Muscle pains after suxamethonium

Effects of high-dose propofol on succinylcholine-induced fasciculations and myalgia

BACKGROUND

The purpose of this prospective study was to determine the effects of high-dose propofol on the incidence of fasciculations and myalgia, and to evaluate changes in creatine kinase levels following the administration of succinylcholine in 90 women who underwent laparoscopy.

METHODS

Patients were randomly assigned to one of three groups. Induction of anesthesia was performed with thiopentone 5 mg kg(-1) in Group I (n = 30), propofol 2 mg kg(-1) in Group II (n = 30), and propofol 3.5 mg kg(-1) in Group III (n = 30). Then succinylcholine 1 mg kg(-1) was administered to the patients for intubation.

RESULTS

Fasciculation was absent in 20% of Group III patients, and no vigorous fasciculation occurred in this group. Furthermore, the severity of fasciculation in Group III was significantly lower than in the other two groups (P = 0.01). Seventy per cent of patients had no myalgia in Group III, 39.2% in Group II and 37% in Group I (P = 0.007). Severity of myalgia was also significantly lower in Group III compared with the other two groups (P = 0.011). Post-operative creatine kinase levels were significantly higher than their baseline values in Groups I and II (P < 0.0001).

CONCLUSION

Administration of propofol 3.5 mg kg-1 is effective in reducing fasciculations and myalgia after succinylcholine.

Suxamethonium myalgia: an ethnic comparison with and without pancuronium pretreatment

The incidence of myalgia after suxamethonium was determined in 200 fit military male dental patients of European, Chinese and Nepalese descent. Half received pancuronium 1 mg and the other half received saline pretreatment on a randomised double-blind basis. The percentage incidence of postsuxamethonium myalgia after saline or pancuronium was found to be: Europeans 26%, 13%; Chinese 13%, 7%; Nepalese 20%, 14%. Although pancuronium reduced the incidence of myalgia by about 50% overall, these values were not significantly different from each other. The recovery of spontaneous ventilation following suxamethonium was quicker in the Europeans than in the Asians (p < 0.05). Pancuronium pretreatment also delayed the recovery of spontaneous ventilation and recovery from neuromuscular block (p < 0.05) but this was independent of ethnicity. The Europeans recovered from anaesthesia more quickly than the Asians. It was concluded that ethnicity affected recovery from suxamethonium and from anaesthesia but was not of clinical relevance to the incidence of myalgia in male Asians and Europeans.

Alfentanil inhibits muscle fasciculations caused by suxamethonium in children and in young adults

The effect of alfentanil on suxamethonium-induced muscle fasciculations was studied in a double-blind study in 34 children (mean age 6.8 years) and in 30 adults (mean age 20 years). After pretreatment with either alfentanil 50 micrograms kg-1 or saline, each patient was anaesthetized with a sleep dose of thiopental followed by suxamethonium 1.5 mg kg-1 for endotracheal intubation. Compared to the control groups, alfentanil significantly decreased the intensity of visible muscle fasciculations caused by suxamethonium. In children, the duration of muscle fasciculations was shorter in the alfentanil than in the control group. In adults, the intensity rather than the duration of fasciculations was attenuated by alfentanil. The inhibition of fasciculations caused by alfentanil was also demonstrated in children in the surface electromyogram recorded on the biceps. There was no circulatory response to endotracheal intubation in the groups pretreated with alfentanil.

Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium

We studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone, N2O, isoflurane anaesthesia. Four groups of 20 patients each were pretreated with saline (group 1), tubocurarine 0.05 mg/kg (group 2), vecuronium 0.006 mg/kg (group 3), or midazolam 0.025 mg/kg (group 4), followed by suxamethonium 1.5 mg/kg. Group 5 received only vecuronium 0.1 mg/kg as relaxant (no suxamethonium). Fasciculations were graded, and postoperative myalgias rated on the first and third postoperative days. In groups 1-5 the incidence of fasciculations was 95, 15, 25, 95 and 0%; the incidence of myalgias on the first day after operation was 70, 45, 65, 75 and 60%, and on the third day after operation 20, 5, 20, 20, and 5%, respectively. We conclude that pretreatment with vecuronium, but not midazolam, decreases the incidence of fasciculations after suxamethonium (p less than 0.05) and that in this patient population, postoperative myalgias appear to be unrelated to the use of suxamethonium.

A defasciculating dose of d-tubocurarine causes resistance to succinylcholine

Forty-four patients, ASA physical status I or II, undergoing thiamylal, fentanyl, N2O/O2 anaesthesia were studied to determine the dose-response to succinylcholine (Sch) without prior defasciculation (24 pt - Group 1), or three minutes following d-tubocurarine (dTC), 0.043 mg.kg-1 (20 pt - Group 2). The individual log dose-logit response curve for each patient was determined using a cumulative dose plus infusion technique and integrated EMG monitoring of the first dorsal interosseous muscle. The mean (+/- SEM) ED50, ED90 and ED95 values for Sch in Group 1 were 0.13 +/- 0.01, 0.19 +/- 0.01 and 0.22 +- 0.01 mg.kg-1, and in Group 2 were 0.16 +/- 0.01, 0.25 +/- 0.01 and 0.29 +/- 0.02 mg.kg-1, respectively. The mean ED values in Group 2 were significantly greater than the equivalent values in Group 1 (P less than 0.05). Compared with values in Group 1, ED values in Group 2 represented mean increases of 23, 32, and 32 per cent, respectively. These pharmacodynamic data indicate that the dose of Sch needs to be increased by 32 per cent following a defasciculating dose of dTC 3 mg.70 kg-1 (0.043 mg.kg-1).

Optimal time interval between pretreatment with alcuronium and suxamethonium during anaesthetic induction

Alcuronium 0.03 mg/kg was studied in a double-blind randomized fashion as a pretreatment before suxamethonium using different time intervals between the administration of the drugs in 78 patients (ASA I-II) undergoing otolaryngological surgery. Alcuronium was given 1, 2 or 3 min before suxamethonium 1.5 mg/kg. The control group received saline as a pretreatment and suxamethonium 1 mg/kg. Anaesthesia was induced with thiopental 5.5 mg/kg over 60 s. Muscle fasciculations, intubating conditions, cardiovascular responses to endotracheal intubation and duration of neuromuscular block were assessed. Muscle fasciculations were statistically and similarly inhibited (P less than 0.01) at all time intervals between alcuronium and suxamethonium. Intubating conditions were worse (P less than 0.05) in the 3-min group than in the other groups. Cardiovascular responses to endotracheal intubation were similar in all groups. The neuromuscular block after suxamethonium was significantly shorter (P less than 0.05) in the 2- and 3-min groups than in the other groups. In conclusion, from the clinical point of view the 1-min time interval between alcuronium and suxamethonium is optimal since muscle fasciculations are inhibited and intubating conditions are satisfactory.

Failure of two benzodiazepines to prevent suxamethonium-induced muscle pain

In a randomised double-blind trial carried out on fit, unpremedicated patients undergoing standard minor operations with early postoperative mobility, using a standard form of anaesthesia, pretreatment with diazepam 0.15 mg/kg or midazolam 0.1 mg/kg failed to reduce significantly the incidence of postoperative muscle pains following suxamethonium 1 mg/kg. By contrast, tubocurarine 0.05 mg/kg proved to be effective as a pretreatment. Neither benzodiazepine influenced the incidence or severity of fasciculations seen with suxamethonium or the duration of neuromuscular block. Tubocurarine virtually abolished visible fasciculation and, in the dose used, reduced the intensity and duration of the neuromuscular block. There were no clinically significant changes in serum potassium, creatinine phosphokinase or aldolase after suxamethonium, although 5 out of 47 showed an atypical rise in creatinine phosphokinase.

Pain-reducing effect of self-taming suxamethonium

The effect was evaluated of a small "self-taming" dose of suxamethonium (0.1 mg/kg) on fasciculations and postoperative muscle pain following a normal intubating dose of suxamethonium (1.0 mg/kg). Forty outpatients undergoing bronchoscopy were randomly allocated to pretreatment with either sodium chloride or suxamethonium 0.1 mg/kg. The pretreatment dose was followed in 60 s by suxamethonium 1.0 mg/kg. Visual rating and mechanical registration of muscle fasciculations were done separately. Muscle pain was found in 74% and in 26% of the patients following pretreatment with sodium chloride and suxamethonium 0.1 mg/kg, respectively (P less than 0.01). No significant relationship was found between pain and muscle fasciculations. It is concluded that self-taming with suxamethonium has a marked pain-reducing effect; and this technique may be used as an alternative to pretreatment with a non-depolarizing relaxant.

Five non-depolarizing muscle relaxants in precurarization

Five different non-depolarizing muscle relaxants and a control solution of saline were studied as precurarization agents. Two hundred and twenty-two surgical patients (ASA I-II) were allocated in a double-blind fashion to one of the following groups: d-tubocurarine 0.05 mg/kg, alcuronium 0.03 mg/kg, pancuronium 0.01 mg/kg, gallamine 0.25 mg/kg, ORG NC-45 (vecuronium) 0.01 mg/kg and saline solution 0.005 ml/kg. Pretreatment was performed 4 min before administering a 1.5 mg/kg bolus of succinylcholine (SCh). Fasciculations, intubation conditions, duration of neuromuscular blockade after SCh, serum potassium changes and postoperative myalgias (in 60 patients) were recorded. All the drugs studied prevented fasciculations significantly (P less than 0.05) more than in the control group. d-Tubocurarine and alcuronium were superior to the others in this respect. Intubation conditions were best in the control and pancuronium groups, but there was no significant difference between the pancuronium and d-tubocurarine or between the d-tubocurarine and alcuronium groups. Pancuronium pretreatment prolonged the SCh block significantly, whereas other agents shortened the duration of the SCh block. The antagonism of the SCh block apparently also affected intubation conditions, although intubation remained satisfactory. A statistically significant rise in serum potassium level was measured only in the control and pancuronium groups. In the control and pancuronium groups, four patients out of 10 had postoperative myalgias, whereas in the other groups only one or none out of 10 had them (0/10 vs. 4/10; 0.10 greater than P greater than 0.05). In conclusion, d-tubocurarine and alcuronium seem to have advantages over pancuronium, ORG NC-45 and gallamine for precurarization.

Effects of precurarization on the blood pressure and heart rate changes induced by suxamethonium facilitated laryngoscopy and intubation

The effects of precurarization on blood pressure and heart rate increases during laryngoscopy and intubation were studied in 60 surgical patients, who were randomly allocated to four groups, receiving as a pretreatment d-tubocurarine (0.05 mg/kg), alcuronium (0.03 mk/kg) , pancuronium (0.008 mg/kg) or saline in a double-blind fashion. d-Tubocurarine and alcuronium pretreatments seemed to attenuate the blood pressure increase during laryngoscopy and intubation under suxamethonium. Moreover, d-tubocurarine pretreatment protected effectively against high blood-pressure increases. Heart-rate increases were of the same magnitude in all the pretreated groups. d-Tubocurarine pretreatment abolished suxamethonium-induced fasciculations completely, whereas alcuronium pretreatment gave protection in 93% and pancuronium pretreatment in 43% of patients.