Lignocaine pretreatment for suxamethonium. A clinicobiochemical study

Lidocaine pre-treatment for Succinylcholine induced postoperative myalgia and associated factors: Longitudinal study

Introduction

Postoperative myalgia in surgical patients is mainly caused by the routinely administered depolarizing muscle relaxant, Succinylcholine. There are many proposed strategies but no one were indicated as ideal preventive mechanisms for Succinylcholine induced post-operative myalgia. Even if data were sparse, Lidocaine pretreatment can reduce postoperative myalgia which requires further supportive evidences urging the initiation of this study.

Methods

Prospective longitudinal cohort study was conducted from March to May 2021 at Dessie Comprehensive Specialized Hospital on 208 adult surgical patients. Patients pretreated with Lidocaine preoperatively were grouped as exposed and others as unexposed. Patients meeting the inclusion criteria during the study period were selected sequentially from the daily operation schedule list. Postoperative myalgia level was measured using post-operative myalgia survey repeatedly. The result was analyzed by Cochran's Q test and generalized estimating equation (GEE). Adjusted odds ratio with 95 % confidence interval and p value < 0.05 was used to show the difference, direction and strength of association.

Result

Exposure specific incidence rate showed that 22 %, 22 % and 29.8 % of patients exposed to Lidocaine and 40.6 %, 42.7 % and 34 % not exposed to Lidocaine developed myalgia at 12, 24, and 48 h respectively. There is no significant difference in the incidence of myalgia over time between the repeated measurements in Lidocaine exposed patients (p = 0.513) but in non-exposed patients (p = 0.003). Also, there is no difference in the distribution of other predictors between Lidocaine exposed and non-exposed groups (p > 0.05). Exposure to Lidocaine reduces postoperative myalgia significantly [AOR = 0.33, 95 % CI = (0.17,0.66)]. Multimodal analgesia [AOR = 0.32, 95 % CI = (0.18,0.55)], non-steroidal anti-inflammatory drugs alone [AOR = 0.47, 95 % CI = (0.29,0.76)], postoperative immobility [AOR = 0.61, 95 % CI = (0.47,0.8)], and being male [AOR = 0.48, 95 % CI = (0.26,0.87)] were other determinants in reducing Succinylcholine induced postoperative myalgia.

Conclusion

Lidocaine pretreatment can significantly reduce the occurrence of Succinylcholine induced postoperative myalgia. Additionally, usage of multimodal analgesia with non-steroidal anti-inflammatory drugs or even only non-steroidal anti-inflammatory drugs in the intraoperative and postoperative period can reduce Succinylcholine induced postoperative myalgia.

Succinylcholine-associated postoperative myalgia

The subject of postoperative myalgia associated with the use of succinylcholine is reviewed. We discuss the mechanisms of succinylcholine-induced myalgia and the techniques available to prevent and treat the myalgia. In situations where patients are at risk of developing myalgia and succinylcholine is the neuromuscular blocker of choice, the use of a combination of techniques may prove to be a useful strategy.

Fasciculations, myalgia and biochemical changes following succinylcholine with atracurium and lidocaine pretreatment

PURPOSE

To determine the attenuation in the incidence of myalgia, fasciculations and changes in serum potassium and creatinine kinase concentrations when atracurium and lidocaine were used in combination and separately as pretreatment before succinylcholine.

METHODS

In a prospective, double blind randomized study, 80 ASA 1 patients 20-50 yr were assigned to one of four groups. Anaesthesia was induced with thiopentone and fentanyl. Group C received placebo pretreatment before 1.5 mg.kg-1 succinylcholine; Group A 0.05 mg.kg-1 atracurium three minutes before; Group L, 1.5 mg.kg-1 lidocaine 30 sec before; and group AL both atracurium and lidocaine. Serum potassium five minutes after succinylcholine, and creatinine kinase 24 hr after operation were measured and the increases from preinduction values were compared. Fasciculations and postoperative myalgia at 24 and 48 hr were recorded. Patients received iv meperidine or po paracetamol for postoperative analgesia.

RESULTS

The increase in serum potassium concentration (0.36 +/- 0.23 mEq.l-1) was not attenuated by any regimen (P < 0.05). The incidence of fasciculations (P < 0.05) and the increase in creatinine kinase (P < 0.01) was less in the atracurium (40%; 20.93 IU.l-1) and atracurium-lidocaine (30%; 22.85 IU.l-1) than in the lidocaine (85%; 45.01 IU.l-1) and control (100%; 56.5 IU.l-1) groups. Postoperative myalgia on Days 1 and 2 was lowest (P < 0.05) in the atracurium-lidocaine group (5%; 0%) followed by the atracurium (35%; 25%) and lidocaine (30%; 35%) groups and highest in the control (75%; 65%).

CONCLUSION

Atracurium and lidocaine individually reduce postoperative myalgia, with further decrease occurring when used together.

Propofol permits tracheal intubation but does not affect postoperative myalgias

STUDY OBJECTIVE

To determine the effect of propofol without succinylcholine on intubating conditions and postoperative myalgias in ambulatory surgical patients undergoing general anesthesia.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Ambulatory surgery adult patients.

PATIENTS

56 ASA physical status I and II adult patients undergoing general endotracheal anesthesia.

INTERVENTIONS

Group 1 patients received thiamylal plus succinylcholine, Group 2 patients received propofol plus succinylcholine; and Group 3 patients received propofol plus saline. All patients received fentanyl, lidocaine, and nitrous oxide plus isoflurane in oxygen.

MEASUREMENTS AND MAIN RESULTS

Incidence and severity of fasciculations, tracheal intubating conditions, and myalgias on the first and third postoperative days were measured. Propofol did not affect the incidence or severity of fasciculations following succinylcholine, or the incidence of myalgias. Of patients who received propofol without succinylcholine, intubation was successful in 85%.

CONCLUSIONS

Propofol did not affect the incidence or severity of postoperative myalgias following succinylcholine.

Adverse effects of depolarising neuromuscular blocking agents. Incidence, prevention and management

Muscle relaxants block neuromuscular transmission, acting at nicotinic acetylcholine receptors of the neuromuscular junction. Suxamethonium (succinylcholine) is a depolarising agent, whereas all other relaxants in clinical use are nondepolarising. The desired neuromuscular block results from the structural similarity of muscle relaxants to acetylcholine, enabling the interaction with receptors at the neuromuscular junction. Adverse effects of suxamethonium are generally related to its agonist mode of action. Autonomic cardiovascular effects may result. Other adverse effects include anaphylactic or anaphylactoid reactions, and histamine release. Various disease states may present specific considerations in the use of muscle relaxants. Although many complications of muscle relaxants (such as prolonged block or resistance) are easily treated, others may require immediate intervention and vigorous therapy. Careful selection of appropriate relaxants for particular patients will usually prevent the occurrence of complications.

A comparison of the effect of propofol or thiopentone on the incidence and severity of suxamethonium-induced myalgia

We conducted a prospective, randomised single-blind study in 48 adult women undergoing laparoscopic gynaecological surgery to assess the incidence of suxamethonium-induced myalgia. Anaesthesia was induced with either thiopentone or propofol. All other aspects of clinical care were standardised between the groups. The propofol group had a significantly lower incidence of suxamethonium myalgia (19%) compared with the thiopentone group (63%) (P < 0.05). The mechanism of this effect is not understood.

Midazolam pretreatment does not ameliorate myoglobinemia or the clinical side effects of succinylcholine

STUDY OBJECTIVE

To determine whether the levels of serum myoglobin and the occurrence of fasciculations and postoperative symptoms following a single dose of succinylcholine are modified by the prior administration of midazolam.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Outpatient surgical service of a university hospital.

PATIENTS

69 ASA physical status I and II healthy, adult female outpatients undergoing laparoscopy (for diagnosis or tubal ligation) with general anesthesia that included succinylcholine.

INTERVENTIONS

Patients received pretreatment of either a saline placebo (Group 1, n = 31) or intravenous midazolam 0.03 mg/kg (Group 2, n = 38) 5 minutes before succinylcholine.

MEASUREMENTS AND MAIN RESULTS

Serum myoglobin prior to pretreatment and at 5 (t5) and 30 (t30) minutes after succinylcholine was determined by radioimmunoassay. Pain was assessed by telephone interview 24 to 36 hours postoperatively. Baseline myoglobin levels ranged from 14 to 69 ng/ml; the 5- and 30-minute samples varied widely (range, 16 to 900 ng/ml). The rise was 3 or more SDs above the baseline mean in 23% and 42% of Group 1 at t5 and t30, respectively, and in 21% and 35% of Group 2 at t5 and t30, respectively. The differences between groups were not significant. The frequency of fasciculations (77% in Group 1, 87% in Group 2), postoperative sore throat (64% in Group 1, 57% in Group 2), and myalgias (44% in Group 1, 51% in Group 2) also was not significantly different between groups.

CONCLUSIONS

Midazolam had no effect on myoglobin level or postoperative symptoms following succinylcholine.

Prevention of succinylcholine-induced myalgia with lidocaine pretreatment

We studied the effects of 3 mg.kg(-1) lidocaine iv on the succinylcholine (SCh)-induced myalgia in 94 unpremedicated ambulant patients undergoing dilatation and curettage of the uterus. The post-SCh myalgia was confirmed through interview by telephone. The data were correlated with the degree of fasciculation and changes in the serum electrolytes and creatine kinase (CK) levels following SCh administration. Pretreatment with lidocaine, 3 mg.kg(-1) iv, significantly reduced the incidence of myalgia from 40.4% of control group to 12.8% lidocaine-treated group, but not the CK levels. The severity of myalgia was not related to the intensity of fasciculation assessed by visual observation. The pretreatment with lidocaine had no untoward effect on the circulation, although the peak arterial and peak venous lidocaine levels achieved were 29.6 +/- 23 micro g.ml(-1) and 10.1 +/- 3.3 micro g.ml(-1) respectively. These finding indicated that the pretreatment with lidocaine, 3 mg.kg(-1) iv, was effective in prevention of SCh-induced myalgia.

Suxamethonium and hyperkalaemia

Severe life-threatening hyperkalaemia may occur following administration of suxamethonium during certain periods after burns, neurological injuries, and in certain other conditions. Although this response is well-known, there is disagreement about when it may occur. This review describes the normal hyperkalaemic response to suxamethonium, the factors affecting it, the conditions in which it may be exaggerated, and the periods of high risk.

Decreasing post-succinylcholine myalgia in outpatients

The effectiveness of four pretreatment regimens in decreasing succinylcholine-induced myalgias was studied in healthy outpatients undergoing general anaesthesia for ambulatory surgery. Four hundred and forty adult females were randomly assigned to one of four pretreatment groups. Three hundred and ninety-five patients completed the study. One of the following pretreatments was given prior to injection of 1.5 mg X kg-1 of succinylcholine: normal saline IV three minutes and again immediately prior to succinylcholine; 0.06 mg X kg-1 d-tubo-curarine (dTc) IV three minutes prior and normal saline IV immediately prior; normal saline IV three minutes prior and 1.5 mg X kg-1 lidocaine IV immediately prior; 0.06 mg X kg-1 dTc IV three minutes prior and 1.5 mg X kg-1 lidocaine IV immediately prior. Fasciculations after injection of succinylcholine were observed and recorded. Patients were contacted by telephone 40-48 hours postoperatively and questioned about the presence of muscle pains. These pains, if present, were graded either mild or moderate to severe. The patients in the two dTc-containing groups exhibited less fasciculations than patients in the other two experimental groups. The dTc-lidocaine group had a lower incidence of moderate to severe fasciculations than in any of the other three groups. Patients in the dTc, lidocaine, and dTc-lidocaine experimental groups reported a higher incidence of absence of muscle pain and a lower incidence of moderate-severe pain than did patients in the saline group. The dTc-lidocaine group had more patients without myalgia and less patients with moderate to severe myalgias than any of the other groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Myalgia and biochemical changes following intermittent suxamethonium administration. Effects of alcuronium, lignocaine, midazolam and suxamethonium pretreatments on serum myoglobin, creatinine kinase and myalgia

One hundred gynaecological patients for laparoscopy divided into five groups were studied to determine the effects of a number of pretreatments on serum myoglobin, creatinine kinase and myalgia following intermittent suxamethonium administration. One group acted as controls, while the other groups were given intravenous pretreatments of alcuronium 2 mg, midazolam 0.15 mg/kg, lignocaine 1.5 mg/kg and suxamethonium 7 mg. Serum myoglobin was determined by radio-immunoassay. The mean increases in the control group were 167 micrograms/litre myoglobin at 20 minutes and 196 IU creatinine kinase at 24 hours; 13 out of 20 patients responded with a marked increase of serum myoglobin at 20 minutes and of creatinine kinase at 24 hours. Only alcuronium pretreatment prevented myoglobin increase at 20 minutes, abolished creatinine kinase increase at 24 hours and reduced 24-hour myalgia. The other pretreatments slightly reduced myoglobin increase at 20 minutes and 24-hour creatinine kinase but did not reduce myalgia. Only one patient in the whole study had markedly elevated serum myoglobin at 24 hours. We conclude that only non-depolarising relaxant pretreatment is effective in the reduction of some of the adverse effects of suxamethonium administration.

Biochemical changes following suxamethonium. Serum myoglobin, potassium and creatinine kinase changes before commencement of surgery

Forty patients were investigated for serum myoglobin changes following induction of anaesthesia but before the commencement of surgery. Blood was drawn for potassium, creatinine kinase and serum myoglobin immediately prior to and 5, 10 and 20 minutes after administration of thiopentone 4 mg/kg and suxamethonium 1.2 mg/kg. Twenty patients were given either 2 mg alcuronium or 20 mg gallamine as pretreatment 2 to 3 minutes before the suxamethonium to reduce the fasciculations. Anaesthesia was maintained with artificial ventilation and alcuronium, or spontaneous ventilation with halothane. Serum myoglobin was assayed by radioimmunoassay. All pre-induction myoglobin levels were within the normal range. Of the 20 patients who were not pretreated, six showed a marked rise of serum myoglobin within 5 minutes, increasing to 150-200 micrograms/litre at 20 minutes. The remaining 14 patients had no such rise. No patients in the pretreatment group had any significant rise in serum myoglobin, suggesting that although the fasciculations were not completely abolished, there was protection against one of the effects of suxamethonium on the muscle. Although there was no clear relationship between intensity of fasciculations and increase in serum myoglobin, there was no marked rise in serum myoglobin values in any patient who did not have muscle fasciculations. There were no consistent changes in potassium or creatinine kinase in any group during the period of study.