From the Guidelines
Succinylcholine is contraindicated in patients with a history of malignant hyperthermia, severe burns, crush injuries, spinal cord injuries, neuromuscular diseases, or myopathies due to the risk of life-threatening hyperkalemia. The use of succinylcholine in these conditions can lead to a dangerous hyperkalemic response, potentially causing cardiac arrhythmias or arrest 1.
Conditions to Avoid Succinylcholine
- Personal or family history of malignant hyperthermia
- Skeletal muscle myopathies, such as Duchenne muscular dystrophy
- Hyperkalemia
- Patients who have sustained major burns, crush injuries, or denervation injuries beyond 48-72 hours post-injury and up to 6 months afterward
- Penetrating eye injuries
- Increased intracranial pressure
- Pseudocholinesterase deficiency
In patients with myopathies like Duchenne muscular dystrophy, succinylcholine may trigger rhabdomyolysis, and its use is absolutely contraindicated due to the risk of fatal reactions 1. For patients with pseudocholinesterase deficiency, the drug's effect can be prolonged from minutes to hours, causing extended paralysis.
Alternative Agents
When succinylcholine is contraindicated but rapid sequence intubation is needed, alternative agents like rocuronium at 1.2 mg/kg can provide comparable intubating conditions. It is essential to consider the patient's medical history and current condition to determine the safest and most effective alternative agent 1.
Key Considerations
- Monitor patients closely for signs of hyperkalemia, such as cardiac arrhythmias or arrest, when administering succinylcholine
- Optimize the medical setting and personnel in attendance when patients with contraindications undergo general anesthesia or procedural sedation
- Have an ICU available for postprocedure care for patients with high-risk conditions 1
From the FDA Drug Label
Succinylcholine is contraindicated in persons with personal or familial history of malignant hyperthermia, skeletal muscle myopathies and known hypersensitivity to the drug. It is also contraindicated in patients after the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury, because succinylcholine administered to such individuals may result in severe hyperkalemia which may result in cardiac arrest
The contraindications for Succinylcholine (Suxamethonium) are:
- Personal or familial history of malignant hyperthermia
- Skeletal muscle myopathies
- Known hypersensitivity to the drug
- Patients after the acute phase of injury following:
- Major burns
- Multiple trauma
- Extensive denervation of skeletal muscle
- Upper motor neuron injury 2
From the Research
Contraindications for Succinylcholine (Suxamethonium)
The following are contraindications for succinylcholine:
- Hyperkalemia 3, 4, 5, 6
- Bedridden patients 3
- Rhabdomyolysis 3
- Muscle trauma 3
- Burns 3, 5, 6
- Infusion of neuromuscular blocking agents 3
- Acute renal failure 3
- Chronic renal failure 3
- Intraocular hypertension 3
- Intracranial hypertension 3
- Statin use 3
- Malignant hyperthermia 3, 6
- Neuromuscular disease 3, 7, 6
- Spinal cord sectioning 3
- Bradycardia < 50 bpm 3, 6
- Succinylcholine allergy 3
- Pseudo-cholinesterase deficiency 3, 6
- Anticonvulsant therapy 7
- Trauma patients 5
- Infection 5
- Immobility 5
- Acute respiratory acidosis 5