Defasciculating dose before Succs?

Specialties CRNA

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So in lecture, we're educated that 10mg of Roc is to be given before your induction dose of Succinylcholine to block post op myalgia. I thought this was a non-negotiable thing, similar to giving Robinul before Neostigmine. I've come across a couple people during rotations that request I don't use a defasciculating dose. This seems cruel to me but my experience is limited to mostly theory at this point. I understand they like to see the physical fasciculations but is that necessary and is it worth the pain post op? Have you actually visited them post op and heard them complain of myalgia?

I'm just interested in what more experienced CRNAs think about this.

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The practice is dogma from days long ago. It is no longer required as it once was. Some people still probably insist on you doing it in school, and that is fine, but it just does not matter. Not even a little bit. Pretreat or not, same K+ shifts, same increase in IOP, same increase in abdominal pressure, same myalgias. It really just makes the patient look better at induction, but there is a literal ton of literature out there that says they will still have just as much myalgias. Like cricoid pressure, it is going to take several generations for this dogma to die.

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Specializes in Anesthesia.

There is a lot of dogma in Anesthesia/medicine/nursing.

Here are a few:

Dogma/Evidence

High concentration O2 causes absorption atlectasis in surgical patients not only is it not true but high concentrations of 80+% decrease surgical infection rates.

Ephedrine is better than phenylephrine in OB patients. Phenylephrine is actually better for OB patients.

Large (>0.1mg/kg) doses of decadron increase SSIs. Decadron given in >0.1mg/kg decreases Post pain scores, ponv, does not increase ssi, or significantly increase BG in Type 2 DM.

Ancef is contraindicated in PCN allergy patients. There is no significant increase in cross-sensitivity with PCN allergy patients, no matter the severity, with cephalosporins as long as the R1 side chain is different.

Pregnancy equals full stomach after X weeks. Gastric emptying does not change in pregnancy.

You can find meta-analysis or sytematic reviews on all these.

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And there's no need to give robinul before neostigmine, ie, you can very safely mix the two in the same syringe.

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I agree the dogma is rampant wtbCRNA which I find frustrating as an SRNA spending my life chained to a desk learning a tidal wave of information to only find it's dogma or not clinically applicable. The only question I have about the topics you listed (which are contentious in the anesthesia community) is the risk for aspiration after X weeks in pregnancy. We were taught that the actual number of weeks is flexible but many choose to tube after 12-14 weeks due to the progesterone effects of relaxing the lower esophageal sphincter. Have you found this to not be true?

Offlabel, I do know people who give them mixed in the same syringe. I believe the onset is faster in the robinul which is why it can be justified to be given in the same syringe. Now if you tell me you don't give it at all and don't have muscarinic side effects you'll blow my mind.

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Specializes in Anesthesia.
I agree the dogma is rampant wtbCRNA which I find frustrating as an SRNA spending my life chained to a desk learning a tidal wave of information to only find it's dogma or not clinically applicable. The only question I have about the topics you listed (which are contentious in the anesthesia community) is the risk for aspiration after X weeks in pregnancy. We were taught that the actual number of weeks is flexible but many choose to tube after 12-14 weeks due to the progesterone effects of relaxing the lower esophageal sphincter. Have you found this to not be true?

Offlabel, I do know people who give them mixed in the same syringe. I believe the onset is faster in the robinul which is why it can be justified to be given in the same syringe. Now if you tell me you don't give it at all and don't have muscarinic side effects you'll blow my mind.

I don't believe aspiration is increased risk over other patients unless the pregnant patient is symptomatic/GERD symptoms. There isn't increased gastric volumes but the esphogheal sphincter threshold pressure may be reduced.

I'm actually involved in a research project looking at eating during labor now. I think the risk of aspiration in pregnancy is more dogma than anything, but it is one of those that is hard to study.

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I don't believe aspiration is increased risk....

And I don't believe in aspiration of CSF at the end of a spinal injection either!

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Bluebolt,

i wish my anesthesiologist had given me roc with sux last week. I woke up at 3 the next morning with every muscle in my body inflamed as tho I had a terrible case of the flu. I had gone in for an arthroscopic that had been done before with Propofol and a strong local, but the new anesthesiologist required GA. It was at an outpatient clinic so I was in their recovery for a very short time before I was discharged and out the door. I was in extreme muscle pain for 2 days and actually had to use a cane to walk.

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Specializes in Anesthesia.
Bluebolt,

i wish my anesthesiologist had given me roc with sux last week. I woke up at 3 the next morning with every muscle in my body inflamed as tho I had a terrible case of the flu. I had gone in for an arthroscopic that had been done before with Propofol and a strong local, but the new anesthesiologist required GA. It was at an outpatient clinic so I was in their recovery for a very short time before I was discharged and out the door. I was in extreme muscle pain for 2 days and actually had to use a cane to walk.

There is no clear indication between fasculations and myalgias. There are a variety of reasons for myalgias after surgery. Severe myalgias are also unlikely to be caused from succinylcholine. Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

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I'm still not sure why folks use succs for non (bonafide) RSI in the first place when they're just going to follow it up with with an NDM anyway.

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Specializes in Anesthesia, ICU, OR, Med-Surg.

We know in anesthesia e4very drug has its side effects and unfortunately, Sux is one of them. I try not to use it unless I have an obese patient with a questionable airway or if I am doing a case where neuromonitoring of motor evoked potentials is being used. We know that guys who are very muscular experience myalgia and should be avoided. I work in the Bronx NY area and at my trauma center job most of the docs routinely like to use Sux but at my per diem ambulatory surgery job, we like to use Roc since most of our cases tend to be ASA 1 and II type patients. Thank God for Suggamadex in our aresenal.

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Specializes in Nurse Anesthesiology.
I'm still not sure why folks use succs for non (bonafide) RSI in the first place when they're just going to follow it up with with an NDM anyway.

I am someone who mostly uses Succs for all my cases, but I do avoid non depolarizes all together for most cases as well.

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