[Contraindications to succinylcholine in the intensive care unit. A prevalence study]. / Prevalencia de contraindicaciones a succinilcolina en unidades de cuidados intensivos.

OBJECTIVE: To determine the prevalence of contraindications to succinylcholine in patients admitted to the ICU. DESIGN: An observational study was carried out, describing the frequency of succinylcholine contraindication by stays, and associating the contraindications to population variables. SETTING: The adult general ICU of a reference hospital. PATIENTS: Clinical-surgical critically ill patients. Thirty consecutive days were analyzed. INTERVENTIONS: None. VARIABLES: Population variables: age, sex, APACHE II and SOFA scores, illness, days of hospitalization, mechanical ventilation and renal replacement therapy. CONTRAINDICATIONS: hyperkalemia, bedridden patients, rhabdomyolysis, muscle trauma, burns, infusion of neuromuscular blocking agents, acute renal failure, chronic renal failure, intraocular hypertension, intracranial hypertension, statin use, malignant hyperthermia, neuromuscular disease, spinal cord sectioning, bradycardia < 50 bpm, succinylcholine allergy, and pseudo-cholinesterase deficiency. RESULTS: A total of 102 patients were admitted, aged 60 ± 16 years (56.9% males), with the generation of 657 stays. Main diseases: elective heart surgery (33%), respiratory failure (22%) and sepsis (14%). We documented 466 stays (70.9%) with contraindications, particularly bedridden patients (n=140), neuromuscular blocking agents (n=101), acute renal failure (n=126), statin use (n=167), neuromuscular disease (n=159) and bradycardia (n=76). We recorded 74 stays (11.3%) at high risk of complications, secondary to hyperkalemic risk associated to receptor dysregulation. A high risk of complications was associated to advanced age, prolonged hospitalization, prolonged length of stay in the ICU, higher APACHE II and SOFA scores, mechanical ventilation and renal replacement therapy. CONCLUSION: Given the high prevalence of contraindications to succinylcholine observed, we discourage its use in patients admitted to the ICU.

Preoperative pregabalin prevents succinylcholine-induced fasciculation and myalgia: A meta-analysis of randomized trials.

Succinylcholine is the gold standard neuromuscular blocker for rapid sequence induction; however, its use is associated with fasciculation and myalgia. We performed a systematic review and meta-analysis of randomized controlled clinical trials comparing gabapentinoids versus placebo for the prevention of fasciculations and succinylcholine-induced myalgias. Six randomized clinical studies were included with a total of 481 patients - 241 in the intervention group and 240 in the placebo group. Gabapentinoids reduced the incidence of succinylcholine-induced myalgia (RR = 0.69, 95% CI 0.56-0.84, P < .001), which remained statistically significant for pregabalin (RR = 0.71, 95% CI 0.54-0.93, P = .013) and gabapentin (RR = 0.61, 95% CI 0.45-0.82, P = .001) separately. There was no difference in fasciculations between the groups (RR = 0.92, 95% CI 0.82-1.03, P = .148). Preoperative use of gabapentinoids is associated with lower incidence of succinylcholine-induced myalgias within the first 24 h of surgery.

Hipertermia maligna / Malignant hyperthermia

Resumen: La hipertermia maligna es un raro desorden farmacogenético potencialmente mortal, que se presenta como una respuesta hipermetabólica a los anestésicos volátiles y relajantes musculares despolarizantes en individuos susceptibles. Esta susceptibilidad se asocia a mutaciones en tres genes: RYR1, CACNA1S y STAC3. Puede manifestarse con síntomas leves o como una crisis fulminante, con rabdomiólisis severa, fibrilación ventricular e insuficiencia renal y circulatoria aguda, por lo tanto, el pronóstico depende de qué tan pronto se sospeche del diagnóstico y qué tan rápido se inicie el tratamiento. El diagnóstico definitivo se basa en una prueba de sensibilidad en biopsia muscular fresca y en pruebas genéticas. La mejor manera de prevenir un evento es la detección precoz de los pacientes susceptibles así como contar con el equipo para responder ante una crisis en cada centro donde se administren anestésicos volátiles y la capacitación del personal. Esta revisión sintetiza los conceptos actuales clínicos y biomédicos para detección, prevención, diagnóstico y manejo de la hipertermia maligna.

Abstract: Malignant hyperthermia is a rare, life-threatening pharmacogenetic disorder which presents as a hypermetabolic response to volatile anesthetics and depolarizing muscle relaxants in susceptible individuals. This susceptibility is associated with mutations in three genes: RYR1, CACNA1S and STAC3. Can manifest with mild symptoms or as a fulminant crisis, with severe rhabdomyolysis, ventricular fibrillation and acute renal and circulatory failure, therefore the prognosis depends on how soon the diagnosis is suspected and how fast treatment is started. The definitive diagnosis is based on a fresh muscle biopsy sensitivity test and genetic testing. The best way to prevent an event is the early detection of susceptible, as well as have equipment to respond to a crisis in each center where volatile anesthetics are administered and the training of staff. This review synthesizes current clinical and biomedical concepts for detection, prevention, diagnosis and management of malignant hyperthermia.

Comparación entre rocuronio y succinilcolina para secuencia de intubación rápida en departamento de emergencias / Rocuronium and succinilcholine comparison in emergency department

Introduction: The rapid intubation sequence is a basic intervention for the management of the airway in the emergency department. The use of neuromuscular blockers is essential for this intervention. Succinylcholine and rocuronium being the most used, which present pharmacological differences between them. Methods: A single-blind, randomized, controlled study was conducted of all patients who were admitted to the emergency department of the Hospital Municipal de Urgencias and who required a rapid intubation sequence for 13 months using succinylcholine or rocuronium as a neuromuscular blocking drug. Intubation conditions, ease of intubation were assessed, and serum potassium was recorded on admission and 15 minutes after the infusion of the blocker. Results: 80 patients were included in the study, 35 for the rocuronium group and 45 for the succinylcholine group. For the analysis, patients with intubation conditions were classified as clinically acceptable or clinically poor according to the Goldberg scale. In the Rocuronium group 94.3% were clinically acceptable conditions, 5.7% poor conditions and with succinylcholine 82.2% were acceptable conditions and 17.8% in poor conditions. Better intubation conditions are observed with Rocuronium compared to Succinylcholine (RR 0.73 IC 95% 0.23-2,31) but without statistically significant differences. Regarding alteration of serum potassium, there were no statistically significant differences between the two regarding its incidence (RR 1.0 IC 95% 0.53-1.87). Conclusions: Although several studies indicate the superiority of succinylcholine in creating better conditions over rocuronium for intubation, in our study carried out in an emergency department it was observed that rocuronium generates better intubation conditions in relation to succinylcholine although without statistically significant differences and there were no differences in serum potassium levels between both drugs.

Introducción: La secuencia de intubación rápida es una intervención fundamental para el manejo de la vía aérea en la especialidad de Medicina de Emergencias. El uso de bloqueantes neuromusculares es esencial para esta intervención siendo los más usados la succinilcolina y el rocuronio los cuales presentan diferencias farmacológicas entre sí. Método: Se realizó un estudio controlado, aleatorizado, a simple ciego de todos los pacientes que ingresaron al Shock Room del Hospital Municipal de Urgencias y que requirieron secuencia de intubación rápida durante 13 meses utilizando succinilcolina o rocuronio como fármaco bloqueante neuromuscular. Se valoraron condiciones de intubación y facilidad de intubación y se registró el potasio sérico al ingreso y a los 15 minutos posteriores a la infusión del bloqueante. Resultados: Se incluyeron en el estudio a 80 pacientes, 35 para el grupo rocuronio y 45 para el grupo succinilcolina. Para el análisis se clasificaron a los pacientes con condiciones de intubación en clínicamente aceptables o clínicamente pobres según la escala de Goldberg. Del grupo rocuronio el 94,3% tenían condiciones clínicamente aceptables, 5,7% condiciones pobres y con succinilcolina el 82,2% en condiciones aceptables y 17,8% en condiciones pobres. Se observaron mejores condiciones de intubación con rocuronio respecto a succinilcolina (RR 0,73 IC 95% 0,23-2,31), pero sin diferencias estadísticamente significativas. En cuanto a alteración del potasio sérico no hubo diferencias estadísticamente significativas entre ambos respecto a su incidencia (RR 1,0 IC 95% 0,53-1,87). Conclusiones: Aunque varios estudios indican una la superioridad de la succinilcolina en crear mejores condiciones sobre el rocuronio para la intubación, en nuestro estudio realizado en un departamento de emergencias se observó que el rocuronio genera mejores condiciones de intubación en relación a succinilcolina aunque sin diferencias estadísticamente significativas y no hay diferencias en la elevación del potasio sérico entre ambos fármacos.

[Inadvertent injection of succinylcholine as an epidural test dose]. / Injeção inadvertida de succinilcolina como uma dose teste epidural.

BACKGROUND AND OBJECTIVES: Epidural action of neuromuscular blocking agents could be explained under the light of their physicochemical characteristics and epidural space properties. In the literature there are few cases of accidental neuromuscular agent's epidural administration, manifesting mainly with neuromuscular blockade institution or fasciculations. CASE REPORT: We report a case of accidental succinylcholine administration as an epidural test dose, in a female patient undergoing scheduled laparotomy, under combined general and epidural anesthesia. Approximately 2min after the succinylcholine injection the patient complained for shortness of breath, while mild fasciculations appeared in her trunk and face, managed by immediate general anesthesia institution. With the exception of a relatively longer duration of neuromuscular blockade compared with intravenous administration, no neurological or cardiovascular sequelae or other symptoms of local or systemic toxicity were observed. CONCLUSIONS: Oral administration of diazepam seems to lessen the adverse effects from accidental epidural administration of succinylcholine. The meticulous and discriminative labeling of syringes, as well as keeping persistent cautions during all anesthesia procedures remains of crucial importance.

Rocuronium-sugammadex for electroconvulsive therapy management in neuroleptic malignant syndrome: A case report. / Rocuronio-sugammadex para el manejo de la terapia electroconvulsiva en el síndrome neuroléptico maligno, a propósito de un caso.

Neuroleptics are a group of drugs widely used in the treatment of psychotic symptoms. Among their adverse effects is the ability to trigger a neuroleptic malignant syndrome (NMS). The diagnosis of NMS is determined by exclusion, and its initial therapeutic management should be the withdrawal of neuroleptics, the administration of benzodiazepines, and electroconvulsive therapy (ECT). ECT is an effective treatment in these patients, and in those cases with a poor response to treatment with antipsychotic drugs. A review is presented on the treatment options and anaesthetic implications of ECT used to handle a patient diagnosed with paranoid schizophrenia in the context of NMS.

Desarrollo tecnológico e introducción del inyectable succinilcolina 50 mg/mL en el cuadro básico de medicamentos nacional de Cuba / Technological development and introduction of the injectable succinylcholine 50 mg/mL in the basic table of national medicines of Cuba / Desenvolvimento tecnológico e introdução da succinilcolina injetável 50 mg/mL na mesa da medicina básica de Cuba

RESUMEN Introducción: El inyectable succinilcolina 50 mg/mL se utiliza para intubaciones traqueales rápidas. Objetivo: Desarrollar e introducir el inyectable succinilcolina 50 mg/mL en el cuadro básico de medicamentos. Tres variantes de formulación fueron diseñadas: dos con preservantes antimicrobianos y presentación (bulbos 6R y 10R) y una sin preservantes (bulbos 6R). Metodología: Se validaron los métodos empleados para el control de calidad y estabilidad. A los lotes elaborados a escala de laboratorio, piloto e industrial con la fórmula seleccionada se les realizó estudio de estabilidad acelerada y vida útil. Las variantes diseñadas evidenciaron adecuada calidad, la no preservada fue seleccionada para realizar lotes a diferentes escalas. Las técnicas cromatográficas empleadas para la cuantificación de la succinilcolina cumplieron con los criterios de validación establecidos. Resultados: Se demostró el desempeño de las pruebas de esterilidad y ensayo de endotoxinas bacterianas. El producto en estudio de estabilidad indicó un adecuado comportamiento físico, químico y micro-biológico durante el período evaluado. Se comprobó la factibilidad del desarrollo tecnológico, con la fórmula seleccionada para el inyectable succinilcolina 50 mg/mL. Se introdujo el inyectable en el cuadro básico de medicamentos nacional.

SUMMARY Introduction: The injectable succinylcholine 50 mg/mL is used for rapid tracheal intubations. Aim: To develop and introduce the injectable succinylcholine 50 mg/mL into the basic drug table. Three formulation variants were designed: two with antimicrobial and presentation preservatives (6R and 10R bulbs) and one unpreserved (6R bulbs). Methodology: The methods used for quality control and stability were validated. Laboratory, pilot and industrial-scale batches with the selected formula were studied for accelerated stability and service life. The designed variants showed adequate quality, selecting the non-preserved, to make batches at different scales. Chromatographic techniques used for the quantification of succinylcholine met established validation criteria. Results: The performance of sterility tests and bacterial endotoxin testing was demonstrated. The product under stability study indicated adequate physical and chemical behavior during the period evaluated. The feasibility of technological development was verified, with the formula selected for the injectable succinylcholine 50 mg/mL. Injectable was introduced in the national medicines basic table.

RESUMO Introdução: A succinilcolina injetável 50 mg/mL é utilizada para intubações traqueais rápidas. Objetivo: Desenvolver e introduzir a succinilcolina injetável 50 mg/mL na tabela básica de medicamentos. Três variantes de formulação foram projetadas: duas com conservantes antimicrobianos e apresentação (lâmpadas 6R e 10R) e uma sem conservantes (lâmpadas 6R). Metodologia: Foram validados os métodos utilizados para o controle de qualidade e estabilidade. Estudos acelerados de estabilidade e vida de prateleira foram realizados nos lotes produzidos em escala laboratorial, piloto e industrial com a fórmula selecionada. As variantes projetadas apresentaram qualidade adequada, a não preservada foi selecionada para a realização de lotes em diferentes escalas. As técnicas cromatográficas utilizadas para a quantificação da succinilcolina atenderam aos critérios de validação estabelecidos. Resultados: Foi demonstrado o desempenho dos testes de esterilidade e do ensaio de endotoxinas bacterianas. O produto em estudo de estabilidade indicou comportamento físico, químico e microbiológico adequado durante o período avaliado. Foi verificada a viabilidade do desenvolvimento tecnológico, com a fórmula selecionada para a succinilcolina injetável 50 mg/mL. O injetável foi introduzido na tabela nacional de medicamentos básicos.

[Prophylactic use of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia: a randomized, double-blinded, placebo-controlled study]. / Uso profilático de pregabalina para prevenção de mialgia e fasciculação induzidas por succinilcolina: estudo randômico, duplo-cego e controlado por placebo.

BACKGROUND: Succinylcholine is commonly used to achieve profound neuromuscular blockade of rapid onset and short duration. OBJECTIVE: The present study compared the efficacy of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia. DESIGN: Prospective, randomized, placebo controlled, double blinded study. MATERIALS AND METHODS: Patients of both genders undergoing elective spine surgery were randomly assigned to two groups. Patients in Group P (pregabalin group) received 150mg of pregabalin orally 1h prior to induction of anesthesia with sips of water and patients in Group C (control group) received placebo. Anesthesia was induced with fentanyl 1.5mcg/kg, propofol 1.5-2.0mg/kg followed by succinylcholine 1.5mg/kg. The intensity of fasciculations was assessed by an observer blinded to the group allotment of the patient on a 4-point scale. A blinded observer recorded postoperative myalgia grade after 24h of surgery. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. RESULTS: Demographic data of both groups were comparable (p>0.05). The incidence of muscle fasciculation's was not significant between two groups (p=0.707), while more patients in group C had moderate to severe fasciculation's compared to group P (p=0.028). The incidence and severity of myalgia were significantly lower in group P (p<0.05). CONCLUSION: Pregabalin 150mg prevents succinylcholine-induced fasciculations and myalgia and also decreases the fentanyl consumption in elective sine surgery.

Prophylactic use of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia: a randomized, double-blinded, placebo-controlled study.

BACKGROUND: Succinylcholine is commonly used to achieve profound neuromuscular blockade of rapid onset and short duration. OBJECTIVE: The present study compared the efficacy of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia. DESIGN: Prospective, randomized, placebo controlled, double blinded study. MATERIALS AND METHODS: Patients of both genders undergoing elective spine surgery were randomly assigned to two groups. Patients in Group P (pregabalin group) received 150mg of pregabalin orally 1h prior to induction of anesthesia with sips of water and patients in Group C (control group) received placebo. Anesthesia was induced with fentanyl 1.5mcg/kg, propofol 1.5-2.0mg/kg followed by succinylcholine 1.5mg/kg. The intensity of fasciculations was assessed by an observer blinded to the group allotment of the patient on a 4-point scale. A blinded observer recorded postoperative myalgia grade after 24h of surgery. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. RESULTS: Demographic data of both groups were comparable (p>0.05). The incidence of muscle fasciculation's was not significant between two groups (p=0.707), while more patients in group C had moderate to severe fasciculation's compared to group P (p=0.028). The incidence and severity of myalgia were significantly lower in group P (p<0.05). CONCLUSION: Pregabalin 150mg prevents succinylcholine-induced fasciculations and myalgia and also decreases the fentanyl consumption in elective sine surgery.

Deficiencia de butirilcolinesterasa: Una revisión narrativa de la literatura / Butirilcholinesterase Deficiency: A Narrative Review of Literature

RESUMEN La butirilcolinesterasa es una enzima que metaboliza relajantes neuromusculares despolarizantes como la succinilcolina, fármaco de elección para procedimientos que requieran parálisis muscular a corto plazo como facilitar la intubación endotraqueal en pacientes sometidos a procedimientos de emergencia. La deficiencia de butirilcolinesterasa se define como la reducción cuantitativa de dicha enzima y su actividad para hidrolizar moléculas, constituyéndose en la principal causa de bloqueo neuromuscular prolongado tras la administración de relajantes neuromusculares como la succinilcolina. Es una condición patológica que puede ser de origen hereditario o adquirido; siendo más común la deficiencia enzimática de origen genético y de carácter autosómico recesivo, la cual se presenta aproximadamente en una de cada 3200 a 5000 personas en todo el mundo. Su manifestación clínica se caracteriza por relajación muscular persistente, la cual puede producir insuficiencia respiratoria aguda. El diagnóstico debe estar orientado a la identificación de sus características clínicas, la cuantificación serológica y el monitoreo neuromuscular. Debido a que no existe cura para esta deficiencia, el manejo debe estar orientado a realizar ventilación mecánica del paciente hasta que el medicamento empleado se metabolice por completo. Este artículo tiene como objetivo realizar una revisión del estado del arte, describiendo su epidemiología, etiología, fisiopatología, manifestaciones clínicas y actualidades en su diagnóstico y tratamiento.

ABSTRACT Butyrylcholinesterase is an enzyme that metabolizes depolarizing neuromuscular relaxants, such as succinylcholine, a chosen medication for procedures that require short-term muscular paralysis, to facilitate endotracheal intubation in patients undergoing emergency procedures, for example. Butyrylcholinesterase deficiency can be defined as a quantitative reduction of the enzyme and its activity to hydrolyze molecules, becoming the main cause of prolonged neuromuscular blockade after the administration of neuromuscular relaxants such as succinylcholine. It is a pathological condition that can be of either hereditary or acquired origin; being more common the enzymatic deficiency of genetic origin and of auto-somal recessive character, occurring in approximately one in 3,200 to 5,000 people worldwide. Its clinical manifestation is characterized by persistent muscle relaxation which can lead to acute respiratory failure. The diagnosis must be oriented to the identification of its clinical characteristics, serological quantification, and neuromuscular monitoring. Because a cure does not exist for this deficiency, management should be directed to mechanical ventilation of the patient, until the used drug is fully metabolized. This article aims to review the state of the art, describing its epidemiology, etiology, pathophysiology, clinical manifestations, and updates in its diagnosis and treatment.

Capacidad del índice de El-Ganzouri para predecir el grado de dificultad en la intubación traqueal / El-Ganzouri index effectiveness for predicting the degree difficulty in tracheal intubation

Introducción: La intubación de la vía respiratoria difícil constituye un problema de salud. Para prevenirla, se han utilizado diferentes índices. Objetivo: Evaluar la utilidad del índice de El-Ganzouri en la predicción del grado de dificultad en la intubación traqueal mediante laringoscopia convencional. Método: Se realizó un estudio descriptivo de corte transversal, en pacientes que requirieron intubación traqueal, en el Hospital Hermanos Ameijeiras, entre febrero de 2014 y 2017. Esta prueba combina y estratifica siete variables derivadas de parámetros observacionales asociadas individualmente. Se estratificó sus valores y se interpretó < 4 vía respiratoria de fácil acceso y ; 4 vía respiratoria de difícil acceso. Resultados: Se estudiaron 94 pacientes en los que se evaluó el índice de El-Ganzouri. Predominó el grupo etáreo de 50 a 59 años (29,8 por ciento) y el sexo masculino 52,1 por ciento. ASA II fue más frecuente en 66 por ciento. El índice de El Ganzouri primó la apertura oral lt; 4 cm, la distancia tiromentoniana gt; 6.5 cm, El Mallamapati I en 91,5 por ciento, los movimientos del cuello gt; 90°, el peso corporal < 90 kg y ningún antecedente de historia de dificultad en la intubación 67,0 por ciento. Al corroborar las pruebas predictivas con la de Cormack y Lehane, se observó que 92,6 por ciento de los pacientes presentaron una vía respiratoria fácil y esta condición se obtuvo en el 78,7 por ciento con el Índice El Ganzouri. La sensibilidad fue de 71,43 por ciento y la especificidad fue de 20,69 por ciento. El valor predictivo positivo de 6,76 y 90,0 de predictivo negativo. Conclusiones: Se confirmó la utilidad del índice de riesgo multivariado de El-Ganzouri en la predicción del grado de dificultad en la intubación traqueal mediante laringoscopia convencional. Se identificó la sensibilidad, especificidad, valores predictivos positivos y negativos los cuales mostraron buena predicción de vía respiratoria anatómicamente difícil(AU)

Rocuronio versus succinilcolina en el paciente obeso tratado con cirugía bariátrica laparoscópica / Rocuronium versus succinylcholine in the obese patient treated with laparoscopic bariatric surgery

Introducción: Las personas obesas son consideradas pacientes de riesgo para la intubación, de modo que el tiempo entre la pérdida de la consciencia y la intubación de la tráquea debe ser el más corto posible. Objetivo: Evaluar las condiciones de intubación traqueal en obesos tratados con cirugía bariátrica laparoscópica al usar rocuronio comparado con succinilcolina. Métodos: Estudio cuasiexperimental, comparativo y transversal realizado en el Hospital Universitario Gral. Calixto García, desde enero de 2016 hasta diciembre de 2017, en 64 pacientes obesos programados electivamente para cirugía bariátrica laparoscópica, divididos en dos grupos: Grupo S: succinilcolina 1 mg/Kg de peso real y Grupo R: rocuronio 0,6 mg/Kg de peso ideal. Las variables analizadas fueron: edad, sexo, índice de masa corporal, tiempo de latencia, índice de bloqueo máximo, condiciones de intubación y efectos secundarios. Resultados: El rango de edad que predominó en ambos grupos fue 40 a 59 años, y en su mayoría mujeres. El mayor número de pacientes presentaron una obesidad grado III y estado físico ASA II. Los tiempos medios de latencia e índices de bloqueo máximo fueron significativamente menores en los pacientes en que se usó succinilcolina respecto a los que usaron rocuronio. Las condiciones de intubación a los 40 seg en los dos grupos, según la escala de Cooper, fueron excelentes y buenas, sin diferencias significativas. Conclusiones: El rocuronio es una alternativa segura para conseguir condiciones óptimas de intubación en pacientes obesos tratados con cirugía bariátrica laparoscópica, al compararlo con la succinilcolina(AU).

Introduction: Obese people are considered patients at risk for intubation, so that the time between loss of consciousness and intubation of the trachea should be as short as possible. Objective: To evaluate the conditions of tracheal intubation in obese patients treated with laparoscopic bariatric surgery when using rocuronium compared to succinylcholine. Methods: Quasi-experimental, comparative and cross-sectional study carried out in General Calixto García University Hospital, from January 2016 to December 2017, in 64 obese patients electively scheduled for laparoscopic bariatric surgery, divided into two groups: Group S: succinylcholine 1 mg/Kg of real weight and Group R: rocuronium 0.6 mg/Kg of ideal weight. The variables analyzed were: age, sex, body mass index, latency time, maximum blocking index, intubation conditions and side effects. Results: The age range that predominated in both groups was 40 to 59 years, and mostly women. The highest number of patients presented a grade 3 obesity and physical state ASA II. Mean latency times and maximal blockade rates were significantly lower in patients in whom succinylcholine was used than in those who used rocuronium. The conditions of intubation at 40 seconds in the two groups, according to the Cooper scale, were excellent and good, without significant differences. Conclusions: Rocuronium is a safe alternative to achieve optimal intubation conditions in obese patients treated with laparoscopic bariatric surgery, when compared to succinylcholine(AU)

Eficacia de tres dosis de succinilcolina en la inducción de secuencia rápida / Effectiveness of three doses of succinylcholine in rapid sequence induction

Introducción: La intubación de secuencia de rápida es un procedimiento que minimiza el tiempo necesario para asegurar la vía respiratoria en pacientes con alto riesgo de broncoaspiración. Objetivo: Comparar la eficacia de tres dosis de succinilcolina en la inducción de secuencia rápida en pacientes con estómago y la calidad de la intubación, así como los efectos secundarios de dichos fármacos. Métodos: Se realizó un estudio observacional, de corte transversal para evaluar la calidad de la intubación con inducción de secuencia rápida en pacientes de urgencia, con estómago lleno. Se administraron 0,4 mg/kg de succinilcolina al grupo I, 0,6 mg/kg al grupo II y 1 mg/kg al grupo III. En todos los pacientes se evaluó la vía respiratoria. El estudio se realizó en el Hospital Clínico Quirúrgico "Hermanos Ameijeiras" entre agosto de 2013 y 2016. Resultados: El tiempo de visualización de las cuerdas vocales fue rápido en los tres grupos. Los mejores resultados se obtuvieron en el grupo III, seguido del grupo II. Las condiciones de intubación fueron excelentes en el grupo III (90 %), buenas en grupo II (80 %) y regulares en el grupo I (70 %). Las variables hemodinámicas mostraron diferencias significativas entre grupos (p=0,008). Conclusiones: Se determinó la eficacia del empleo de tres dosis de succinilcolina en la inducción de secuencia rápida, con intubación óptima y segura cuando se empleó la succinilcolina a dosis de 1 mg/kg; pero con mayor porcentaje de alteraciones hemodinámicas como efectos adversos(AU)

Introduction: Rapid sequence intubation is a procedure that minimizes the time required to guarantee the respiratory airway in patients with high risk of bronchoaspiration. Objectives: To compare the quality of intubation with three doses of succinylcholine in rapid sequence induction in patients with full stomach, as well as the side effects of such drugs. Methods: An observational, cross-sectional study was carried out to assess the quality of intubation with rapid sequence intubation in emergency patients and with full stomach. The group I was administered 0.4 mg/kg of succinylcholine; the group II, 0.6 mg/kg; and the group III 1 mg/kg. The respiratory airway was assessed in all patients. The study was carried out in Hermanos Ameijeiras Clinical Surgical Hospital, between August 2013 and 2016. Results: The time of visualization of the vocal folds was fast in the three groups. The best results were obtained in the group III, followed by the group II. The intubation conditions were excellent in the group III (90%), good in the group II (80%), and fair in the group I (70%). The hemodynamic variables showed significant differences among the three groups (p=0.008). Conclusions: The effectiveness was determined of using three doses of succinylcholine in rapid sequence intubation, with optimal and safe intubation when succinylcholine was used at doses of 1 mg/kg, but it had a higher percentage of hemodynamic alterations as adverse effects(AU)

Manejo anestésico en la enfermedad de Von Recklinghausen. Reporte de un caso / Von Recklinghausen syndrome: Case report and anesthesis management

La enfermedad de Von Recklinghausen o neurofibromatosis tipo I es una enfermedad caracterizada por tendencia a la formación de tumores de tejidos del ectodermo y mesodermo. Existen diversas implicaciones anestésicas que incluyen la sensibilidad alterada a la succinilcolina y a relajantes neuromusculares no-despolarizantes, además de alteraciones en la anatomía normal de la vía aérea; se presenta el caso de una paciente de 58 años programada para la resección de tumoración cutánea temporo-parietal derecha, se utilizó succinilcolina como relajante muscular en donde a pesar de la vida media corta de éste, no se requirió de dosis subsecuentes durante el tiempo de duración de la cirugía; por lo que se corroboro una sensibilidad alterada hacia los relajantes musculares de tipo despolarizantes en este tipo de pacientes.

Von Recklinghausen disease or neurofibromatosis type I is a disease characterized by the tendency to form tissue tumors of the ectoderm and mesoderm. There are several anesthetic implications that include altered sensitivity to succinylcholine and non-depolarizing neuromuscular relaxants, in addition to alterations in the normal anatomy of the airway; we present the case of a 58 year old patient scheduled for the resection of the right temporo-parietal cutaneous tumor. Succinylcholine was used as a muscle relaxant. Despite its short half-life, no subsequent doses were required during the treatment period duration of surgery; Therefore, an altered sensitivity towards muscle relaxants of depolarizing type was corroborated in this type of patients.

Deficiencia de butirilcolinesterasa identificada después de la administración de succinilcolina. Reporte del caso / Butyrylcholinesterase deficiency identified after succinylcholine administration. Case report

RESUMEN La función principal de la enzima butirilcolinesterasa es hidrolizar ésteres exógenos como los que están presentes en el relajante neuromuscular succinilcolina, que se utiliza con frecuencia en procedimientos quirúrgicos de corta duración. Se considera que la herencia de butirilcolinesterasa atípica o deficiencia de butirilcolinesterasa es un rasgo autosómico recesivo que se presenta aproximadamente en una de cada 3200 a 5000 personas. Dicha deficiencia puede tener consecuencias graves en pacientes anestesiados con dicho relajante porque en ocasiones causa prolongación de la parálisis o apnea posoperatoria. Se presenta el caso de una paciente de 73 años admitida al servicio de cirugía para una tiroidectomía subtotal. Finalizada la intervención, no emergió espontáneamente del anestésico, presentó signos de relajación con mal esfuerzo inspiratorio y sin recuperar la respuesta neuromuscular; por ello se procedió a revertir con neostigmina, previa aplicación de atropina. La reversión falló por lo que fue trasladada a la unidad de cuidados intensivos. En los exámenes se halló reducido el nivel de colinesterasa sérica, lo que indicó una deficiencia de butirilcolinesterasa compatible con sus síntomas. Tal situación está descrita en la literatura médica.

SUMMARY The main function of the enzyme butyrylcholinesterase is to hydrolyze exogenous esters such as those present in the neuromuscular blocking agent succinylcholine, which is frequently used in short surgical procedures. Inheritance of atypical butyrylcholinesterase or butyrylcholinesterase deficiency is considered an autosomal recessive characteristic and occurs worldwide in approximately one out of 3200 to 5000 people. Such deficiency may have serious consequences for patients anesthetized with that relaxant because sometimes it causes an extension of paralysis or postoperative apnea. We report the case of a 73-year-old woman submitted to subtotal thyroidectomy. After surgery, she did not spontaneously emerge from anesthesia, had signs of relaxation with poor inspiratory effort, and no recovery of neuromuscular response. After application of atropine, reversal was attempted with neostigmine, but it failed, and she was transferred to the ICU. Laboratory results revealed a reduced level of serum cholinesterase indicating a deficiency in butyrylcholinesterase consistent with her symptoms. Such situation has been described in medical literature.

Duración del bloqueo neuromuscular con succinilcolina y su relación con niveles de colinesterasa plasmática en pacientes sépticos: Hospital Central Universitario Dr. Antonio María Pineda / Neuromuscular blockade duration with succinylcholine and its correlation with levels of plasma cholinesterase in septic patients: Hospital Central Universitario Dr. Antonio María Pineda

La succinilcolina es un fármaco neuromuscular despolarizante generalmente utilizado en el contexto de protocolo de intubación de secuencia rápida indicada en pacientes en los cuales es necesario asegurar la vía aérea en menos de sesenta segundos. Se realizó un estudio descriptivo transversal con el objetivo de determinar la duración del bloqueo neuromuscular con succinilcolina y los niveles de colinesterasa plasmática en pacientes sépticos intervenidos en el Hospital Central Universitario Dr. Antonio María Pineda. Se incluyeron 30 pacientes con sepsis con un promedio de edad de 49,6 ± 17,4 años y predominio del sexo masculino (70%); la principal indicación de cirugía abdominal fue obstrucción intestinal (36,6%) y peritonitis secundaria (23,3%). Los valores de colinesterasa plasmática se registraron disminuidos en 42,8% de los hombres y 33,3% de las mujeres encontrándose valores promedios de 5554,1 ± 1220,5 U/L y 4770,1 ± 1627,4 U/L, respectivamente. La duración del bloqueo neuromuscular fue mayor de 14 minutos en 66,6% de las mujeres; el promedio de duración fue de 14,4 ± 5,1 min (mujeres) y 9,4 ± 4,3 min en hombres. Hubo una pobre correlación entre los niveles de colinesterasa plasmática y la duración así como el tiempo de recuperación del bloqueo neuromuscular. En conclusión, el bloqueo neuromuscular prolongado debido a la baja actividad de la colinesterasa después de la administración de succinilcolina se presenta en menos de la mitad de los pacientes sépticos estudiados(AU)

Succinylcholine is a depolarizing neuromuscular drug generally used in the context of rapid sequence intubation indicated in patients in whom it is necessary to secure the airway in less than sixty seconds. A descriptive cross-sectional study was conducted in order to determine the duration of neuromuscular blockade with succinylcholine and plasma cholinesterase levels in septic patients admitted at Hospital Central Universitario Dr. Antonio Maria Pineda. A sample of 30 patients with sepsis were studied, with a mean age of 49.6 ± 17.4 years, predominantly male (70%). The main indication for abdominal surgery was intestinal obstruction (36.6%) and secondary peritonitis (23.3%). Diminished values of plasma cholinesterase were recorded in 42.8% of men and 33.3% of women; mean plasma levels were 5554.1 ± 1220.5 U/L and 4770.1 ± 1627.4 U/L, respectively. Duration of neuromuscular blockade was longer in women (66.6%) with an average duration of 14.4 ± 5.1 min and 9.4 ± 4.3 min for men. A poor correlation between cholinesterase plasmatic levels and duration as well as time of recovery of neuromuscular blockage was found. Prolonged neuromuscular blockade is due to low cholinesterase activity after administration of succinylcholine and occurs in less than half of septic patients studied(AU)

Análisis costo-efectividad de rocuronio y succinilcolina en tiroidectomías programadas / Cost-effectiveness analisys ofrocuronium and succinylcholine in programmed thyroidectomy

RESUMEN En el presente trabajo se realiza un análisis costo-efectividad de la succinilcolina y del rocuronio utilizados en la intubación de pacientes sometidos a tiroidectomía programada, mediante un estudio descriptivo prospectivo, donde se tuvo en cuenta la calidad de intubación, los tiempos de latencia y de relajación muscular, necesidad de reversión farmacológica del bloqueo neuromuscular, parámetros hemodinámicos, reacciones adversas y costos directos e indirectos en 30 pacientes sometidos al procedimiento. El análisis económico evidenció la existencia de diferencias significativas entre los costos asociados al tiempo de latencia de la relajación muscular. En cuanto a los costos relacionados al bloqueo muscular, se observó que el grupo con succinilcolina presentó unos costos totales de 10972 ± 341,7 pesos colombianos, mientras que con rocuronio fueron de 63088 ± 1.184 con valor P < 0,0001. La succinilcolina mostró mayor costo-efectividad al presentar menor tiempo de latencia, mejores condiciones de intubación, no provocar cambios hemodinámicos clínicamente significativos y bajo costo al ser comparado con rocuronio.

SUMMARY The goal of this work was to perform a cost-effectiveness analysis of succinylcho-line and rocuronium used in the intubation of patients undergoing programmed thyroidectomy was compared by means of a prospective descriptive study, which included intubation quality, latency and muscle relaxation times, pharmacological reversion Neuromuscular blockade, hemodynamic parameters, adverse reactions and direct and indirect costs in 30 patients undergoing the procedure. The economic analysis evidenced the existence of significant differences between the costs associated with the latency time of muscle relaxation. Regarding the costs related to muscle blockade, it was observed that the succinylcholine group performed a total cost of 10972 ± 341.7 Colombian pesos, while with rocuronium it was 63088 ± 1184 with P value < 0.0001. Succinylcholine showed higher cost/effectiveness when presenting the shortest latency time, the best intubation conditions, no clinically significant cost changes and low cost when compared to rocuronium.

Inadvertent injection of succinylcholine as an epidural test dose / Injeção inadvertida de succinilcolina como uma dose teste epidural

Abstract Background and objectives: Epidural action of neuromuscular blocking agents could be explained under the light of their physicochemical characteristics and epidural space properties. In the literature there are few cases of accidental neuromuscular agent's epidural administration, manifesting mainly with neuromuscular blockade institution or fasciculations. Case report: We report a case of accidental succinylcholine administration as an epidural test dose, in a female patient undergoing scheduled laparotomy, under combined general and epidural anesthesia. Approximately 2 min after the succinylcholine injection the patient complained for shortness of breath, while mild fasciculations appeared in her trunk and face, managed by immediate general anesthesia institution. With the exception of a relatively longer duration of neuromuscular blockade compared with intravenous administration, no neurological or cardiovascular sequelae or other symptoms of local or systemic toxicity were observed. Conclusions: Oral administration of diazepam seems to lessen the adverse effects from accidental epidural administration of succinylcholine. The meticulous and discriminative labeling of syringes, as well as keeping persistent cautions during all anesthesia procedures remains of crucial importance.

Resumo Justificativa e objetivos: A ação epidural de agentes bloqueadores neuromusculares pode ser explicada à luz de suas características físico-químicas e propriedades do espaço epidural. Na literatura existem poucos casos sobre a administração acidental em espaço epidural de agente neuromuscular que se manifesta principalmente com a instituição de bloqueio neuromuscular ou fasciculações. Relato de caso: Relatamos um caso de administração acidental de succinilcolina como uma dose teste epidural em uma paciente submetida à laparotomia programada, sob anestesia combinada geral e peridural. Aproximadamente dois minutos após a injeção de succinilcolina, a paciente queixou-se de falta de ar, enquanto fasciculações leves apareceram em seu tronco e rosto, tratadas com a instituição imediata de anestesia geral. Exceto pela duração relativamente longa do bloqueio neuromuscular em comparação com a administração intravenosa, sequelas neurológicas ou cardiovasculares ou outros sintomas de toxicidade local ou sistêmica não foram observados. Conclusões: A administração oral de diazepam parece diminuir os efeitos adversos da administração epidural acidental de succinilcolina. A meticulosidade e discriminação dos rótulos das seringas, bem como os cuidados persistentes mantidos durante todos os procedimentos de anestesia, continuam a ser de importância crucial.

Prophylactic use of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia: a randomized, double-blinded, placebo-controlled study / Uso profilático de pregabalina para prevenção de mialgia e fasciculação induzidas por succinilcolina: estudo randômico, duplo-cego e controlado por placebo

ABSTRACT BACKGROUND: Succinylcholine is commonly used to achieve profound neuromuscular blockade of rapid onset and short duration. OBJECTIVE: The present study compared the efficacy of pregabalin for prevention of succinylcholine-induced fasciculation and myalgia. DESIGN: Prospective, randomized, placebo controlled, double blinded study. MATERIALS AND METHODS: Patients of both genders undergoing elective spine surgery were randomly assigned to two groups. Patients in Group P (pregabalin group) received 150 mg of pregabalin orally 1 h prior to induction of anesthesia with sips of water and patients in Group C (control group) received placebo. Anesthesia was induced with fentanyl 1.5 mcg/kg, propofol 1.5-2.0 mg/kg followed by succinylcholine 1.5 mg/kg. The intensity of fasciculations was assessed by an observer blinded to the group allotment of the patient on a 4-point scale. A blinded observer recorded postoperative myalgia grade after 24 h of surgery. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. RESULTS: Demographic data of both groups were comparable (p > 0.05). The incidence of muscle fasciculation's was not significant between two groups (p = 0.707), while more patients in group C had moderate to severe fasciculation's compared to group P (p = 0.028). The incidence and severity of myalgia were significantly lower in group P (p < 0.05). CONCLUSION: Pregabalin 150 mg prevents succinylcholine-induced fasciculations and myalgia and also decreases the fentanyl consumption in elective sine surgery.

RESUMO JUSTIFICATIVA: A succinilcolina é comumente usada para atingir um bloqueio neuromuscular profundo, de início rápido e de curta duração. OBJETIVO: Comparar a eficácia de pregabalina na prevenção de mialgia e fasciculação induzidas por succinilcolina. DESENHO: Estudo prospectivo, randômico, duplo-cego e controlado por placebo. MATERIAIS E MÉTODOS: Pacientes de ambos os sexos submetidos a cirurgia eletiva de coluna foram aleatoriamente divididos em dois grupos. Os pacientes do Grupo P (pregabalina) receberam 150 mg de pregabalina oral uma hora antes da indução da anestesia e os pacientes do Grupo C (controle) receberam placebo. A anestesia foi induzida com fentanil (1,5 mcg/kg) e propofol (1,5-2,0 mg/kg), seguidos de succinilcolina 1,5 mg/kg. A intensidade da fasciculação foi avaliada por um observador, cego para a alocação dos grupos, com uma escala de 4 pontos. Um observador cego registrou o grau pós-operatório de mialgia após 24 horas de cirurgia. Para o alívio da dor no pós-operatório, fentanil foi usado em sistema de analgesia controlada pelo paciente. RESULTADOS: Os dados demográficos de ambos os grupos eram comparáveis (p > 0,05). A incidência de fasciculação muscular não foi significativa entre os dois grupos (p = 0,707), enquanto mais pacientes do Grupo C apresentaram fasciculação de moderada a grave em relação ao Grupo P (p = 0,028). A incidência e a gravidade da mialgia foram significativamente menores no grupo P (p < 0,05). CONCLUSÃO: Pregabalina (150 mg) previne mialgia e fasciculação induzidas por succinilcolina, além de diminur o consumo de fentanil em cirurgia eletiva de coluna.

Desarrollo tecnológico de succinilcolina infantil 100 mg, inyectable en solución / Technological development of 100 mg infant succinylcoline, injectable in a solution

Objetivo: desarrollar una nueva formulación inyectable en solución acuosa de succinilcolina, para uso pediátrico. Métodos: se utiliza la materia prima cloruro de succinilcolina con demostrada calidad para el diseño de la formulación. Fueron ensayadas tres variantes de formulación, durante seis meses, a una temperatura de 25±2 oC y una humedad relativa de 60±5 por ciento, se analiza la influencia de los componentes y el envase sobre el contenido del fármaco. Resultados: la formulación envasada en bulbos 6R, sin agentes preservantes, se selecciona como la mejor variante. Los tres lotes a escala de laboratorio cumplieron con los parámetros de calidad establecidos y se realizó el escalado piloto. Conclusiones: se comprobó la factibilidad del desarrollo del inyectable en solución de succinilcolina infantil 100mg(AU)

Objective: to develop a new injectable formulation in aqueos solution of succinylcoline for pediatric uses. Methods: the raw material for the formulation was succinylcoline chloride with proven quality for this design. Three variants of formulation were tested for six months at a temperature of 25±2 oC and relative humidity of 60±5 percent. The influence of the components and of the packing on the contents of the drug was analyzed. Results: the formulation packed in flasks 6R with no preserving agent was chosen as the best. Three batches at lab scale met the set quality parameters and also a pilot scale-up was performed. Conclusions: the feasibility of the development of an injectable product in 100mg infant succinylcoline solution(AU)