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Prevention of Succinylcholine Induced Postoperative Myalgia by Pretreatment with Lignocaine: A Randomized Controlled Study
Abstract
Succinylcholine, a depolarizing muscle relaxant possesses a unique property of rapid onset and short duration of action, but is accompanied by side effects such as fasciculation and myalgia. The aim of this study was to investigate the prophylactic effect of intravenous lignocaine on the incidence and severity of succinylcholine-induced postoperative myalgia. This was a randomized controlled double blind study conducted at National Institute of ENT Dhaka, during September to December 2017. Eighty adult patients of American Society of Anesthesiologists status I and II of both sexes for elective surgery under general anesthesia were randomly allocated into two equal groups, lignocaine group and normal saline group. The patients of lignocaine group were pretreated with lignocaine 1.5 mg/kg body weight in 5 ml volume, while patients of normal saline group were given isotonic saline 0.9% in the same volume (5 ml) intravenously. Thereafter, anesthesia was induced in all patients, by injecting 1.5 mg/kg of fentanyl and 2 mg/kg of propofol intravenously. Following the loss of eyelid reflex, 1.5 mg/kg of succinylcholine was injected intravenously as a muscle relaxant and then the patients were intubated. The incidence and severity of myalgia were assessed by a blinded observer 24 hours after surgery. In terms of demographic data, the results of this study showed that there is no significant difference between patients in both groups (P>0.05). Overall, the incidence and severity of succinylcholine-induced myalgia in lignocaine group was significantly less, when compared with normal saline group (P<0.05). Pretreatment with intravenous lignocaine is effective in prevention of postoperative succinylcholine induced myalgia. Faridpur Med. Coll. J. Jan 2019;14(1): 13-15
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To evaluate the biochemical changes associated with succinylcholine administration after pretreatment with rocuronium at different time intervals.
The prospective, randomised, single-blinded study was conducted at the Combined Military Hospital, Rawalpindi, from January to May 2010. Ninety male, aged 18-60 years, American Society of Anaesthesiology I or II patients undergoing elective inguinal herniotomy or external haemorrhoidectomy were included. The patients were randomly divided into three equal groups. Group A received a normal saline 5 ml as placebo 1 minute before succinylcholine; Group B received rocuronium 0.06 mg/kg 1 intravenously minute before succinylcholine, while Group C received intravenous injection of rocuronium 0.06 mg/kg 5 minute before succinylcholine. Venous blood samples for creatinine phosphokinase, lactate dehydrogenase and myoglobin plasma concentrations were obtained at 0, 30 minutes, 6 hours and 24 hours after succinylcholine administration.
Mean serum creatinine phosphokinase and myoglobin concentrations were significantly decreased in Groups B and C compared to Group A at 30 minutes and 24 hours (p < 0.05). However, no significant difference in the enzyme levels at any time interval was observed among the rocuronium groups. There was a significant rise in lactate dehydrogenase concentrations at 6 hours and 24 hours in Group A compared to Groups B and C (p < 0.05).
Pretreatment with rocuronium effectively reduces the biochemical changes associated with succinylcholine-induced muscle fasciculations. However, whether it is given 1 minute or 5 minutes before succinylcholine does not make much difference.
Background:
Succinylcholine is used for rapid-sequence induction of anesthesia. Fasciculations and myalgia are adverse effects. The pretreatment modalities prevent or minimize its adverse effects.
Aims:
The present study is designed to evaluate the efficacy of gabapentin on the incidence of fasciculation and succinylcholine-induced myalgia.
Settings and design:
The study was conducted at a tertiary care teaching hospital in a randomized, double-blinded, placebo-controlled manner.
Materials and methods:
Patients of both genders undergoing laparoscopic cholecystectomy were randomly assigned to two groups. Patients in Group I (Gabapentin group) received 600 mg of gabapentin orally 2 h prior to surgery and patients in Group II (placebo group) received matching placebo. Anesthesia was induced with fentanyl 3 μg/kg, thiopentone 3-5 mg/kg and succinylcholine 1.5 mg/kg. All patients were observed and graded for fasciculations by a blinded observer and patients were intubated. Anesthesia was maintained with oxygen in air, sevoflurane and intermittent vecuronium bromide. After completion of surgery, neuromuscular blockade was reversed. A blinded observer recorded myalgia grade at 24 h. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief.
Statistical analysis:
Demographic data, fasciculation grade, fentanyl consumption, and myalgia grade were compared using student t test and test of proportions.
Results:
The study included 76 American Society of Anesthesiologists' Grade I or II patients of either gender undergoing laparoscopic cholecystectomy. But only 70 patients completed the study. Results demonstrated that the prophylactic use of gabapentin significantly decreases the incidence and the severity of myalgia (20/35 vs. 11/35) (P<0.05) and decreases fentanyl consumption significantly in the study group (620+164 μg vs. 989+238 μg) (P<0.05) without any effects on the incidence and severity of fasciculations.
Conclusions:
Prophylactic use of gabapentin 600 mg in laparoscopic cholecystectomy decreases the incidence and severity of myalgia and fentanyl consumption.
We have studied the effects of preoperative administration of diclofenac on suxamethonium-induced myalgia, plasma met-enkephalin-like
activity (ELA), prostaglandin E2-like activity (PGE2-LA), leukotriene C4-like activity (LTC4-LA), and histamine-like activity (H-LA). Thirty-four ASA I patients undergoing elective ophthalmic surgery were allocated
randomly to two groups to receive either saline placebo or diclofenac 75 mg i.m. 20 min before operation, in a double-blind
design. Anaesthesia was induced with thiopentone 5–7 mg kg−1 followed by suxamethonium 1.5mg kg−1 and maintained with 67% nitrous oxide and halothane in oxygen. Plasma PGE2-LA, LTC4-LA, H-LA and E-LA were measured before premedication, 1 min after the administration of suxamethonium and 24 h after operation.
Muscle fasciculations, intubation conditions and postoperative myalgia were graded numerically. Postoperative myalgia in the
diclofenac group was significantly (P<0.05) less (47.1 %) than in the control group (76.5%). Postsuxamethonium and 24-h concentrations of plasma PGE2-LA and LTC4 were also significantly (P<0.05) greater than baseline in the control group. Plasma H-LA was increased in both groups after suxamethonium and this increase
was significant (P<0.05) in the control group. We conclude that diclofenac reduces significantly the incidence and intensity of suxamethonium-induced
myalgia.
Neuromuscular, circulatory, and adverse effects of intravenous succinylcholine (SCh), mg/kg, were compared in 3 groups of 40 patients each. Group I served as control; group II received diazepam, 0.05 mg/kg, 5 min before SCh; and group III was given d-tubocurarine (d-Tc), 0.05 mg/kg, for pretreatment. Diazepam pretreatment prevented muscle fasciculations, increases in serum potassium (K+) and creatinine phosphokinase (CPK) levels, increased heart rate and arterial pressure, and postoperative myalgia associated with SCh administration. The neuromuscular blocking action of SCh was not affected. Pretreatment with d-Tc did not abolish increases in serum K+ and CPK levels, was associated with a higher incidence of postoperative myalgia, and decreased the onset and magnitude of SCh-induced muscle paralysis. Our data demonstrate that diazepam, a predominant centrally acting muscle relaxant, is more effective than d-Tc in preventing the adverse effects of SCh, a peripherally acting muscle relaxant.
The incidence of muscle pains and changes in serum concentrations of potassium, calcium and creatine kinase following suxamethonium were investigated after no pretreatment or pretreatment with intravenous tubocurarine 0.05 mg.kg-1, intravenous chlorpromazine 0.1 mg.kg-1, alphatocopherol (vitamin E) 600 mg in three divided doses orally, aspirin 600 mg orally or intravenous calcium chloride 5 mg.kg-1 in groups of 20 patients each. The incidence of myalgia was reduced significantly by tubocurarine, chlorpromazine and alphatocopherol. However, the increase in creatine kinase was attenuated only in the groups of patients who received tubocurarine and chlorpromazine. The changes in serum potassium and calcium concentrations were within acceptable limits. The intubating conditions were not as good in the patients who received tubocurarine as in the other groups. Effectiveness of chlorpromazine in preventing both the myalgia and the biochemical changes suggests the involvement of phospholipases in the pathogenesis of suxamethonium-induced muscle damage.
We compared the incidence of postoperative myalgia (POM) and fasciculations when atracurium (ATR) or d-tubocurarine (DTC) was given prior to succinylcholine (SDC) for tracheal intubation in 44 ASA class I or II outpatient females undergoing laparoscopy. The subjects were assigned to one of three groups: group 1 received 0.025 mg/kg ATR; group 2 received 0.05 mg/kg DTC; and group 3 received saline (NS), all in a double-blind manner. Thiopental was administered 1 min and 45 sec after pretreatment in doses adequate to allow control of ventilation. Three minutes after pretreatment, SDC 1.5 mg/kg was given, and fasciculations were recorded on a scale of 0-3. All patients were questioned 1 and 3 days postoperatively about POM, using a scale of 0-3. Fasciculations occurred in 79% of patients given saline, in 46% of those receiving ATR, and in 12% of those given DTC. Eighty-five percent of ATR patients were free of POM on postoperative day 1. The corresponding figures for DTC and NS were 59% and 43%, respectively. Only the difference between ATR and NS achieved statistical significance. On the third postoperative day, POM was rare and there were no significant differences among the groups. We conclude that DTC is a better defasciculant than ATR. DTC was, however, not significantly better than NS in the prevention of POM. The findings suggest that ATR may be the drug choice for the prevention of POM.
The effect of pretreatment with 60 mg/kg magnesium sulfate on the neuromuscular blockade and consequent potassium release produced by 1.5 mg/kg succinylcholine in ten normal patients was compared with ten saline pretreated control patients. Magnesium had no significant effect on the characteristics of the paralysis. In control patients, serum potassium increased by an average of 0.57 +/- 0.20 (SEM) mmol/L. No patient in the magnesium group had an increase in serum potassium (mean change -0.05 +/- 0.02 mmol/L). The difference between the groups was statistically significant (P less than 0.01).
Administration of d-tubocurarine (dTC) or diphenylhydantoin (DPH) was evaluated as a pretreatment to prevent succinylcholine (Sch) evoked fasciculations. Experiments were designed to determine the nature of the drug-drug interactions, sites of interaction, and site of fasciculation suppression. Sch is known to evoke repetitive discharge generation by motor nerve terminals (MNTs). Transmission of these prejunctional discharges causes fasciculations. A cat soleus neuromuscular preparation in situ, which enables recording of nerve action potentials initiated by MNTs, their transmitted muscle action potentials, and the resultant contractile responses, was used to explore Sch effects before and after iv pretreatment with dTC or DPH. dTC is known to act prejunctionally to suppress repetitive discharges initiated by facilitatory drugs and tetanic conditioning of MNTs. Accordingly, pretreatment with dTC 50 micrograms X kg-1 suppressed the Sch-induced MNT repetitive discharging and correspondingly suppressed generalized fasciculations without affecting twitch. This dTC dose, however, also reduced Sch blocking potency by 33%, slowed its rate, and shortened block duration. These latter effects represent competitive postjunctional antagonism. DPH is also known to suppress MNT repetitive discharging. Correspondingly, Sch-induced repetitive firing and ensuing fasciculations were suppressed by DPH (30 mg X kg-1) without affecting twitch. Unlike dTC, this DPH dose increased Sch blocking potency by 50%, increased the initial rate of block, and did not alter block duration. These DPH effects were dose-dependent and within the anticonvulsant range for cats. Therefore, patients with anticonvulsant levels of DPH may not require pretreatment before Sch.(ABSTRACT TRUNCATED AT 250 WORDS)
One hundred and ninety-eight patients undergoing minor surgery were assessed for evidence of post-suxamethonium muscle pain on the 1st and 2nd days following surgery. Patients were allocated to nine groups and were given one of four non-depolarizing neuromuscular blocking drugs (vecuronium, gallamine, tubocurarine or pancuronium) 1 or 2 min before the administration of suxamethonium. A control group received an inert medication. Forty-one per cent of patients receiving no pretreatment experienced muscle pain. This frequency was decreased to around 20% following pretreatment. In general, the frequency of pain was less in the groups receiving pretreatment at 1 min, but the difference was not significant. The groups receiving vecuronium before suxamethonium had the lowest overall frequency of pain over the 2 days (19%), although this was not significantly different from other pretreatments.
Lignocaine pretreatment (2 mg/kg) significantly restricted the increase in serum potassium and decrease in serum calcium caused by suxamethonium. Suxamethonium muscle pains occurred in only 8% of patients who received lignocaine just before induction of anaesthesia. The incidence of muscle pains was 45% in those patients who were not given lignocaine.
We have evaluated the effect of ketorolac in the prevention of suxamethonium myalgia. Sixty ASA I patients who presented for extraction of wisdom teeth as day cases were allocated randomly to one of three equal groups. Patients received either 0.9% saline (placebo), atracurium 0.05 mg kg-1 i.v. or ketorolac 10 mg i.v., 3 min before induction of anaesthesia. Follow-up postal questionnaires (97% response rate) at 48 h showed no reduction in the incidence of myalgia after ketorolac pretreatment compared with saline. The use of atracurium reduced the incidence of myalgia by 60% (P < 0.001) and the severity of fasciculations (P < 0.001). There was no difference in the severity of fasciculations between the saline and ketorolac groups. Intubating conditions were comparable in the three groups.
We conducted a prospective, randomised single-blind study in 48 adult women undergoing laparoscopic gynaecological surgery to assess the incidence of suxamethonium-induced myalgia. Anaesthesia was induced with either thiopentone or propofol. All other aspects of clinical care were standardised between the groups. The propofol group had a significantly lower incidence of suxamethonium myalgia (19%) compared with the thiopentone group (63%) (P < 0.05). The mechanism of this effect is not understood.
To determine the attenuation in the incidence of myalgia, fasciculations and changes in serum potassium and creatinine kinase concentrations when atracurium and lidocaine were used in combination and separately as pretreatment before succinylcholine.
In a prospective, double blind randomized study, 80 ASA 1 patients 20-50 yr were assigned to one of four groups. Anaesthesia was induced with thiopentone and fentanyl. Group C received placebo pretreatment before 1.5 mg.kg-1 succinylcholine; Group A 0.05 mg.kg-1 atracurium three minutes before; Group L, 1.5 mg.kg-1 lidocaine 30 sec before; and group AL both atracurium and lidocaine. Serum potassium five minutes after succinylcholine, and creatinine kinase 24 hr after operation were measured and the increases from preinduction values were compared. Fasciculations and postoperative myalgia at 24 and 48 hr were recorded. Patients received iv meperidine or po paracetamol for postoperative analgesia.
The increase in serum potassium concentration (0.36 +/- 0.23 mEq.l-1) was not attenuated by any regimen (P < 0.05). The incidence of fasciculations (P < 0.05) and the increase in creatinine kinase (P < 0.01) was less in the atracurium (40%; 20.93 IU.l-1) and atracurium-lidocaine (30%; 22.85 IU.l-1) than in the lidocaine (85%; 45.01 IU.l-1) and control (100%; 56.5 IU.l-1) groups. Postoperative myalgia on Days 1 and 2 was lowest (P < 0.05) in the atracurium-lidocaine group (5%; 0%) followed by the atracurium (35%; 25%) and lidocaine (30%; 35%) groups and highest in the control (75%; 65%).
Atracurium and lidocaine individually reduce postoperative myalgia, with further decrease occurring when used together.
We compared d-tubocurarine and rocuronium for the prevention of succinylcholine-induced fasciculations and postoperative myalgia (POM) and evaluated the influence of both drugs on the speed of onset and recovery of succinylcholine.
Seventy-five women undergoing surgery of short duration were studied. They were randomized to one of three groups: group SAL received normal saline followed three minutes later by 1.0 mg.kg-1 succinylcholine; group ROC received 0.05 mg.kg-1 rocuronium + 1.5 mg.kg-1 succinylcholine; group DTC received 0.05 mg.kg-1 d-tubocurarine + 1.5 mg.kg-1 succinylcholine. Single-twitch stimulation was applied to the ulnar nerve every 10 sec and the EMG response of the adductor pollicis was recorded. Fasciculations were assessed by a blinded observer on a scale of 0-3. Patients were asked 24 and 48 hr later to rate POM using a scale of 0-10.
The interval needed for twitch height to decrease to 10% of initial value after succinylcholine was longer in group ROC (58 +/- 20 sec) (mean +/- SD) compared with group SAL (44 +/- 13 sec) (P < 0.05). Recovery to 20% occurred faster in group ROC (324 +/- 83 sec) than in groups SAL (456 +/- 103 sec) and DTC (450 +/-132 sec) (P < 0.05). Fasciculations were more intense in groups SAL than in groups ROC and DTC (P < 0.001). Patients rated POM as less intense 24hr postoperatively only in group ROC (1.2 +/- 2.4) compared with group SAL (3.3 +/- 3.5) (P < 0.05).
Rocuronium prevents succinylcholine-induced fasciculations and POM. Rocuronium also delays the onset of succinylcholine and shortens its duration compared with d-tubocurarine.
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.
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.
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).
Administration of propofol 3.5 mg kg-1 is effective in reducing fasciculations and myalgia after succinylcholine.
We studied the effects of 3 mg.kg(-1) lidocaine iv on the succinylcholine (SCh)-induced myalgia in 94 unpremedicated ambulant patients undergoing dilatation and curettage of the uterus. The post-SCh myalgia was confirmed through interview by telephone. The data were correlated with the degree of fasciculation and changes in the serum electrolytes and creatine kinase (CK) levels following SCh administration. Pretreatment with lidocaine, 3 mg.kg(-1) iv, significantly reduced the incidence of myalgia from 40.4% of control group to 12.8% lidocaine-treated group, but not the CK levels. The severity of myalgia was not related to the intensity of fasciculation assessed by visual observation. The pretreatment with lidocaine had no untoward effect on the circulation, although the peak arterial and peak venous lidocaine levels achieved were 29.6 +/- 23 micro g.ml(-1) and 10.1 +/- 3.3 micro g.ml(-1) respectively. These finding indicated that the pretreatment with lidocaine, 3 mg.kg(-1) iv, was effective in prevention of SCh-induced myalgia.
To study the effect of pretreatment with lidocaine and diclofenac in reducing succinylcholine induced myalgia
- A K Pandey
- K V Sunil
- R Saraf
- S Kale
Pandey AK, Sunil KV, Saraf R, Kale S. To study the effect of
pretreatment with lidocaine and diclofenac in reducing
succinylcholine induced myalgia. VIMSHSJ 2014; 1(1):17-22.