been life-threatening and fatal. due to the potential severity of these reactions, the necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken. precautions should also be taken in those individuals who have had previous anaphylactic reactions to other neuromuscular blocking agents since cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported in this class of drugs. risk of death due to medication errors administration of succinylcholine chloride injection results in paralysis, which may lead to respiratory arrest and death; this progression may be more likely to occur in a patient for whom it is not intended. confirm proper selection of intended product and avoid confusion with other injectable solutions that are present in critical care and other clinical settings. if another healthcare provider is administering the product, ensure that the intended dose is clearly labeled and communicated. hyperkalemia (see box warning ) succinylcholine should be administered with great caution to patients suffering from electrolyte abnormalities and those who may have massive digitalis toxicity, because in these circumstances succinylcholine may induce serious cardiac arrhythmias or cardiac arrest due to hyperkalemia. great caution should be observed if succinylcholine is administered to patients during the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury (see contraindications ). the risk of hyperkalemia in these patients increases over time and usually peaks at 7 to 10 days after the injury. the risk is dependent on the extent and location of the injury. the precise time of onset and the duration of the risk period are undetermined. patients with chronic abdominal infection, subarachnoid hemorrhage, or conditions causing degeneration of central and peripheral nervous systems should receive succinylcholine with great caution because of the potential for developing severe hyperkalemia. malignant hyperthermia succinylcholine administration has been associated with acute onset of malignant hyperthermia, a potentially fatal hypermetabolic state of skeletal muscle. the risk of developing malignant hyperthermia following succinylcholine administration increases with the concomitant administration of volatile anesthetics. malignant hyperthermia frequently presents as intractable spasm of the jaw muscles (masseter spasm) which may progress to generalized rigidity, increased oxygen demand, tachycardia, tachypnea and profound hyperpyrexia. successful outcome depends on recognition of early signs, such as jaw muscle spasm, acidosis, or generalized rigidity to initial administration of succinylcholine for tracheal intubation, or failure of tachycardia to respond to deepening anesthesia. skin mottling, rising temperature and coagulopathies may occur later in the course of the hypermetabolic process. recognition of the syndrome is a signal for discontinuance of anesthesia, attention to increased oxygen consumption, correction of acidosis, support of circulation, assurance of adequate urinary output and institution of measures to control rising temperature. intravenous dantrolene sodium is recommended as an adjunct to supportive measures in the management of this problem. consult literature references and the dantrolene prescribing information for additional information about the management of malignant hyperthermic crisis. continuous monitoring of temperature and expired co2 is recommended as an aid to early recognition of malignant hyperthermia. other: in both adults and pediatric patients the incidence of bradycardia, which may progress to asystole, is higher following a second dose of succinylcholine. the incidence and severity of bradycardia is higher in pediatric patients than adults. whereas bradycardia is common in pediatric patients after an initial dose of 1.5 mg/kg, bradycardia is seen in adults only after repeated exposure. pretreatment with anticholinergic agents (e.g., atropine) may reduce the occurrence of bradyarrhythmias. succinylcholine causes an increase in intraocular pressure. it should not be used in instances in which an increase in intraocular pressure is undesirable (e.g., narrow angle glaucoma, penetrating eye injury) unless the potential benefit of its use outweighs the potential risk. succinylcholine is acidic (ph = 3.5) and should not be mixed with alkaline solutions having a ph greater than 8.5 (e.g., barbiturate solutions).

his range, neuromuscular blockade develops in about 1 minute; maximum blockade may persist for about 2 minutes, after which recovery takes place within 4 to 6 minutes. however, very large doses may result in more prolonged blockade. a 5 to 10 mg test dose may be used to determine the sensitivity of the patient and the individual recovery time (see precautions ). for long surgical procedures the dose of succinylcholine administered by infusion depends upon the duration of the surgical procedure and the need for muscle relaxation. the average rate for an adult ranges between 2.5 and 4.3 mg per minute. intermittent intravenous injections of succinylcholine may also be used to provide muscle relaxation for long procedures. an intravenous injection of 0.3 to 1.1 mg/kg may be given initially, followed, at appropriate intervals, by further injections of 0.04 to 0.07 mg/kg to maintain the degree of relaxation required. pediatrics for emergency tracheal intubation or in instances where immediate securing of the airway is necessary, the intravenous dose of succinylcholine is 2 mg/kg for infants and small pediatric patients; for older pediatric patients and adolescents the dose is 1 mg/kg (see box warning and precautions :pediatric use). it is currently known that the effective dose of succinylcholine in pediatric patients may be higher than that predicted by body weight dosing alone. for example, the usual adult iv dose of 0.6 mg/kg is comparable to a dose of 2-3 mg/kg in neonates and infants to 6 months and 1-2 mg/kg in infants up to 2 years of age. this is thought to be due to the relatively large volume of distribution in the pediatric patient versus the adult patient. rarely, intravenous bolus administration of succinylcholine in infants and pediatric patients may result in malignant ventricular arrythmias and cardiac arrest secondary to acute rhabdomyolysis with hyperkalemia. in such situations, an underlying myopathy should be suspected. intravenous bolus administration of succinylcholine in infants or pediatric patients may result in profound bradycardia or, rarely, asystole. as in adults, the incidence of bradycardia in pediatric patients is higher following a second dose of succinylcholine. whereas bradycardia is common in pediatric patients after an initial dose of 1.5 mg/kg, bradycardia is seen in adults only after repeated exposure. the occurrence of bradyarrhythmias may be reduced by pretreatment with atropine (see precautions : pediatric use). intramuscular use if necessary, succinylcholine may be given intramuscularly to infants, older pediatric patients or adults when a suitable vein is inaccessible. a dose of up to 3 to 4 mg/kg may be given, but not more than 150 mg total dose should be administered by this route. the onset of effect of succinylcholine given intramuscularly is usually observed in about 2 to 3 minutes.

atening and fatal. because these reactions were reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency (see warnings and precautions ).

n (14) anesthetized patients. the paralysis following administration of succinylcholine is progressive, with differing sensitivities of different muscles. this initially involves consecutively the levator muscles of the face, muscles of the glottis and finally the intercostals and the diaphragm and all other skeletal muscles. succinylcholine has no direct action on the uterus or other smooth muscle structures. because it is highly ionized and has low fat solubility, it does not readily cross the placenta. tachyphylaxis occurs with repeated administration (see precautions ). 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). this may be associated with prolonged respiratory muscle paralysis or weakness in patients who manifest the transition to phase ii block. when this diagnosis is confirmed by peripheral nerve stimulation, it may sometimes be reversed with anticholinesterase drugs such as neostigmine (see precautions ). anticholinesterase drugs may not always be effective. if given before succinylcholine is metabolized by cholinesterase, anticholinesterase drugs may prolong rather than shorten paralysis. succinylcholine has no direct effect on the myocardium. succinylcholine stimulates both autonomic ganglia and muscarinic receptors which may cause changes in cardiac rhythm, including cardiac arrest. changes in rhythm, including cardiac arrest, may also result from vagal stimulation, which may occur during surgical procedures, or from hyperkalemia, particularly in pediatric patients (see precautions : pediatric use). these effects are enhanced by halogenated anesthetics. succinylcholine causes an increase in intraocular pressure immediately after its injection and during the fasciculation phase, and slight increases which may persist after onset of complete paralysis (see warnings ). succinylcholine may cause slight increases in intracranial pressure immediately after its injection and during the fasciculation phase (see precautions ). as with other neuromuscular blocking agents, the potential for releasing histamine is present following succinylcholine administration. signs and symptoms of histamine mediated release such as flushing, hypotension and bronchoconstriction are, however, uncommon in normal clinical usage. succinylcholine has no effect on consciousness, pain threshold or cerebration. it should be used only with adequate anesthesia (see warnings ).