in which a significant release of histamine may be contraindicated. Also, NMBAs cause respiratory muscle paralysis; residual muscle weakness and decreased respiratory function (respiratory depression) can persist even after drug discontinuation. Use NMBAs with caution in patients with pulmonary disease and conditions associated with low pulmonary function reserve, such as chronic obstructive pulmonary disease (COPD) or neonatal chronic lung disease (CLD). Carefully monitor respiratory status and adequacy of ventilation after drug recovery until the patient is clearly stabilized.

    Myasthenia gravis, neuromuscular disease, obesity

    Use succinylcholine with caution in patients with neuromuscular disease (e.g., myasthenia gravis, myasthenic syndrome [Eaton Lambert syndrome]); prolonged or exaggerated neuromuscular blockade may occur after neuromuscular blocking agent use.[52486] [53645] Because myasthenia gravis involves destruction of acetylcholine receptors instead of receptor upregulation, as seen in other neuromuscular diseases, these patients tend to be less sensitive to the effects of succinylcholine compared to nondepolarizing agents (e.g., rocuronium, vecuronium).[53645] [54397] Additionally, patients with weak muscle tone or severe obesity are at an increased risk for airway and ventilation complications. Monitor patients carefully until recovery is fully complete.[48672] Use ideal body weight or adjusted body weight for dosing in obese and morbidly obese adult patients (body mass index 30 kg/m2 or more).[62859] 

    Anemia, cardiac disease, cholinesterase inhibitor toxicity, corticosteroid therapy, hepatic disease, infection, myxedema, peptic ulcer disease, pseudocholinesterase deficiency, renal disease

    Succinylcholine use is not recommended in patients with reduced plasma cholinesterase activity (pseudocholinesterase deficiency) due to the potential for prolonged neuromuscular blockade. Plasma cholinesterase activity may be diminished in the presence of genetic abnormalities of plasma cholinesterase (e.g., patients heterozygous or homozygous for atypical plasma cholinesterase gene), severe hepatic disease, severe renal disease, malignant tumors, infection, burns, anemia, decompensated cardiac disease, peptic ulcer disease, or myxedema. Patients homozygous for atypical plasma cholinesterase gene are extremely sensitive to the neuromuscular blocking effect of succinylcholine. Plasma cholinesterase activity may also be diminished by chronic administration of oral contraceptives, corticosteroid therapy, or certain monoamine oxidase inhibitors and by cholinesterase inhibitor toxicity due to irreversible inhibitors of plasma cholinesterase (e.g., organophosphate insecticides, echothiophate, and certain antineoplastic drugs). Treat resulting apnea or prolonged muscle paralysis with controlled respiration.[42039] [52486]

    Children, infants, malignant hyperthermia, myopathy, neonates, rhabdomyolysis

    Succinylcholine is contraindicated in persons with skeletal muscle myopathy or known or suspected genetic susceptibility to malignant hyperthermia. Succinylcholine can induce malignant hyperthermia in persons with known or suspected susceptibility based on genetic factors or family history, including those with certain inherited ryanodine receptor (RYR1) or dihydropyridine receptor (CACNA1S) variants. Multiple pathogenic variants of RYR1 and CACNA1S genes have been associated with malignant hyperthermia susceptibility in persons receiving succinylcholine. Assess variant pathogenicity based on prior clinical experience, functional studies, prevalence information, or other evidence. Concomitant use of volatile anesthetics may further increase the risk of malignant hyperthermia. In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute immediate treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspected, initiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.[42039]

    Glaucoma, ocular trauma

    Avoid succinylcholine use in patients in whom an increase in intraocular pressure is undesirable (e.g., narrow-angle glaucoma, penetrating ocular trauma) unless the potential benefit of its use outweighs the potential risk. Succinylcholine causes an increase in intraocular pressure.[42039]

    Bone fractures

    Use succinylcholine with caution in patients with bone fractures or muscle spasm as initial muscle fasciculations may cause additional injury. Monitor neuromuscular transmission and the development of fasciculations throughout the use of neuromuscular blocking agents.[42039]

    Labor, obstetric delivery, pregnancy

    Available data over decades of use with succinylcholine during pregnancy have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Plasma cholinesterase concentrations are decreased by approximately 24% during pregnancy and for several days postpartum which can prolong the effect of succinylcholine; therefore, some pregnant patients may experience prolonged apnea. Succinylcholine is commonly used for muscle relaxation during labor and obstetric delivery by cesarean section. Succinylcholine crosses the placental barrier in an amount dependent on the concentration gradient between the maternal and fetal circulations. Residual neuromuscular blockade (apnea and flaccidity) may occur in the newborn after repeated high doses to, or in the presence of atypical plasma cholinesterase in, the mother. Animal reproduction studies have not been conducted with succinylcholine.[42039]

    Breast-feeding

    There are no data on the presence of succinylcholine or its metabolite in human milk, the effects on the breast-fed infant, or the effects on milk production. However, the drug is rapidly eliminated and has poor oral absorption, so it is not likely to reach the circulation or cause adverse effects in breast-fed infants. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for succinylcholine and any potential adverse effects on the breast-fed child from succinylcholine or the underlying condition. 

    ADVERSE REACTIONS

    Severe

    renal failure (unspecified) / Delayed / Incidence not known
    cardiac arrest / Early / Incidence not known
    hyperkalemia / Delayed / Incidence not known
    rhabdomyolysis / Delayed / Incidence not known
    myoglobinuria / Delayed / Incidence not known
    asystole / Rapid / Incidence not known
    bradycardia / Rapid / Incidence not known
    bronchospasm / Rapid / Incidence not known
    anaphylactoid reactions / Rapid / Incidence not known
    angioedema / Rapid / Incidence not known
    malignant hyperthermia / Rapid / Incidence not known
    muscle paralysis / Delayed / Incidence not known
    apnea / Delayed / Incidence not known
    acute quadriplegic myopathy syndrome / Delayed / Incidence not known
    thrombosis / Delayed / Incidence not known
    keratitis / Delayed / Incidence not known
    increased intracranial pressure / Early / Incidence not known
    ocular hypertension / Delayed / Incidence not known

    Moderate

    hypertension / Early / Incidence not known
    erythema / Early / Incidence not known
    sinus tachycardia / Rapid / Incidence not known
    hypotension / Rapid / Incidence not known
    wheezing / Rapid / Incidence not known
    hypoxia / Early / Incidence not known
    respiratory depression / Rapid / Incidence not known
    myopathy / Delayed / Incidence not known
    dyspnea / Early / Incidence not known
    skin erosion / Delayed / Incidence not known
    conjunctivitis / Delayed / Incidence not known
    skin ulcer / Delayed / Incidence not known
    tolerance / Delayed / Incidence not known

    Mild

    urticaria / Rapid / Incidence not known
    rash / Early / Incidence not known
    flushing / Rapid / Incidence not known
    pruritus / Rapid / Incidence not known
    weakness / Early / Incidence not known
    xerophthalmia / Early / Incidence not known
    anxiety / Delayed / Incidence not known
    myalgia / Early / Incidence not known
    hypersalivation / Early / Incidence not known

    DRUG INTERACTIONS

    Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Acetazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
    Aliskiren; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Aliskiren; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Amphotericin B cholesteryl sulfate complex (ABCD): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
    Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
    Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
    Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
    Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Atracurium: (Major) If succinylcholine is used before atracurium, delay atracurium administration until recovery from succinylcholine-induced neuromuscular blockade begins. With succinylcholine as the intubating agent, use an initial atracurium dose of 0.3 to 0.4 mg/kg for adults under balanced anesthesia. Prior administration of succinylcholine quickens the onset and may increase the depth of the neuromuscular block induced by atracurium. The time to maximum block by atracurium is decreased by 2 to 3 minutes with prior use of succinylcholine.
    Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Bendroflumethiazide; Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
    Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate; Risedronate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
    Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
    Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Chloroquine: (Moderate) Concomitant use of succinylcholine and chloroquine may prolong neuromuscular blockade.
    Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Cisatracurium: (Moderate) The use of succinylcholine before cisatracurium administration may decrease the time to onset of maximum neuromuscular blockade but has no effect on the duration of neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
    Cyclophosphamide: (Major) Notify the anesthesiologist if a patient has been treated with cyclophosphamide within 10 days of general anesthesia. Cyclophosphamide treatment causes a marked and persistent inhibition of cholinesterase activity; prolonged apnea may occur with concurrent use of depolarizing muscle relaxants such as succinylcholine.
    Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
    Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Desflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and desflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia. Anesthetic concentrations of desflurane at equilibrium (administered for 15 or more minutes before testing) reduced the effective dose (ED95) of succinylcholine by approximately 30% compared to nitrous oxide/opioid anesthesia.
    Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Digoxin: (Moderate) Succinylcholine-induced potassium release from muscle cells may cause arrhythmias in patients receiving digoxin.
    Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Donepezil: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as donepezil.
    Donepezil; Memantine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as donepezil.
    Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
    Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Enalapril; Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Galantamine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as galantamine.
    Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
    Irinotecan Liposomal: (Moderate) Concomitant use of succinylcholine and irinotecan may prolong neuromuscular blockade. Irinotecan has anticholinesterase activity.
    Irinotecan: (Moderate) Concomitant use of succinylcholine and irinotecan may prolong neuromuscular blockade. Irinotecan has anticholinesterase activity.
    Isoflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and isoflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia. Anesthetic concentrations of isoflurane at equilibrium reduced the effective dose (ED95) of succinylcholine by approximately 25% to 40% or more compared to nitrous oxide/opioid anesthesia.
    Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Levobetaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
    Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Methazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
    Metoclopramide: (Moderate) Consider reducing the dose of succinylcholine when metoclopramide is given concomitantly. Concomitant use of succinylcholine and metoclopramide may prolong neuromuscular blockade, possibly due to plasma cholinesterase inhibition by metoclopramide.
    Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Mivacurium: (Major) If succinylcholine is used before mivacurium, delay mivacurium administration until recovery from succinylcholine-induced neuromuscular blockade begins. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of mivacurium.
    Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Neostigmine: (Moderate) Neostigmine does not antagonize, and may prolong, the Phase I block of succinylcholine. If given before succinylcholine is metabolized by cholinesterase, neostigmine may prolong rather than shorten paralysis. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). When this diagnosis is confirmed with a peripheral nerve stimulator, it may sometimes be reversed with anticholinesterase drugs, such as neostigmine. Anticholinesterase drugs may not always be effective.
    Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Nifedipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Oral Contraceptives: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Oxytocin: (Moderate) Concomitant use of succinylcholine and oxytocin may prolong neuromuscular blockade.
    Pancuronium: (Major) If succinylcholine is used before pancuronium, delay pancuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of pancuronium and increase its duration of action. If a small dose of pancuronium is given at least 3 minutes before administration of succinylcholine, in order to reduce the incidence and intensity of succinylcholine-induced fasciculations, this dose may induce a degree of neuromuscular block sufficient to cause respiratory depression in some patients.
    Penbutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Phenelzine: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of phenelzine; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Physostigmine: (Contraindicated) Physostigmine is contraindicated in patients receiving succinylcholine due to reduced plasma cholinesterase activity and prolonged neuromuscular blockade.
    Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
    Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Pyridostigmine: (Moderate) Pyridostigmine does not antagonize, and may prolong, the Phase I block of succinylcholine. If given before succinylcholine is metabolized by cholinesterase, pyridostigmine may prolong rather than shorten paralysis. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). When this diagnosis is confirmed with a peripheral nerve stimulator, it may sometimes be reversed with anticholinesterase drugs, such as pyridostigmine. Anticholinesterase drugs may not always be effective.
    Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
    Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
    Rivastigmine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as rivastigmine.
    Rocuronium: (Major) If succinylcholine is used before rocuronium, delay rocuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. The median duration of action of rocuronium 0.6 mg/kg administered after succinylcholine 1 mg/kg when T1 (defined as 3 twitches of train-of-four) returned to 75% of control was 36 minutes (range: 14 to 57, n = 12) vs. 28 minutes (range: 17 to 51, n = 12) without succinylcholine.
    Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Sevoflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and sevoflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia.
    Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Terbutaline: (Moderate) Concomitant use of succinylcholine and terbutaline may prolong neuromuscular blockade.
    Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Thalidomide: (Moderate) Use succinylcholine with caution in patients taking thalidomide due the risk of additive bradycardia.
    Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
    Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
    Thiotepa: (Moderate) Concomitant use of succinylcholine and thiotepa may prolong neuromuscular blockade. It has been theorized that this is caused by the anticholinesterase activity of anticancer drugs such as thiotepa.
    Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
    Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
    Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
    Vecuronium: (Major) If succinylcholine is used before vecuronium, delay vecuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. With succinylcholine as the intubating agent, use initial vecuronium doses of 0.04 to 0.06 mg/kg with inhalation anesthesia and 0.05 to 0.06 mg/kg with balanced anesthesia. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of vecuronium and its duration of action.
    Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.

    PREGNANCY AND LACTATION

    Pregnancy

    There are no data on the presence of succinylcholine or its metabolite in human milk, the effects on the breast-fed infant, or the effects on milk production. However, the drug is rapidly eliminated and has poor oral absorption, so it is not likely to reach the circulation or cause adverse effects in breast-fed infants. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for succinylcholine and any potential adverse effects on the breast-fed child from succinylcholine or the underlying condition. 

    MECHANISM OF ACTION

    Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction.[52452] Succinylcholine, a depolarizing neuromuscular blocking agent, produces skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate. Like ACh, it activates the receptor and causes membrane depolarization. Because succinylcholine is resistant to degradation by acetylcholinesterase, it remains bound to the receptor and thereby inhibits repolarization, resulting in an extended duration of neuromuscular blockade. Depolarization results in fasciculation of the skeletal muscles and muscle paralysis. Neuromuscular transmission is inhibited until succinylcholine is degraded by pseudocholinesterase.[42039] [52452] [52486] The paralysis after succinylcholine administration is selective. Initially, paralysis involves the levator muscles of the face and muscles of the glottis. Paralysis consecutively involves the intercostals, the diaphragm, and all other skeletal muscles. Muscle tone generally returns in the reverse order. Succinylcholine has no direct effect on the uterus, myocardium, or other smooth muscle structures. Succinylcholine does, however, stimulate both autonomic ganglia and muscarinic receptors, which may affect cardiac rhythm.[42039]

    PHARMACOKINETICS

    Succinylcholine can be administered intravenously or intramuscularly. Succinylcholine is highly ionized and has low lipid solubility; it is rapidly distributed into the extracellular space. Succinylcholine is rapidly hydrolyzed by plasma cholinesterase to succinylmonocholine, a metabolite which possesses clinically insignificant depolarizing neuromuscular blocking properties. Succinylmonocholine is further hydrolyzed to succinic acid and choline. Up to 10% of a succinylcholine dose is excreted unchanged in the urine.[42039] [52452]
     
    Plasma cholinesterase activity may be diminished in patients with genetic abnormalities of plasma cholinesterase, malignant tumors, infections, burns, anemia, decompensated heart disease, peptic ulcer, severe hepatic or renal dysfunction, or myxedema. In addition, chronic administration of drugs that antagonize plasma cholinesterase (e.g., oral contraceptives, glucocorticoids, monoamine oxidase inhibitors, cyclophosphamide) may decrease cholinesterase activity and increase duration of neuromuscular blockade.[42039] [52452]
     
    Affected cytochrome P450 isoenzymes and drug transporters: none

    Intravenous Route

    After administration of succinylcholine 0.3 to 1.1 mg/kg IV in adults, neuromuscular blockade occurs in approximately 1 minute, maximum blockade may persist for about 2 minutes, after which recovery takes place within 4 to 6 minutes. Patients with low pseudocholinesterase concentrations may experience longer durations of action.[42039]

    Intramuscular Route

    Onset of paralysis occurs in approximately 2 to 3 minutes after intramuscular administration. Patients with low pseudocholinesterase concentrations may experience longer durations of action.[42039]