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Is Succinylcholine After Pretreatment With d-Tubocurarine and Lidocaine Contraindicated for Outpatient Anesthesia?

Ambulatory Anesthesia


Department of Anesthesiology, Edward Hines Veterans Administration Hospital, Hines, Illinois; Department of Anesthesiology, Northwestern University Medical School, Chicago, Illinois; and Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois

Anesth. Analg., 91: 312–316, 2000

Because of its obvious advantages, such as low cost, fast onset, and no need for reversal of neuromuscular block, succinylcholine is often used to aid endotracheal intubation in the ambulatory setting. Whether succinylcholine is associated with an increased incidence of postoperative myalgias compared with other, more expensive nondepolarizing muscle relaxants was studied in 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. Anesthesia was induced with propofol/lidocaine, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed using a fiberscope. Patients were randomly allocated to one of two muscle relaxant groups. Patients in group 1 received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Patients in group 2 were given mivacurium 0.2 mg/kg. After recovery from anesthesia, patients were asked whether they had any muscle pain and/or stiffness. Pain was categorized by location and quantified using a verbal scale from 0 to 10. The use of analgesia and the presence of myalgias that limited ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on postoperative day 1; if they complained of myalgias, they were called again on days 2 and 3. Only one patient in the group treated with mivacurium reported myalgia as a limitation to ambulation or resumption of normal activity. No differences existed between groups in the incidence (21% in the succinylcholine group and 18% in the mivacurium group), location, or severity of myalgia. Researchers concluded that succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) was not associated with a greater incidence of myalgias compared with mivacurium, when used to aid tracheal intubation in patients undergoing ambulatory nasal surgery.

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Succinylcholine-related myalgias were first described by Churchill-Davidson in 1954. 1 Many subsequent studies have attempted to define the problem, its etiologies, and the best prophylaxis. The literature pertaining to this problem, however, is as confusing as it is voluminous. Indeed, the reported incidence of succinylcholine-associated myalgias varies widely among investigations, ranging from 4.5 to 85 percent. 1–6 This variation is likely related to the effects of a host of factors other than the choice of muscle relaxant. These potentially confounding variables include type and location of surgery, intraoperative positioning, intubation trauma, postoperative ambulation, and incidence and degree of postoperative surgical pain necessitating analgesics. Indeed, ambulatory surgery patients are said to be at higher risk for succinylcholine-associated postoperative myalgias than are hospitalized patients, possibly owing to delayed ambulation and the use of stronger analgesics, which might mask muscle pains in hospitalized patients. Hence, Trepanier and colleagues 2 postulate that there may be a baseline incidence of myalgia in ambulatory surgery patients that is unrelated to the choice or use of muscle relaxants.

The current study used fiberoptic laryngoscopy to eliminate the trauma of rigid laryngoscopy as a possible trigger for postoperative myalgias. Moreover, age and sex distributions were similar between groups, anesthetic techniques and postoperative care were standardized, all patients underwent surgical procedures unlikely to cause muscle injury or limit ambulation, and all were discharged home on the day of surgery.

No doubt the etiology of postoperative myalgia is multifactorial. Several studies have shown, for example, that the substitution of nondepolarizing muscle relaxants for succinylcholine or the omission of muscle relaxants altogether failed to reduce the incidence of myalgia in patients undergoing gynecologic laparoscopy in the outpatient venue. 3,7,8 In this context, I believe that a limitation of this study is the absence of a control group that received succinylcholine 1.5 mg/kg alone, without pretreatment.

Kathryn E. McGoldrick M.D.

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1. Churchill-Davidson HC. Suxamethonium chloride and muscle pains. Br Med J 1954; 1:74–5.
2. Trepainer CA, Brosseau L, Lacertel L. Myalgia in outpatient surgery: a comparison of atracurium and succinylcholine. Can Anaesth Soc J 1998; 35:225–9.
3. Zahl K, Apfelbaum JL. Muscle pain occurs after outpatient laparoscopy despite the substitution of vercuronium for succinylcholine. Anesthesiology 1989; 70:408–11.
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7. Martin R, Carrier J. Pirlet M, et al. Rocuronium is the best nondepolarizing relaxant to prevent succinylcholine fasciculations and myalgia. Can J Anaesth 1998; 45:521–5.
8. Collins KM, Docherty PW, Plantevin PM. Postoperative morbidity following gynecologic outpatient laparoscopy: a reappraisal of the service. Anaesthesia 1984; 39:819–22.
© 2001 Lippincott Williams & Wilkins, Inc.