Clinical Conundrum-Patient case and labs come back post-intubation using succinylcholine and Oops the potassium is high? When does the increase in serum potassium occur (onset) and how long (duration) does it last after giving a single dose of succinylcholine for intubation? Does having renal failure in a patient change the onset and duration?
Background
-Succinylcholine (SCh) is a depolarizing neuromuscular blockade agent often used in rapid-sequence intubation.
-SCh binds to nicotinic receptors at motor end plates generating an action potential and causes prolonged depolarization and muscle paralysis. As a result of depolarization, K+ is released from cells causing an increase in serum potassium.
Answer
-Typically, the increase in K+ occurs within 3-5 minutes after administration of SCh and lasts less than 15 minutes.
-In a case series by Walton and Farman looking at 12 patients who were candidates for renal transplantation, only seven patients experienced an elevation of K+ and the largest increase in K+ was by 1.2 mEq/L observed after two minutes, however a decrease was observed at six minutes, which falls into our normal range for patients with normal renal function.
-Four controlled studies measuring serial K+ levels after SCh administration, and in patients with renal failure, the increase in K+ levels were similar to patients without renal dysfunction, suggesting there is not an exaggerated response in K+ level, in terms of onset, or duration for patients with renal failure like those seen in patients with burns, traumas, or neurological lesions.
-Although, prior to administration still be cautious using SCh if the serum potassium level is sufficiently elevated to cause EKG changes. Fortunately, this adverse effect is rare.
Written by:
Joanne C. Routsolias, PharmD, RN, BCPS
Clinical PharmD Specialist - Emergency Medicine/Toxicology
Cook County Health
References:
1. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015;2015(10):CD002788.
2. Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anesth Analg. 2000;91(1):237-241.
3. Walton JD, Farman JV. Suxamethonium, potassium and renal failure. Anaesthesia. 1973;28(6):626-630.