succinylcholine

Brand: Anectine, Quelicin

⚠ BBW ISMP High Alert Prototype Drug

Drug Class: neuromuscular blocking agent (NMBA)

Drug Family: neuromuscular blocking agent

Subclass: depolarizing NMBA

Organ Systems: cnsmusculoskeletal

Mechanism of Action

Binds and activates nicotinic ACh receptors at the neuromuscular junction causing initial fasciculations followed by sustained depolarization that blocks further transmission. Terminated by plasma cholinesterase hydrolysis. Cannot be reversed by neostigmine.

nicotinic acetylcholine receptor at neuromuscular junction

Indications

rapid sequence intubation (RSI)
facilitation of endotracheal intubation where rapid onset and short duration are needed

Contraindications

denervation or immobility >48-72 hours (hyperkalemia risk)
major burns >24-48 hours
motor neuron disorders
malignant hyperthermia susceptibility

Adverse Effects

Common

muscle fasciculations
post-operative myalgia
transient hyperkalemia
increased intraocular pressure

Serious

malignant hyperthermia (fatal if untreated)
life-threatening hyperkalemia in susceptible patients
prolonged paralysis in pseudocholinesterase deficiency

Pharmacokinetics (ADME)

Absorption	IV only for intubation
Distribution	rapidly distributes to NMJ
Metabolism	hydrolysis by plasma cholinesterase (pseudocholinesterase)
Excretion	renal
Half-life	2-4 minutes
Onset	30-60 seconds IV
Peak	60 seconds IV
Duration	6-10 minutes IV in normal patients
Protein Binding	minimal
Vd	0.2 L/kg

Drug Interactions

Drug / Agent	Mechanism	Severity
aminoglycosides	potentiate neuromuscular blockade	moderate
cholinesterase inhibitors (neostigmine)	inhibit plasma cholinesterase; prolong succinylcholine duration	major

Nursing Considerations

Agent of choice for RSI due to ultra-rapid onset (30-60 seconds) and short duration (6-10 minutes); identify contraindications before administration.
Malignant hyperthermia: rising temperature, rigidity returning after paralysis, or hypercapnia despite ventilation require immediate dantrolene and MH protocol.
Pseudocholinesterase deficiency causes prolonged paralysis lasting hours; ensure ventilatory support is available.
Do not use in patients with burns, denervation, or prolonged immobility due to life-threatening hyperkalemia from upregulated AChR.

Clinical Pearls

Succinylcholine unique niche is RSI: 30-60 second onset is faster than any non-depolarizing NMBA, and 6-10 minute duration allows reassessment if intubation fails.
Rocuronium at 1.2 mg/kg produces comparable onset and is used as succinylcholine alternative when malignant hyperthermia susceptibility is a concern, requiring sugammadex for reversal.

Safety Profile

Pregnancy use-with-caution

Lactation use-with-caution

Renal Adjustment Not required

Hepatic Adjustment Not required

TDM Not required

Concordance Terms

Cross-referenced clinical concepts — click any term to see all content where it appears.

Facilitation Of Endotracheal Intubation Where Rapid Onset And Short Duration Are Needed Neuromuscular Blocking Agent (NMBA) Rapid Sequence Intubation (RSI)

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