Suxamethonium is considered by many to be the best drug for providing ideal intubating conditions, short surgical procedures, and rapid sequence induction. However, its usefulness is limited by the frequent occurrence of adverse effects like postoperative myalgia. Therefore this study aimed to assess the prevalence and associated factors of postoperative suxamethonium-induced myalgia. An institutional-based cross-sectional study was conducted on 210 patients who underwent surgery with general anesthesia. The data was collected by using structured and pretested questionnaires and analyzed using SPSS version 20.0. Logistic regression was conducted to identify significant predictors based on a P-value of less than 0.05 with a 95% confidence level. Among 210 patients the prevalence of suxamethonium-induced postoperative myalgia in the first 48 h was 88 (41.9%). Patients having previous anesthesia and surgical exposure (AOR 5.29, 95% CI 1.86-15.05), patients having a co-existing disease (AOR 2.69, 95% CI 1.08-6.67), patients that had not taken premedication (analgesia) (AOR 4.64, 95% CI 1.69-12.74), anesthesia maintenance using halothane (AOR 4.5 95% CI 1.7-11.4) and relaxation maintained with suxamethonium (AOR 3.1, 95% CI 1.2-8.1) were significantly associated with the prevalence of postoperative myalgia. The magnitude of suxamethonium-induced postoperative myalgia was high. So it is better to do with preventive techniques. As much as possible it is better to avoid using suxamethonium and necessary to use better to Premedicate with nonsteroidal anti-inflammatory drugs and non-depolarizing neuromuscular medications.

BACKGROUND: Malignant hyperthermia is a potentially lethal condition triggered by specific anesthetic drugs, especially a depolarizing muscle relaxant of succinylcholine (Suxamethonium). Despite the frequent use of succinylcholine with electroconvulsive therapy (ECT), there has been no reported case of potentially lethal malignant hyperthermia following ECT. In addition, the time interval between the administration of succinylcholine and the onset of malignant hyperthermia has not been outlined in the context of ECT.
METHODS: We present the case of a 79-year-old woman suffering from severe depression, who experienced severe malignant hyperthermia due to succinylcholine administration during an ECT session. She presented with a high fever of 40.2 °C, tachycardia of 140/min, hypertension with a blood pressure exceeding 200 mmHg, significant muscle rigidity, and impaired consciousness. These symptoms emerged two hours after ECT, which occurred in a psychiatric ward rather than an operating room, and reached their peak in less than 24 h. She was given 60 mg of dantrolene, which quickly reduced the muscular rigidity. Subsequently, she received two additional doses of 20 mg and 60 mg of dantrolene, which brought her fever down to 36.2 °C and completely eased her muscle rigidity within two days after ECT.
CONCLUSIONS: This is the first reported case of potentially lethal malignant hyperthermia after ECT. In addition, it highlights the delayed onset of malignant hyperthermia following an ECT procedure, emphasizing the necessity for psychiatrists to recognize its onset even after the treatment. In the light of potentially lethal consequences of malignant hyperthermia, it is critically important for psychiatrists to closely monitor both intraoperative and postoperative patient\'s vital signs and characteristic physical presentations, promptly identify any symptomatic emergence, and treat it immediately with dantrolene.

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BACKGROUND: Suxamethonium is hydrolysed by butyrylcholinesterase (BChE) and a low BChE activity can result in a prolonged duration of action of suxamethonium. The BChE activity is reduced during pregnancy and postpartum period by up to 33%. However, it can also be reduced by mutations in the BChE gene. In this study, we assessed BChE activity and mutations in the BChE gene in pregnant and postpartum patients with prolonged duration of action of suxamethonium. It was hypothesised that at least 30% of patients with a low BChE activity did not have a mutation in the BChE gene.
METHODS: In this registry study we focused on pregnant and postpartum patients with a history of prolonged duration of action of suxamethonium referred to the Danish Cholinesterase Research Unit (DCRU) between March 2007 and January 2023. Primary outcome was the proportion of patients without a mutation among patients with a low BChE activity. Secondary outcomes were the proportion of patients with a low BChE activity and the proportion of patients with a mutation out of the total number of patients.
RESULTS: A total of 40 patients were included and among patients with a low BChE activity, 6% (95% CI: 1%-21%) did not have a mutation. Out of the total number of included patients referred to the DCRU, 90% (95% CI: 76%-97%) had a mutation and 94% (95% CI: 80%-99%) had a low BChE activity.
CONCLUSIONS: Among pregnant and postpartum patients with a history of prolonged duration of action of suxamethonium and a low BChE activity, 6% did not have a mutation in the BChE gene. Our findings suggest that during pregnancy and postpartum clinically relevant prolonged duration of action of suxamethonium rarely occurs in genotypically normal patients.

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UNASSIGNED: Following propofol induction, suxamethonium tremendously improves intubating conditions in children and has been the gold standard agent for this purpose. However, suxamethonium could be absolutely contraindicated in some patients. Fentanyl, a short acting opioid, has been investigated as a suitable alternative with varying results.
UNASSIGNED: This study compares the ease of tracheal intubation between propofol-suxamethonium (1.5 mg/kg) and propofol-fentanyl (3 mcg/kg) during general anaesthesia among children.
UNASSIGNED: In this double-blind randomised controlled study, 84 ASA I or II patients booked for elective surgery under general anaesthesia requiring tracheal intubation were randomised into two groups (F and S). Induction was with propofol 3 mg/kg over 30 s followed by either fentanyl 3 mcg/kg or suxamethonium 1.5 mg/kg. Two minutes later, there was an attempt at intubation and intubating conditions were assessed using Steyn\'s modification of Helbo-Hansen\'s score (ease of laryngoscopy, jaw relaxation, coughing, vocal cord position, and limb movement).
UNASSIGNED: All patients in both groups had successful intubation at the first attempt. Patients in group S (suxamethonium) had significantly better overall intubating conditions compared to those in group F (fentanyl) (p=0.0001), 85.7% in group S compared to 21.4% in group F had excellent intubation condition. None of the patients in the two groups demonstrated fair or poor intubation condition.
UNASSIGNED: A combination of propofol-fentanyl can be used as an alternative to propofol-suxamethonium to ease intubation in paediatric patients.

BACKGROUND: Anesthesia-associated rhabdomyolysis is a rare complication of surgery that causes postoperative myalgia, weakness, and potential renal failure if not managed promptly. Predisposing conditions that may lead to this complication include muscular dystrophies and myopathies.
METHODS: This rare case describes a pediatric non-Indigenous Australian patient developing this complication, with no known predisposing risk factors, and no clear etiology. A 9-year-old child with a background of asthma underwent an elective removal of keloid scar on her chest wall. The procedure was brief and uncomplicated, with an uneventful induction of anesthesia. During the emergence period, she developed acutely raised airway pressures with bronchospasm and laryngospasm requiring the use of salbutamol and suxamethonium with good effect. In the initial postoperative period, the patient complained of generalized myalgia and muscle weakness and was unable to mobilize independently. There was transient recovery to normal function; however, a recurrence of symptoms the following day with associated myalgias warranted admission to hospital. She was found to have rhabdomyolysis that was managed conservatively with a full recovery of several weeks. She was thoroughly investigated for any underlying cause, including genetic testing for malignant hyperthermia susceptibility (she had a variant of unknown significance but was negative for the known genetic abnormalities that cause malignant hyperthermia).
CONCLUSIONS: This case report demonstrates the importance of considering anesthesia-associated rhabdomyolysis as a differential for acute postoperative weakness, and outlines an investigative approach. To the best of our knowledge, it is the first case described in the pediatric literature to report biphasic progression of symptoms.

This study sought to describe the phenotype and genotype characteristics of patients referred to our laboratory to undergo further assessment due to a suspicion of a prolonged effect of suxamethonium attributed to BChE deficiency.
All patients referred to our laboratory from January 2016 to December 2019 due to the suspicion of a prolonged effect of suxamethonium were included in this study. The determination of BChE activity and genotyping using complete nucleotide sequencing of the entire complementary DNA-coding region with flanking intron-exon boundaries were completed.
During this four-year period, 58 patients were referred to our laboratory for the investigation of prolonged neuromuscular block due to BChE deficiency. Among them, 52 showed a BChE deficiency related to BCHE gene mutations. The most commonly detected genotype was compound homozygous atypical variant (p.Asp98Gly)/homozygous Kalow variant (p.Ala569Thr) (p.[Asp98Gly;Ala567Thr];[p.Asp98Gly;Ala567Thr]). Further, we recorded four new BCHE variants, which seem to be associated with prolonged post suxamethonium apnoea: p.(Trp205Cys), p.(Leu222His), p.(Glu469Gln), and p.(Lys276Ter).
During a four-year period, among the 58 patients referred to our laboratory, we have found four new BCHE variants, which seem to be associated with prolonged post suxamethonium apnoea (p.(Trp205Cys), p.(Leu22His), p.(Glu469Gln), and p.(Lys276Ter)).

Variants of butyrylcholinesterase are frequently associated with prolonged response to suxamethonium or mivacurium. Butyrylcholinesterase (BChE) can be characterized by phenotyping and determination of genotype. Inappropriate timing of blood sampling might interfere with phenotyping methods. However, guidelines regarding delay between exposure to anaesthesia and testing are not clearly defined. In this study, the BChE activity and phenotype in an early (T1) and late (T2) phase were compared and the phenotype/genotype correlation was assessed.
Patients with a prolonged paralysis after mivacurium or suxamethonium were selected after ethical committee approval and written consent. BChE activity was based on butyrylthiocholine hydrolysis rate and phenotyping on differential inhibition of BChE activity with dibucaine and fluoride. DNA sequencing allowed genotypic characterization.
We included the results of 20 patients with prolonged neuromuscular block (NMB) induced by mivacurium or suxamethonium. In these patients, BChE activity was different at T1 and T2 (2120 [1506-2733] U L-1 and 4055 [2810-5301] U L-1 , respectively; P = 0.0014; values are mean [95% CI]). When phenotyping was possible, phenotyping at T1 and T2 yielded identical results. Phenotyping failed to identify one new variant (p.Tyr146Cys) and the K variant in 14 of 16 patients.
Anaesthesia interfered with BChE activity, but not with phenotyping. Phenotyping can be performed on blood drawn during or immediately after recovery of mivacurium or suxamethonium to screen for clinically relevant variants of BChE. However, accurate diagnosis of BChE deficiency needs further confirmation by determination of genotype.

The evidence base for the widely accepted standard regimen of succinylcholine for rapid sequence induction (1.0 mg kg- 1) remains unclear.
We performed a systematic review and meta-analysis of randomized trials comparing any succinylcholine regimen with the standard regimen (1.0 mg kg- 1) and reporting on intubating conditions and/or apnoea times. Results were expressed as absolute risk differences (ARD) for dichotomous data and mean differences (MD) for continuous data.
We retrieved six trials with relevant data of 864 patients (ASA 1 or 2, aged 18-65 years, body mass index < 30 kg m- 2). Four regimens (0.3, 0.4, 0.5, 0.6 mg kg- 1) were compared with 1.0 mg kg- 1 in at least three trials each, and three (0.8, 1.5, 2 mg kg- 1) in one each. With 0.3 to 0.5 mg kg- 1, the likelihood of excellent intubating conditions was significantly decreased (ARD - 22% to - 67%). With 0.3 and 0.4 mg kg- 1, but not with 0.5, 0.6, 0.8, 1.5 and 2.0 mg kg- 1, the likelihood of unacceptable intubating conditions was significantly increased (ARD + 22% and + 32%, respectively). With 2.0 mg kg- 1, but not with 0.8 or 1.5 mg kg- 1, the likelihood of excellent intubating conditions was significantly increased (ARD + 23%). Apnoea times were significantly shorter with regimens ≤0.8 mg kg- 1 (MD - 1.0 to - 3.4 min) but were not reported with 1.5 or 2.0 mg kg- 1.
With succinylcholine regimens ≤0.5 mg kg- 1, excellent intubating conditions are less likely and apnoea times are shorter, compared with 1 mg kg- 1. With 0.3 and 0.4 mg kg- 1, unacceptable intubating conditions are more common. Succinylcholine 1.5 mg kg- 1 does not produce more often excellent conditions compared with 1 mg kg- 1, while 2.0 mg kg- 1 does, but the database with these regimens is weak and apnoea times remain unknown. Limited information size and strong statistical heterogeneity decrease the certainty of the evidence.