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Anesth Analg 2000;91:312-316
© 2000 International Anesthesia Research Society

AMBULATORY ANESTHESIA

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

Marianne Mikat-Stevens, MD*, Radha Sukhani, MD{dagger}, Ana L. Pappas, MD{ddagger}, Elaine Fluder, RN, MSN{ddagger}, Bruce Kleinman, MD*, and Rom A. Stevens, MD{dagger}

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

Address correspondence to Dr. Rom Stevens, Department of Anesthesiology, Northwestern University Medical School, 251 East Huron St., Suite 360, Passavant Pavilion, Chicago, IL 60611.


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix 1.
 References
 
Because succinylcholine has obvious advantages for facilitating endotracheal intubation in the ambulatory setting (e.g., low cost, fast onset, and no need for reversal of neuromuscular block), it is important to determine whether this muscle relaxant is indeed associated with an increased incidence of postoperative myalgias, compared with alternative but more expensive nondepolarizing muscle relaxants. We studied 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. The anesthetic technique consisted of propofol/lidocaine for induction, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed by using a fiberscope. Patients were randomly assigned to one of two muscle relaxant groups. Group 1 patients received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Group 2 patients received 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 by using a verbal scale (from 0 to 10). Analgesic usage and myalgias limiting ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on Postoperative Day 1. If patients complained of myalgias, they were contacted by telephone on Days 2 and 3. Only one patient (in the mivacurium-treated group) reported myalgia as a limiting factor in ambulation or resumption of normal activity. There were no differences between groups with respect to the incidence (21% in the succinylcholine-treated group and 18% in the mivacurium-treated group), location, or severity of myalgia. In conclusion, succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) is not associated with an increased incidence of myalgias, compared with mivacurium, when used to facilitate tracheal intubation in patients undergoing ambulatory nasal surgery.

Implications: The results of this study show that the frequency of muscle pains after surgery in outpatients is approximately 20%, regardless of whether succinylcholine (after precurarization) or mivacurium is used to assist in insertion of the breathing tube.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix 1.
 References
 
Enhanced awareness of pain-related morbidity has led to the consideration of succinylcholine-induced postoperative myalgia (1–5). It has been suggested that succinylcholine may not be a suitable choice for ambulatory patients, because myalgias associated with its use may delay the resumption of normal activity (1,6). Several studies have examined the issue of succinylcholine-induced myalgias in patients undergoing ambulatory surgery (1–6). The results have been conflicting. Two possible explanations for such conflicting results could be as follows: (a) several perioperative factors, i.e., patient position, type of surgery, patient age, patient sex, induction anesthetic, reversal of neuromuscular block, ambulatory patient versus inpatient, and traumatic tracheal intubation, could possibly contribute to postoperative myalgia (3,7–11) and (b) the numbers of patients in published studies might have been too small. Furthermore, the failure to delineate the severity of postoperative myalgias makes the clinical relevance of published data difficult to interpret. For example, a smaller incidence of postoperative myalgia was reported in studies that included only myalgias resulting in limitations of physical activity, compared with other studies in which this distinction was not made (1,2,4,5). In the present study, a population of outpatients undergoing endoscopic nasal sinus surgery and septoplasty was used to answer the following question: "Is succinylcholine (after pretreatment with d-tubocurarine and lidocaine) associated with a larger incidence of clinically relevant myalgias than mivacurium?"


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix 1.
 References
 
After we obtained approval from the Loyola University Medical Center Institutional Review Board and written, informed consent were received, 120 adult patients, ASA physical status I, II, or III, who were undergoing endoscopic nasal sinus surgery and septoplasty under general anesthesia were enrolled in the study. The following patients were excluded: (a) pregnant or lactating patients, (b) patients older than 50 yr, because succinylcholine-induced myalgias are reported to be less common in this group (1,2), (c) patients incapable of understanding the telephone questionnaire because of a language barrier or mental deficiency, (d) patients with neuromuscular disorders or malignant hyperpyrexia, for whom succinylcholine is contraindicated, (e) patients taking any preoperative analgesic medications, including opioid analgesics and nonsteroidal antiinflammatory drugs, (f) patients with histories of muscular pains, such as fibromyositis, fibromyalgia, myofascial pain syndromes, or other chronic pain disorders, and (g) patients who were not expected to be able to resume normal postoperative physical activity. Steroids were not administered to any patient in this study.

The postoperative pain questionnaire and numerical pain score (0–10, 0 = no pain and 10 = the worst pain ever experienced) were discussed preoperatively with all patients. All patients received premedication with midazolam 1–2 mg. The induction of anesthesia was accomplished by using IV propofol 2–2.5 mg/kg and lidocaine 1 mg/kg. Oral tracheal intubation was performed by using a fiberoptic intubating bronchoscope, within 1–2 min after the administration of muscle relaxant. Before the induction of anesthesia, patients were randomized into two groups by using a computer-generated table of random numbers. Group 1 patients received d-tubocurarine 3 mg IV, followed 3–5 min later by succinylcholine 1.5 mg/kg IV. Group 2 patients received mivacurium 0.2 mg/kg IV. Anesthesia was maintained by inhaled anesthetics, i.e., 70% nitrous oxide/30% oxygen with 0.5%–1.5% isoflurane (end-tidal), controlled ventilation, and fentanyl 50–100 µg IV. At the end of surgery, inhaled anesthetics were discontinued, and patients’ tracheas were extubated after protective airway reflexes were observed. No reversal of neuromuscular block was required. After recovery from anesthesia, patients were discharged to home when they met routine discharge criteria (pain was adequately controlled with oral analgesics, patients were able to drink and walk, and there was no evidence of significant surgical or anesthetic complications).

Postoperative care was standardized for all patients. If the tympanic temperature of the patient measured <36°C, if the patient complained of being cold, or if the patient shivered, a forced-air warming blanket was placed on the patient. For the first postoperative hour, pain was treated by using fentanyl, in 25-µg increments, IV. After the first hour, if the patients tolerated clear liquids, they were given one or two oral analgesic tablets (acetaminophen 325 mg/hydrocodone 5 mg) every 4 h as needed for pain. After patients were discharged from the ambulatory surgery center, this medication and dose were continued on an as-needed basis.

Both the patients and the research nurse (EF) were blinded with respect to the group assignment of the patient. For each patient, data collected included the presence or absence of myalgia (muscle pain and/or stiffness), myalgia location, myalgia severity (verbal 0–10 scale, 0 = no pain and 10 = the worst pain ever experienced), the presence or absence and the location of myalgia limiting ambulation, total anesthetic duration, total surgical duration, intra- and postoperative fentanyl doses, postoperative oral analgesic tablets administered, and the time to reaching discharge criteria. Myalgias were assessed in 11 muscle groups (Appendix 1). To simplify data analysis, the 11 muscle groups were localized to one of three areas, i.e., head/neck (neck and/or jaw stiffness), trunk, or extremities (including buttocks). The patients were contacted by telephone on Postoperative Day 1 (24–30 h after surgery), by the research nurse (Appendix 1). The patients were asked whether they had any muscle pains and/or had required any analgesics for pain other than at the site of surgery. If any myalgia was reported by the patient, then the patient was contacted by telephone again on Postoperative Days 2 and 3 or daily until the pain resolved. The patients were again questioned concerning the location and severity of the myalgia.

Myalgias were graded as mild (verbal pain score of <=4) or moderate to severe (score of >4). Data were presented as the mean ± SD or as a percentage. To test for differences between groups, the {chi}2 test, Student’s t-test, or Fisher’s exact test were used as appropriate, with P values of <0.05 being considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix 1.
 References
 
Demographic characteristics are presented in Table 1. One patient was excluded because data collection was incomplete. Therefore, we report data for 119 patients. There were no differences between groups with respect to age, sex, weight, ASA physical status, duration of anesthesia, duration of surgery, or intubation attempts. There were no patients for whom intubation of the trachea was considered difficult or required more than three attempts to complete.


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  		Table 1. Demographic Data, Duration of Anesthesia, and Duration of Surgery
 
Postanesthesia recovery room data are presented in Table 2. There were no differences between groups with respect to duration of stay, incidence of clinically significant vomiting (requiring treatment), dose of fentanyl, or percentage of patients requiring analgesic tablets (acetaminophen/hydrocodone) in the postanesthesia care unit. In the postanesthesia care unit, no patient in either group complained of myalgia.


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  		Table 2. Postanesthesia Recovery Room Data
 
The incidence and severity of myalgias after discharge from the ambulatory surgery center are summarized in Table 3. The overall incidence of myalgias (21% in Group 1 and 18% in Group 2) and their severity did not differ between the groups. Several patients reported myalgias in more than one muscle group. However, one patient, in the mivacurium-treated group, reported myalgia severe enough to limit ambulation and required a large number of oral analgesics (18 tablets during the first 24 h). This patient had a history of osteoarthritis of the neck. His myalgia was limited to his neck and shoulders. No other patient reported myalgias that limited ambulation or required oral analgesics in addition to those necessary to control surgical pain. In the first 24 h after surgery, the mean number of analgesic tablets taken was 4.0 (median 4, range 0–10) for the succinylcholine-treated group. The mean number taken was 5.3 (median 4, range 0–18) for the mivacurium-treated group. There were no differences between groups in the number of postoperative analgesic tablets taken.


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  		Table 3. Incidence of Myalgia After Discharge from the Ambulatory Surgery Center
 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix 1.
 References
 
Ambulatory surgery patients are said to be at greater risk for succinylcholine-induced postoperative myalgia than are hospitalized patients (12,13). This may be because of delayed ambulation and the use of more potent analgesics, which might mask muscle pains in hospitalized patients. It has been proposed that succinylcholine may not be a suitable choice for ambulatory patients, because myalgias associated with its use may delay the resumption of normal activity (1,6). The reported incidence of succinylcholine-induced myalgia varies widely among studies, from 4.5% to 85% (1,2,7,11,12,14). This is likely attributable to the effects of a variety of factors other than the choice of muscle relaxant (e.g., type and location of surgery, intubation trauma, postoperative ambulation, and incidence and degree of postoperative surgical pain requiring analgesics) on the incidence of postoperative myalgias.

Since the first description of succinylcholine-related myalgias by Churchill-Davidson (12) in 1954, there have been many studies attempting to define the problem, its causes, and the best prophylaxis. The literature is both voluminous and confusing (15–17). Our study controlled several confounding perioperative factors that have been suggested as possible causative factors for postoperative myalgias (3,7–11,18). In particular, our study used fiberoptic intubation to eliminate the trauma of laryngoscopy as a possible cause of postoperative myalgias. Age and sex distributions were not different between the groups, anesthetic techniques and postoperative care were standardized, all patients underwent surgical procedures that did not cause muscle injuries or limit ambulation, and all were discharged to home on the day of surgery. The overall incidence of myalgia and the severity of myalgia were not significantly different between the two muscle relaxant-treated groups. None of the patients in the succinylcholine-treated group experienced postoperative myalgia significant enough to limit ambulation or increase the need for postoperative analgesics.

Pretreatment with small doses of a nondepolarizing muscle relaxant before succinylcholine administration has been reported to minimize postoperative myalgia (4,9,11,17,19). However, despite this intervention, various incidences of myalgia, ranging from 20% to 70%, have been reported (1,16,20). Again, this evidence suggests that the mechanism of postoperative myalgia is probably multifactorial. For example, in an ambulatory patient population undergoing general endotracheal anesthesia, Trepanier et al. (1) used d-tubocurarine 3 mg as pretreatment before succinylcholine 1.5 mg/kg administration. The overall incidence of myalgia reported by those authors was 73%, with 50% of patients reporting myalgia severe enough to require bed rest and additional analgesics. The large incidence of moderate-to-severe myalgia reported by Trepanier et al. (1) could be related to the fact that the patients underwent some procedures that could have contributed to postoperative myalgia (e.g., gynecological, orthopedic, or plastic surgical procedures). In fact, 23% of the patients in the study by Trepanier et al. (1) who received atracurium and 20.8% of control patients who did not receive any muscle relaxant reported myalgias. A large incidence of postoperative myalgia has also been reported for patients undergoing gynecological laparoscopy in the ambulatory setting (2,17,21). The substitution of nondepolarizing muscle relaxants for succinylcholine or the omission of muscle relaxants altogether failed to decrease the incidence of myalgia in this patient population.

In our study, the patient population was uniform with respect to the type of surgery, and the incidence and severity of myalgias were not different for the succinylcholine- and mivacurium-treated groups. These observations seem to support the claim of Trepanier et al. (1) 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 position of the patient during surgery (e.g., lithotomy position, neck extension, lying anesthetized on the operating table for prolonged periods without support of the lumbar lordosis, or abdominal distention during laparoscopy) may contribute to postoperative myalgias.

One limitation of our study is that only patients who reported myalgias on Postoperative Day 1 (24–30 hours after surgery) were contacted again on Postoperative Days 2 and 3. Published data suggested that 66%–72% of patients subjected to early ambulation after succinylcholine use experience postoperative myalgia on the first postoperative day (12,22). One study of postoperative myalgia found that 92% of patients who reported myalgias reported them within 24 hours after surgery (23). Another study showed no difference in the incidences of myalgias reported 24 vs 48 hours after surgery (24). Therefore, we expect that our methodology would have identified most, if not all, cases of severe postoperative myalgia.

A significant limitation of this study is that we did not include a control group that received succinylcholine 1.5 mg/kg alone, without pretreatment. We did not do this because of data in the literature that suggest that moderate to severe postoperative myalgia in ambulatory patients who receive succinylcholine without pretreatment is relatively common (up to 40%, depending on the dose of succinylcholine) (1,4,11). For ethical reasons, we did not find it appropriate to include such a group in our study.

Another concern is related to the side effects of precurarization, including dyspnea, diplopia, and heavy eyelids. In our study, we found no evidence that these rare and transient problems produced patient discomfort among outpatients.

In conclusion, the use of succinylcholine in conjunction with d-tubocurarine and lidocaine pretreatment resulted in an incidence and severity of postoperative myalgias that did not differ from those observed after mivacurium administration. None of the patients who received succinylcholine reported myalgia that limited ambulation or increased the need for oral analgesics.


   Appendix 1.
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1.
References
 
Postoperative Questionnaire: Myalgia Study

Go


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  		Table 4.
 


   Footnotes
 
These findings were presented in abstract form at the annual meeting of the Society for Ambulatory Anesthesia on May 3, 1997, in Orlando, FL.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1.
 References
 

  1. Trepanier CA, Brosseau L, Lacertel L. Myalgia in outpatient surgery: a comparison of atracurium and succinylcholine. Can Anaesth Soc J 1988;35:225–9.
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  7. Luyk NH, Weaver JM, Quinn C, et al. A comparative trial of succinylcholine versus low dose atracurium-lidocaine combination for intubation in short outpatient procedures. Anesth Prog 1990;37:238–43.[Medline]
  8. Craig HJL. The protective effect of thiopentone against muscular pain and stiffness which follows the use of suxamethonium chloride. Br J Anaesth 1964;36:612–8.[Abstract/Free Full Text]
  9. Datta S, Crocker JS, Alper MH. Muscle pain following administration of suxamethonium to pregnant and non-pregnant patients undergoing laparoscopic tubal ligation. Br J Anaesth 1977;49:625–8.[Abstract/Free Full Text]
  10. Ding Y, Freedman B, White PF. Use of mivacurium during laparoscopic surgery: effect of reversal drugs on postoperative recovery. Anesth Analg 1994;78:450–4.[Abstract/Free Full Text]
  11. Manchikanti L, Grow JB, Colliver JA, et al. Atracurium pretreatment for succinylcholine-induced fasciculations and postoperative myalgia. Anesth Analg 1985;64:1010–4.[Free Full Text]
  12. Churchill-Davidson HC. Suxamethonium chloride and muscle pains. Br Med J 1954;1:74–5.
  13. Burtles R, Tunstall ME. Suxamethonium chloride and muscle pains. Br J Anaesth 1961;33:24–8.[Free Full Text]
  14. Durant NN, Katz RL. Suxamethonium. Br J Anaesth 1982;54:195–208.[Free Full Text]
  15. Cannon JE. Precurarization. Can J Anaesth 1994;41:177–83.[Web of Science][Medline]
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  17. Martin R, Carrier J, Pirlet M, et al. Rocuronium is the best non-depolarizing relaxant to prevent succinylcholine fasciculations and myalgia. Can J Anaesth 1998;45:521–5.[Web of Science][Medline]
  18. Kenefick JP, Leader A, Maltby JR, et al. Laparoscopy: blood gas values and minor sequelae associated with three techniques based on isoflurane. Br J Anaesth 1987;59:189–94.[Abstract/Free Full Text]
  19. Ferres CJ, Mirakhur RK, Craig HJL, et al. Pretreatment with vecuronium as a prophylaxis against post suxamethonium muscle pains. Br J Anaesth 1983;55:735–41.[Abstract/Free Full Text]
  20. Bennetts FE, Khalil KI. Reduction of post suxamethonium pain by pretreatment with four nondepolarising agents. Br J Anaesth 1981;53:531–6.[Abstract/Free Full Text]
  21. Collins KM, Docherty PW, Plantevin PM. Postoperative morbidity following gynecological out-patient laparoscopy: a reappraisal of the service. Anaesthesia 1984;39:819–22.[Web of Science][Medline]
  22. Morris DDB, Dunn CH. Suxamethonium chloride administration and postoperative muscle pain. Br Med J 1957;1:383.
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Accepted for publication May 1, 2000.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2000 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press