Anesthesia for electroconvulsive therapy (ECT) requires proper medications and airway management. Besides an induction agent such as methohexital, a neuromuscular blocker such as succinylcholine (SCh) is often given for muscle relaxation. To maintain the patient\'s oxygen saturation, mask ventilation is required due to this transient chemical paralysis even in the presence of adequate preoxygenation. A morbidly obese, middle-aged female experienced multiple life-threatening hypoxic episodes due to \"bronchospasms\" during prior ECT treatments. A drastic reduction in the SCh dose to about half of the original dose led to much smoother anesthesia courses with no more hypoxic episodes during subsequent ECT treatments. We believe that the lower dosing of SCh avoided a long period of chemical paralysis, which led to a quick return of spontaneous respiration, shortened the need for airway support, and therefore avoided hypoxic episodes in subsequent ECT treatments.

The correct use of muscle relaxants and neuromuscular monitoring during anesthesia has been subject of controversial discussions for decades. Particularly important in clinical practice are identification and management of residual neuromuscular blockages and avoidance of associated complications. Despite the differences in the molecular mechanisms of action between depolarizing and non-depolarizing muscle relaxants the blockade of the postsynaptic nicotinic acetylcholine receptor remains a common ending pathway. Due to its unfavorable side effect profile, succinylcholine should only be used in justified exceptional cases. The use of muscle relaxants generally reduces the complication rate in airway management. However, even the single use of muscle relaxants increases the likelihood of postoperative pulmonary complications. These complications associated with the use of muscle relaxants, such as residual neuromuscular blockade, must be anticipated. The application of guideline-based approaches, including continuous neuromuscular monitoring and the application of muscle relaxant reversal agents, may significantly reduce the rate of adverse events associated with the use of muscle relaxants.

This comprehensive review explores the interaction between neuromuscular blocking agents, reversal agents, and renal function, focusing on various drugs commonly used in anesthesia and their effects on kidney health. Succinylcholine, commonly used for anesthesia induction, can trigger elevated potassium levels in patients with specific medical conditions, leading to serious cardiac complications. While studies suggest the use of succinylcholine in patients with renal failure is safe, cases of postoperative hyperkalemia warrant further investigation. Some agents, such as atracurium and mivacurium, are minimally affected by impaired kidney function, whereas others, such as cisatracurium and rocuronium, can have altered clearance, necessitating dose adjustments in patients with renal failure. The reversal agents neostigmine and sugammadex affect renal markers, while cystatin C levels remain relatively stable with sugammadex use, indicating its milder impact on glomerular function, compared with neostigmine. Notably, the combination of rocuronium and sugammadex in rat studies shows potential nephrotoxic effects, cautioning against the simultaneous use of these agents. In conclusion, understanding the interplay between neuromuscular blocking agents and renal function is crucial for optimizing patient care during anesthesia. While some agents can be used safely in patients with renal failure, others can require careful dosing and monitoring. Further research is needed to comprehensively assess the long-term impact of these agents on kidney health, especially in high-risk patient populations. This article aims to review the use of muscle relaxants and reversal for anesthesia in patients with impaired renal function.

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: Pseudocholinesterase (butyrylcholinesterase) deficiency is an acquired or inherited condition in which decreased plasma levels of the pseudocholinesterase enzyme lead to an inability to metabolize the neuromuscular blocking agents succinylcholine and mivacurium, prolonging their paralytic effects. This often results in delayed extubation and additional intensive care requirements in the postoperative period.
METHODS: We describe a case of suspected pseudocholinesterase deficiency in a previously healthy 59-year-old female who underwent a left thyroid lobectomy and isthmusectomy. The patient received 120 mg of succinylcholine chloride before intubation. The patient did not meet extubation criteria following the completion of the procedure approximately two hours after receiving succinylcholine chloride. The patient was transferred to the ICU for respiratory support and for the medication to clear from the patient\'s system. The patient regained muscle control approximately four hours after receiving succinylcholine chloride and was extubated without complication. The patient shared post-extubation that she had a blood relative with the diagnosis of pseudocholinesterase deficiency.
CONCLUSIONS: Pseudocholinesterase deficiency is rare but can result in potentially serious complications following the administration of succinylcholine chloride, mivacurium, or ester local anesthetics due to reduced metabolism and subsequently increased pharmacodynamic effects. Given the widespread use of succinylcholine chloride as a neuromuscular blocking agent, such as in this case, providers must be aware of the presentation, pathophysiology, diagnosis, and management. Additionally, this case demonstrates the importance of thoroughly inquiring about any personal or family history of anesthetic complications during a preoperative assessment.

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Muscle relaxants have broad application in anesthesiology. They can be used for safe intubation, preparing the patient for surgery, or improving mechanical ventilation. Muscle relaxants can be classified based on their mechanism of action into depolarizing and non-depolarizing muscle relaxants and centrally acting muscle relaxants. Non-depolarizing neuromuscular blocking drugs (NMBDs) (eg, tubocurarine, atracurium, pipecuronium, mivacurium, pancuronium, rocuronium, vecuronium) act as competitive antagonists of nicotine receptors. By doing so, these drugs hinder the depolarizing effect of acetylcholine, thereby eliminating the potential stimulation of muscle fibers. Depolarizing drugs like succinylcholine and decamethonium induce an initial activation (depolarization) of the receptor followed by a sustained and steady blockade. These drugs do not act as competitive antagonists; instead, they function as more enduring agonists compared to acetylcholine itself. Many factors can influence the duration of action of these drugs. Among them, electrolyte disturbances and disruptions in acid-base balance can have an impact. Acidosis increases the potency of non-depolarizing muscle relaxants, while alkalosis induces resistance to their effects. In depolarizing drugs, acidosis and alkalosis produce opposite effects. The results of studies on the impact of acid-base balance disturbances on non-depolarizing relaxants have been conflicting. This work is based on the available literature and the authors\' experience. This article aimed to review the use of anesthetic muscle relaxants in patients with acid-base disturbances.

UNASSIGNED: Electroconvulsive therapy (ECT) is an effective intervention for psychiatric patients. Succinylcholine is considered the drug of choice for muscle relaxation for ECT. Significant adverse effects of succinylcholine include fasciculation and myalgia. Dexmedetomidine is a highly selective α-2 adrenergic agonist. This study aims to determine the efficacy of a low dose of dexmedetomidine in reducing succinylcholine-induced myalgia in patients receiving ECT.
UNASSIGNED: This randomised controlled trial was conducted on 100 patients, aged 18-65 years, undergoing ECT, who were randomly allocated into two groups with an allocation ratio of 1:1. Group D received intravenous (IV) dexmedetomidine 0.25 µg/kg, and Group C received IV normal saline (0.9%). Patients\' self-reported myalgia scores were measured after 60 min of the procedure. Fasciculations were noted after IV succinylcholine administration. Heart rate (HR) and mean blood pressure (MBP) were measured at baseline, after infusion (5 min) and after ECT (0, 2.5, 5, 10, 15, 30 min). Continuous data were analysed using a Student\'s t-test for two-group comparisons, a mixed model analysis of variance for group comparisons and various time point analyses. Categorical data were analysed using the Chi-square/Fisher\'s exact test.
UNASSIGNED: There were no differences between the groups regarding demographics. Myalgia and fasciculations were less in Group D than in Group C (P < 0.001). MBP and HR changes were comparable (P > 0.05).
UNASSIGNED: A low dose of dexmedetomidine (0.25 µg/kg) effectively reduces myalgia and fasciculations due to succinylcholine in patients undergoing electroconvulsive therapy.

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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