Depolarizing agent succinylcholine is very much popular as an intubating agent owing to its short duration of action. Following successful intubation, it is customary to give long or intermediate acting non-depolarizing muscle relaxants only after return from the effect of succinylcholine. The view in support of this is to identify those with atypical pseudocholineesterase or pseudocholineesterase deficiency. But is this custom really necessary? The number of patients with atypical pseudocholineesterase or pseudocholineesterase deficiency is very low and the only effective treatment is to keep this patient intubated and ventilated. Allowing patient to return from Sch can result in complete awareness and movements which is unwanted during surgery.
Dear Rajdip
If your patients are aware and moving, don't you think it is an important piece of information telling you that you are not using enough anaesthetic agent? It used to be (probably still is in ENT) a common practice to allow a patient to breathe spontaneously during volatile anaesthesia via a tracheal tube following scoline, so it's not the reversal of scoilne that is your problem, but light anaesthesia.
The problem with not observing a return to normal respiration after succinylcholine, is that if you subsequently use neostigmine to reverse the non-depolarising agent in a case of pseudocholinesterase deficiency you not only prolong the blockade from an inconvenient few hours, to one that may last overnight, but also have the added anxiety of trying to figure out what the problem is.
Although the inherited deficiency is rare (less than 1 in a thousand) there are several acquired causes of a relative deficiency. The one I used to see occasionally was associated with annual crop-spraying using organo-phosphates.
I rarely use scoline these days, preferring to intubate my patients using a non-depolarising relaxant.
Cheers
Chris
I agree with Dr. Christopher Charles Rout that the cause of patient awareness and movement following return from succinylcholine is inadequate anesthesia. Patient awareness is an important problem in India and atypical pseudocholineesterase or pseudocholineesterase deficiency is very low. So in this scenario it is probably safe to administer NDMR immediately after placing the patient on machine, as described by Dr. Natasa Viskovic Filipcic.
I agree with above. In some instances, you can intubate without paralysis. Also, when it come to the reversal, in order to reverse, you need to have at least one twitch (I am referring to the Train-of Four). If you don't and assume that it is OK to reverse, you will prolong paralysis for a long time. As, it was mentioned by Dr. Charles, there are two different issues here: patient awareness and moving. Patient awareness happens from not enough ANESTHESIA!!!!!! Either not enough gas, benzodiazepams, other amnestic agents. Even in the situations when you can hardly use any gas since the patient is unstable, there are other agents to prevent patients from remembering. Moving does not mean the patient is going to have a recall. Breathing does not mean the patient will have a recall. Patients spontaneously breath during surgeries all the time while intubated. Whether or not patient can breath is determined by the type of the surgery. It is the practice of anesthesia. There are multiple ways to intubate without compromising patients safety and well being while they are under anesthesia.
Tatyana
Dear Rajdip
Why not deepen the anaesthesia with volatile anaesthetic? Clearly NDMR would cause muscle paralysis and you may have false sense of security that your patient is adequately anaesthetised as he/she does not move to stimulation while in reality the patient is awake. Muscle relaxant is not anaesthetic
Adequate anesthesia should allow for tracheal intubation without the use of neuromuscular blocking agents in most cases. In my opinion, the use of succinylcholine should be reserved for rapid sequence inductions and similar emergencies. For the use of non-depolarizing agents there should be a clearly defined indication. Routine use should be discouraged.
I agree with Dr Tillmann Hein but with one reservation. The depth of anaesthesia required for atraumatic intubation is quite deep and perhaps undesirable in the compromised patient. With planned anaesthesia for such a patient it sometimes happens that one suspects a difficult intubation even though manual ventilation with a mask is no problem. In such a situation, shortlived relaxation with sux. allows inspection and intubation without resorting to very deep anaesthesia.
I have no objection to Dr.Cox' comment. Succinylcholine remains a very important tool in our pharmacological armamentarium. It should be used judiciously and not routinely.
If you use muscle relaxant use at peripheral nerve stimualtor (they are a standard of care)- they are cheap, harmless and in my mind, even with sugammadex, TOF should document it prior to reversal- this will cover Sux apnoea as well.
As for the "awareness" thing... relaxants are not sedative drugs!!! They amke awareness worse!!
In my mind- sux has the advantage over NDMRs as it gives a defined point of relaxant effect (fasiculation) where as NDMRs do not. Otherwise each used with knowledge and experience are fine.
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