Succinylcholine is a parenteral, short-acting, depolarizing neuromuscular blocking agent (NMBA) indicated as an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation. Succinylcholine has the fastest onset time of any NMBA, typically allowing intubation within 60 seconds. In addition to its rapid onset and short duration, advantages of succinylcholine include its organ-independent metabolism and ability to be administered intramuscularly in patients without venous access. Succinylcholine induces histamine release and vagal stimulation. Bradycardia is more common in infants and children compared to adults; repeated dosing also increases the risk of bradycardia. Succinylcholine-induced muscle contraction and fasciculation can cause sudden, large releases of potassium, which may induce cardiac dysrhythmias. Due to rare reports of ventricular dysrhythmias and fatal cardiac arrest after the administration of succinylcholine in pediatric patients with undiagnosed skeletal muscle myopathies, use in pediatrics is reserved for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach) or for intramuscular use when a suitable vein is inaccessible.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
-Do not mix succinylcholine with alkaline solutions; succinylcholine is acidic (pH 3 to 4.5) and may not be compatible with alkaline solutions having a pH more than 8.5 (e.g., barbiturate solutions).
-Accidental administration of neuromuscular blocking agents can be fatal. Store succinylcholine with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.
-Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of succinylcholine. Adequacy of respiration must be assured through assisted or controlled ventilation.
-To avoid distress to the patient, administer succinylcholine after unconsciousness has been induced; in emergent life-threatening situations, it may be necessary to administer succinylcholine before unconsciousness. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.
-Pretreatment with anticholinergic agents (e.g., atropine) may reduce the occurrence of bradyarrhythmias.
-Monitor heart rate, blood pressure, and oxygen saturation during neuromuscular blockade. Continuously monitor temperature and expired carbon dioxide to aid in early recognition of malignant hyperthermia. Monitor ECG; peaked T-waves are an early sign of cardiac arrest secondary to rhabdomyolysis and hyperkalemia.
-Storage: Store in refrigerator at 2 to 8 degrees C (36 to 46 degrees F) until vial expiration date. Multi-dose vials (20 mg/mL) and prefilled syringes (20 mg/mL) are stable for up to 14 days at room temperature without significant loss of potency. Independent studies have produced inconsistent results, but generally, the drug appears to be stable in unopened vials for 2 months or more at room temperature. Succinylcholine 20 mg/mL and 50 mg/mL products from various manufacturers have been shown to retain at least 90% potency when stored unopened at room temperature for periods ranging from 2 to 8.3 months, depending on the specific product. These results should not be extrapolated to environments with variable temperatures (e.g., emergency transport vehicles), where 10% degradation times have been reported to be shorter (1 to 3 months). Undiluted succinylcholine chloride (20 mg/mL) was stable for 45 days at room temperature (25 degrees C) and 90 days refrigerated (4 degrees C) in 12 mL polypropylene syringes.
-Updates for coronavirus disease 2019 (COVID-19): The FDA is allowing succinylcholine 20 mg/mL to be used beyond the labeled in-use time to help ensure access during COVID-related drug shortages. This period should be as short as possible, and for a maximum of 2 hours at room temperature or 4 hours when refrigerated. In-use time is defined as the maximum amount of time allowed to elapse between penetration of a closed-container system or after reconstitution of a lyophilized drug before patient administration.
Intravenous Administration
-Due to the risk for rhabdomyolysis and life-threatening hyperkalemia that has occurred in pediatric patients with unidentified myopathies, reserve succinylcholine use in pediatric patients for emergent situations when immediate securing of the airway is needed; intermittent IV infusions and continuous IV infusions are generally not recommended in pediatric patients.
Dilution
-Succinylcholine supplied in single-dose vials (100 mg/mL) must be diluted before use. Succinylcholine supplied in multiple-dose vials (20 mg/mL) or prefilled syringes (20 mg/mL) do not require dilution before use.
-Succinylcholine may be diluted to 1 mg/mL or 2 mg/mL in a solution such as 5% Dextrose Injection or 0.9% Sodium Chloride Injection.
-Prepare diluted solution for single patient use only.
-Storage: Store diluted solution in refrigerator at 2 to 8 degrees C (36 to 46 degrees F) and use within 24 hours of preparation. Discard unused portion.
IV Push
-Administer via IV push.
Continuous IV Infusion
-Monitor neuromuscular function with a peripheral nerve stimulator.
Intramuscular Administration
-If necessary, succinylcholine may be administered intramuscularly to infants, older pediatric patients, or adults when intravenous access cannot be secured.-In patients with laryngospasm, relief of the spasm sufficient for effective bag-valve-mask ventilation should occur within 30 seconds of administration to allow for adequate ventilation until intubating conditions are achieved.
-Inject deeply into a large muscle mass. Some experts recommend administration into the deltoid because the time to onset is typically more rapid than with administration into the quadriceps.
There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death after the administration of succinylcholine to apparently healthy pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of succinylcholine in healthy appearing pediatric patients (usually, but not exclusively, males, and most frequently 8 years or younger). There have also been reports in adolescents. Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine, not felt to be due to inadequate ventilation, oxygenation, or anesthetic overdose, institute immediate treatment for hyperkalemia, including intravenous calcium, bicarbonate, glucose with insulin, and hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. Arrhythmias as well as rhabdomyolysis with possible acute renal failure (unspecified) associated with myoglobinuria have been reported with succinylcholine use.
Bradycardia has been reported with succinylcholine use. In both adults and pediatric patients, the incidence of bradycardia, which may progress to asystole, is higher after a second dose of succinylcholine. The incidence and severity of bradycardia are higher in pediatric patients than adults. Whereas bradycardia is common in pediatric patients after an initial dose of 1.5 mg/kg, bradycardia is seen in adults only after repeated exposure. Pretreatment with anticholinergic agents (e.g., atropine) may reduce the occurrence of bradyarrhythmias. Hypertension has also been reported with succinylcholine use.
Severe anaphylactic or anaphylactoid reactions to neuromuscular blocker agents (NMBAs), including succinylcholine, have been reported; some cases have been fatal. Immediate availability of appropriate emergency treatment for anaphylaxis is advised because of the potential life-threatening severity of a reaction. The potential for histamine-release is present after succinylcholine administration; however, signs and symptoms of histamine-mediated release such as flushing, hypotension, and bronchospasm are uncommon in normal clinical usage. Rare hypersensitivity reactions (e.g., angioedema, bronchospasm, wheezing, flushing, rash, erythema, urticaria, pruritus, hypotension, sinus tachycardia) related to histamine release have been reported after succinylcholine administration.
Malignant hyperthermia can be precipitated by many drugs used in anesthetic practice, including halogenated anesthetics and succinylcholine. Fatal malignant hyperthermia has been reported with succinylcholine. The risk of developing malignant hyperthermia after succinylcholine administration increases with the concomitant administration of volatile anesthetics. Signs consistent with malignant hyperthermia may include hyperthermia, hypoxia, hypercapnia, muscle rigidity (e.g., jaw muscle spasm), tachycardia (e.g., particularly that unresponsive to deepening anesthesia or analgesic medication administration), tachypnea, cyanosis, arrhythmias, hypovolemia, and hemodynamic instability. Skin mottling, coagulopathies, and renal failure are clinical signs that may occur later in the course of the hypermetabolic process. Successful treatment of malignant hyperthermia depends on early recognition of clinical signs. If malignant hyperthermia is suspected, discontinue all triggering agents (e.g., volatile anesthetics and succinylcholine), administer intravenous dantrolene sodium, and initiate supportive therapies. Supportive therapies include administration of supplemental oxygen and respiratory support based on clinical need, maintenance of hemodynamic stability and adequate urine output, management of fluid and electrolyte balance, correction of acid-base imbalance, and institution of measures to control rising temperature.
Succinylcholine is used for the purpose of inducing temporary paralysis; however, some of its most serious adverse effects are extensions of its therapeutic use. Careful monitoring of physiologic parameters and response to a peripheral nerve stimulator are recommended during continuous infusions and repeated dosing. Though paralysis may be used to facilitate mechanical ventilation, hypoxia may result from inadequate ventilation and/or a deterioration in pulmonary mechanics associated with prolonged paralysis. Excessive doses or prolonged exposure to neuromuscular blocking agents (NMBAs) can cause skeletal muscle weakness, and patients may consequentially experience prolonged apnea, dyspnea, respiratory depression, and/or profound muscular weakness (muscle paralysis). Muscle weakness in critically ill patients is multifactorial; however, prolonged recovery is most often related to excessive dosing of neuromuscular blockers or use of these agents in patients with hepatic or renal dysfunction. These patients may take hours to days to recover due to long-term accumulation of the drug. Perhaps the most devastating complication of neuromuscular blockade, acute quadriplegic myopathy syndrome (AQMS), presents as acute paresis, myonecrosis with increased creatine phosphokinase (CPK), and abnormal electromyography (EMG). After drug discontinuation, patients present with flaccid paralysis, decreased deep tendon reflexes, and respiratory insufficiency. Sensory function and extraocular movement are preserved, and there are no abnormal cerebrospinal fluid findings. Prolonged rehabilitation as well as chronic ventilatory support are often needed in patients with AQMS. Recovery may take weeks to months. To reduce the risk of prolonged recovery and AQMS, periodic screening of CPK during ongoing neuromuscular blockage may be helpful. Though periodic interruption of therapy is often not feasible and there is no direct evidence showing that it reduces the incidence of AQMS, daily 'drug holidays' may be considered for patients who will tolerate an interruption in therapy.
Patients receiving succinylcholine are at risk for developing xerophthalmia, leading to keratitis, conjunctivitis, and corneal abrasion because muscle paralysis inhibits eyelid movement and complete closure. Prophylactic eye care is essential; use artificial tears or ophthalmic ointment at regular intervals during neuromuscular blockade. Additionally, paralyzed patients with prolonged immobility are at risk for skin erosion, skin ulcer (pressure sore), and deep vein thrombosis (DVT). Frequent repositioning, physical therapy, and sequential compression devices (if age appropriate) are indicated. The use of special mattresses may be considered.
Awake, paralyzed patient-anxiety and panic may be the most bothersome adverse effect associated with neuromuscular blockade. Neuromuscular blockers, such as succinylcholine, do not provide sedation or analgesia and should be administered only after unconsciousness has been induced. In emergent life-threatening situations, it may be necessary to administer succinylcholine before unconsciousness. It is essential that amnesia, sedation, and analgesia are adequately maintained throughout paralyzation. Depth of sedation is difficult to monitor due to lack of movement with paralyzation. Physiologic parameters such as heart rate or blood pressure may be of use; however, there are many confounding influences on these parameters in critically ill patients.
Patients who receive neuromuscular blocking agents for a prolonged period may develop tachyphylaxis (i.e., tolerance). Prolonged neuromuscular blockade leads to proliferation of acetylcholine receptors at the neuromuscular junction resulting in increased drug requirements. Switch patients who develop tachyphylaxis to succinylcholine and still require neuromuscular blockade to another agent. Continuous monitoring of neuromuscular transmission with a peripheral nerve stimulator is strongly recommended during continuous infusion or repeated dosing. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). This may be associated with prolonged respiratory muscle paralysis or weakness in patients who manifest the transition to Phase II block. When this diagnosis is confirmed by peripheral nerve stimulation, it may sometimes be reversed with anticholinesterase drugs such as neostigmine. Anticholinesterase drugs may not always be effective. If given before succinylcholine is metabolized by cholinesterase, anticholinesterase drugs may prolong rather than shorten paralysis.
Muscle fasciculation, jaw rigidity, and postoperative muscle pain (myalgia) have been reported with succinylcholine use.
Succinylcholine may cause transient increased intraocular pressure (ocular hypertension), increased intracranial pressure, and increased intragastric pressure (resulting in regurgitation and aspiration of the stomach contents) immediately after administration and during the fasciculation phase. Slight increases in pressure may persist after the onset of paralysis. Induction of adequate anesthesia before succinylcholine administration may minimize the drug's effect on intracranial pressure.
Hypersalivation has been reported with succinylcholine use.
In emergent life-threatening situations, it may be necessary to administer succinylcholine before unconsciousness. Otherwise, administer succinylcholine only after unconsciousness has been induced; maintain adequate amnesia and analgesia throughout paralyzation. Neuromuscular blocking agents do not cause sedation or analgesia. Individualize succinylcholine doses. Use of a peripheral nerve stimulator will permit the most advantageous use of succinylcholine, minimize the possibility of overdosage or underdosage, and assist in the evaluation of recovery.
Evaluate patients at risk for aspiration and regurgitation and monitor patients during anesthesia induction for clinical signs of vomiting and/or aspiration. Succinylcholine may increase intragastric pressure, resulting in regurgitation and possible aspiration of stomach contents.
Succinylcholine administration requires an experienced clinician who is familiar with its actions and the possible complications that may occur after its use as well as requires a specialized care setting where facilities for intubation, artificial respiration, oxygen therapy, and reversal agents are immediately available. Accidental exposure to a neuromuscular blocking agent may be fatal in a patient for whom it is not intended. Store succinylcholine with cap and ferrule intact and in a manner that minimizes the possibility of selecting the wrong product. Confirm proper medication selection and clearly communicate the intended dose.
Succinylcholine is contraindicated in patients with a known hypersensitivity to the drug. Assess patients for previous neuromuscular blocking agent hypersensitivity before administering succinylcholine, as cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported. Severe anaphylactic reactions, in some cases life-threatening and fatal, have been reported with neuromuscular blocking agents, including succinylcholine. Ensure the necessary precautions, such as the immediate availability of appropriate emergency treatment, are taken before administration.
Succinylcholine is contraindicated in patients after the acute phase of injury after major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury. In such individuals, succinylcholine can cause severe hyperkalemia, which can result in serious cardiac arrhythmias and cardiac arrest. Risk of hyperkalemia increases over time and usually peaks 7 to 10 days after the injury; however, risk is dependent on the extent and location of injury, and the precise onset and duration of the risk period are unknown. Consider avoiding succinylcholine use or verify the patient's serum potassium concentration is within normal range before use in patients with electrolyte abnormalities, digitalis toxicity, chronic abdominal infections, subarachnoid hemorrhage, tetanus, disuse atrophy, Guillain-Barre syndrome, and degenerative nervous system disorders due to increased risk of developing severe hyperkalemia after succinylcholine administration in these patients. Do not use succinylcholine in any patient with a serum potassium of more than 5.5 mEq/L.
Various physiologic states can alter the expected effects of succinylcholine; carefully consider each patient's clinical condition when dosing succinylcholine and monitoring the patient. Cachectic and debilitated patients are more sensitive to neuromuscular blocking agents (NMBAs). Electrolyte imbalance can alter a patient's sensitivity to NMBAs. Hypercalcemia can decrease sensitivity to NMBAs, while most other electrolyte disturbances increase sensitivity (e.g., hypokalemia, hypocalcemia, hypermagnesemia). Correct electrolyte imbalance before administration and monitor neuromuscular transmission throughout use. Use succinylcholine cautiously in patients with conditions that may lead to electrolyte imbalances, such as adrenal insufficiency, severe vomiting or diarrhea, or massive transfusion. Severe acid/base imbalance may alter a patient's sensitivity to NMBAs: metabolic alkalosis, metabolic acidosis, and respiratory acidosis may enhance neuromuscular blockade and/or prolong recovery time, while respiratory alkalosis reduces the potency of the drug. Dehydration and hypothermia can also increase a patient's sensitivity to NMBAs.
Use neuromuscular blocking agents (NMBAs), including succinylcholine, with caution in patients with asthma or other pulmonary conditions. NMBAs stimulate histamine release, which could exacerbate asthma. Histamine-mediated effects (e.g., flushing, hypotension, bronchoconstriction) are uncommon in normal clinical usage of succinylcholine; however, use succinylcholine with caution in patients with any condition in which a significant release of histamine may be contraindicated. Also, NMBAs cause respiratory muscle paralysis; residual muscle weakness and decreased respiratory function (respiratory depression) can persist even after drug discontinuation. Use NMBAs with caution in patients with pulmonary disease and conditions associated with low pulmonary function reserve, such as chronic obstructive pulmonary disease (COPD) or neonatal chronic lung disease (CLD). Carefully monitor respiratory status and adequacy of ventilation after drug recovery until the patient is clearly stabilized.
Use succinylcholine with caution in patients with neuromuscular disease (e.g., myasthenia gravis, myasthenic syndrome [Eaton Lambert syndrome]); prolonged or exaggerated neuromuscular blockade may occur after neuromuscular blocking agent use. Because myasthenia gravis involves destruction of acetylcholine receptors instead of receptor upregulation, as seen in other neuromuscular diseases, these patients tend to be less sensitive to the effects of succinylcholine compared to nondepolarizing agents (e.g., rocuronium, vecuronium). Additionally, patients with weak muscle tone or severe obesity are at an increased risk for airway and ventilation complications. Monitor patients carefully until recovery is fully complete. Use ideal body weight or adjusted body weight for dosing in obese and morbidly obese adult patients (body mass index 30 kg/m2 or more).
Succinylcholine use is not recommended in patients with reduced plasma cholinesterase activity (pseudocholinesterase deficiency) due to the potential for prolonged neuromuscular blockade. Plasma cholinesterase activity may be diminished in the presence of genetic abnormalities of plasma cholinesterase (e.g., patients heterozygous or homozygous for atypical plasma cholinesterase gene), severe hepatic disease, severe renal disease, malignant tumors, infection, burns, anemia, decompensated cardiac disease, peptic ulcer disease, or myxedema. Patients homozygous for atypical plasma cholinesterase gene are extremely sensitive to the neuromuscular blocking effect of succinylcholine. Plasma cholinesterase activity may also be diminished by chronic administration of oral contraceptives, corticosteroid therapy, or certain monoamine oxidase inhibitors and by cholinesterase inhibitor toxicity due to irreversible inhibitors of plasma cholinesterase (e.g., organophosphate insecticides, echothiophate, and certain antineoplastic drugs). Treat resulting apnea or prolonged muscle paralysis with controlled respiration.
Succinylcholine is contraindicated in persons with skeletal muscle myopathy or known or suspected genetic susceptibility to malignant hyperthermia. Succinylcholine can induce malignant hyperthermia in persons with known or suspected susceptibility based on genetic factors or family history, including those with certain inherited ryanodine receptor (RYR1) or dihydropyridine receptor (CACNA1S) variants. Multiple pathogenic variants of RYR1 and CACNA1S genes have been associated with malignant hyperthermia susceptibility in persons receiving succinylcholine. Assess variant pathogenicity based on prior clinical experience, functional studies, prevalence information, or other evidence. Concomitant use of volatile anesthetics may further increase the risk of malignant hyperthermia. In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute immediate treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspected, initiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.
Avoid succinylcholine use in patients in whom an increase in intraocular pressure is undesirable (e.g., narrow-angle glaucoma, penetrating ocular trauma) unless the potential benefit of its use outweighs the potential risk. Succinylcholine causes an increase in intraocular pressure.
Use succinylcholine with caution in patients with bone fractures or muscle spasm as initial muscle fasciculations may cause additional injury. Monitor neuromuscular transmission and the development of fasciculations throughout the use of neuromuscular blocking agents.
Available data over decades of use with succinylcholine during pregnancy have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Plasma cholinesterase concentrations are decreased by approximately 24% during pregnancy and for several days postpartum which can prolong the effect of succinylcholine; therefore, some pregnant patients may experience prolonged apnea. Succinylcholine is commonly used for muscle relaxation during labor and obstetric delivery by cesarean section. Succinylcholine crosses the placental barrier in an amount dependent on the concentration gradient between the maternal and fetal circulations. Residual neuromuscular blockade (apnea and flaccidity) may occur in the newborn after repeated high doses to, or in the presence of atypical plasma cholinesterase in, the mother. Animal reproduction studies have not been conducted with succinylcholine.
There are no data on the presence of succinylcholine or its metabolite in human milk, the effects on the breast-fed infant, or the effects on milk production. However, the drug is rapidly eliminated and has poor oral absorption, so it is not likely to reach the circulation or cause adverse effects in breast-fed infants. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for succinylcholine and any potential adverse effects on the breast-fed child from succinylcholine or the underlying condition.
General dosing information:
-Monitor heart rate, blood pressure, and oxygen saturation. Continuously monitor temperature and expired carbon dioxide to aid in early recognition of malignant hyperthermia. Monitor ECG; peaked T-waves are an early sign of cardiac arrest secondary to rhabdomyolysis and hyperkalemia.
-Pretreatment with anticholinergic agents (e.g., atropine) may reduce the occurrence of bradyarrhythmias.
-Limit the use of succinylcholine in pediatric patients for emergency intubation or when immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach) or for intramuscular use when a suitable vein is inaccessible.
For muscular relaxation during non-emergent endotracheal intubation:
NOTE: Limit the use of succinylcholine in pediatric patients for emergency intubation or when immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach) or for intramuscular use when a suitable vein is inaccessible.
Intravenous dosage:
Adults: 0.6 mg/kg/dose IV. Dosage range: 0.3 to 1.1 mg/kg. Onset of intubating conditions is about 1 minute.
Intramuscular dosage:
Adults: 3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 3 minutes.
Adolescents: 3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.
Infants and Children 6 months to 12 years: 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.
Infants 1 to 5 months: 4 to 5 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.
Neonates: 2 to 4 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.
For muscular relaxation during rapid-sequence intubation:
Intravenous dosage:
Adults: 1.5 mg/kg/dose IV. Onset of intubating conditions is about 1 minute.
Children and Adolescents 2 to 17 years: 1 to 1.5 mg/kg/dose IV. Onset of intubating conditions is 30 to 60 seconds.
Infants and Children 6 to 23 months: 1 to 2 mg/kg/dose IV. Onset of intubating conditions is 30 to 60 seconds.
Infants 1 to 5 months: 2 mg/kg/dose IV. Dosage range: 1 to 3 mg/kg/dose. Onset of intubating conditions is usually 30 to 60 seconds. May repeat 1 mg/kg/dose IV if intubating conditions are not attained within an adequate period (1 to 5 minutes). Max: 4 mg/kg per intubation attempt.
Neonates: 2 mg/kg/dose IV. Dosage range: 1 to 3 mg/kg/dose. Onset of intubating conditions is usually 30 to 60 seconds. May repeat 1 mg/kg/dose IV if intubating conditions are not attained within an adequate period (1 to 5 minutes). Max: 4 mg/kg per intubation attempt.
Intramuscular dosage:
Adults: 3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 3 minutes.
Adolescents: 3 to 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.
Infants and Children 6 months to 12 years: 4 mg/kg/dose (Max: 150 mg/dose) IM. Onset of intubating conditions is 2 to 5 minutes.
Infants 1 to 5 months: 4 to 5 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.
Neonates: 2 to 4 mg/kg/dose IM. Onset of intubating conditions is 2 to 5 minutes.
For neuromuscular blockade during surgery:
Intermittent Intravenous dosage:
Adults: 0.3 to 1.1 mg/kg/dose IV once, followed by 0.04 to 0.07 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response.
Continuous Intravenous Infusion dosage:
Adults: 0.5 to 10 mg/minute continuous IV infusion; titrate to patient's twitch response. Usual dosage range: 2.5 to 4.3 mg/minute.
For muscular relaxation during electroconvulsive therapy (ECT)*:
Intravenous dosage:
Adults: 0.5 to 1.5 mg/kg/dose IV.
Maximum Dosage Limits:
-Adults
1.5 mg/kg/dose IV; 150 mg/dose IM.
-Geriatric
1.5 mg/kg/dose IV; 150 mg/dose IM.
-Adolescents
1.5 mg/kg/dose IV; 4 mg/kg/dose (Max: 150 mg/dose) IM.
-Children
2 to 12 years: 1.5 mg/kg/dose IV; 4 mg/kg/dose (Max: 150 mg/dose) IM.
1 year: 2 mg/kg/dose IV; 4 mg/kg/dose IM.
-Infants
6 to 11 months: 2 mg/kg/dose IV; 4 mg/kg/dose IM.
1 to 5 months: 3 mg/kg/dose IV (Max: 4 mg/kg IV per intubation attempt); 5 mg/kg/dose IM.
-Neonates
3 mg/kg/dose IV (Max: 4 mg/kg IV per intubation attempt); 4 mg/kg/dose IM.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
*non-FDA-approved indication
AbobotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Acetazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Albuterol; Budesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amikacin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amiloride; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Articaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Atracurium: (Major) If succinylcholine is used before atracurium, delay atracurium administration until recovery from succinylcholine-induced neuromuscular blockade begins. With succinylcholine as the intubating agent, use an initial atracurium dose of 0.3 to 0.4 mg/kg for adults under balanced anesthesia. Prior administration of succinylcholine quickens the onset and may increase the depth of the neuromuscular block induced by atracurium. The time to maximum block by atracurium is decreased by 2 to 3 minutes with prior use of succinylcholine.
Azelastine; Fluticasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Azilsartan; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Beclomethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Benazepril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Betamethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Budesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Budesonide; Formoterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Bumetanide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Bupivacaine Liposomal: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Lidocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Meloxicam: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Candesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
Captopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Chloroprocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Chloroquine: (Moderate) Concomitant use of succinylcholine and chloroquine may prolong neuromuscular blockade.
Chlorothiazide: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Ciclesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cisatracurium: (Moderate) The use of succinylcholine before cisatracurium administration may decrease the time to onset of maximum neuromuscular blockade but has no effect on the duration of neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Clindamycin: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Cocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cyclophosphamide: (Major) Notify the anesthesiologist if a patient has been treated with cyclophosphamide within 10 days of general anesthesia. Cyclophosphamide treatment causes a marked and persistent inhibition of cholinesterase activity; prolonged apnea may occur with concurrent use of depolarizing muscle relaxants such as succinylcholine.
Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
DaxibotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Deflazacort: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Desflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and desflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia. Anesthetic concentrations of desflurane at equilibrium (administered for 15 or more minutes before testing) reduced the effective dose (ED95) of succinylcholine by approximately 30% compared to nitrous oxide/opioid anesthesia.
Desogestrel; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Dexamethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Dienogest; Estradiol valerate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Digoxin: (Moderate) Succinylcholine-induced potassium release from muscle cells may cause arrhythmias in patients receiving digoxin.
Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Donepezil: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as donepezil.
Donepezil; Memantine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as donepezil.
Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Drospirenone: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Drospirenone; Estetrol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Drospirenone; Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Drospirenone; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Drospirenone; Ethinyl Estradiol; Levomefolate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Elagolix; Estradiol; Norethindrone acetate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Eprosartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Estradiol; Levonorgestrel: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Estradiol; Norethindrone: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Estradiol; Norgestimate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ethacrynic Acid: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Ethinyl Estradiol; Norelgestromin: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ethinyl Estradiol; Norethindrone Acetate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ethinyl Estradiol; Norgestrel: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ethynodiol Diacetate; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Etonogestrel; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Fludrocortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Flunisolide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Salmeterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Umeclidinium; Vilanterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Vilanterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Formoterol; Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fosinopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Furosemide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Galantamine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as galantamine.
Gentamicin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Hydrochlorothiazide, HCTZ; Moexipril: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Hydrocortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
IncobotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irbesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irinotecan Liposomal: (Moderate) Concomitant use of succinylcholine and irinotecan may prolong neuromuscular blockade. Irinotecan has anticholinesterase activity.
Irinotecan: (Moderate) Concomitant use of succinylcholine and irinotecan may prolong neuromuscular blockade. Irinotecan has anticholinesterase activity.
Isoflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and isoflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia. Anesthetic concentrations of isoflurane at equilibrium reduced the effective dose (ED95) of succinylcholine by approximately 25% to 40% or more compared to nitrous oxide/opioid anesthesia.
Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Leuprolide; Norethindrone: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levonorgestrel: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Levonorgestrel; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lidocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lidocaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lidocaine; Prilocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lincomycin: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lisinopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Losartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Magnesium Salts: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Mepivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Methazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Methylprednisolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Metoclopramide: (Moderate) Consider reducing the dose of succinylcholine when metoclopramide is given concomitantly. Concomitant use of succinylcholine and metoclopramide may prolong neuromuscular blockade, possibly due to plasma cholinesterase inhibition by metoclopramide.
Metolazone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Neostigmine: (Moderate) Neostigmine does not antagonize, and may prolong, the Phase I block of succinylcholine. If given before succinylcholine is metabolized by cholinesterase, neostigmine may prolong rather than shorten paralysis. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). When this diagnosis is confirmed with a peripheral nerve stimulator, it may sometimes be reversed with anticholinesterase drugs, such as neostigmine. Anticholinesterase drugs may not always be effective.
Neostigmine; Glycopyrrolate: (Moderate) Neostigmine does not antagonize, and may prolong, the Phase I block of succinylcholine. If given before succinylcholine is metabolized by cholinesterase, neostigmine may prolong rather than shorten paralysis. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). When this diagnosis is confirmed with a peripheral nerve stimulator, it may sometimes be reversed with anticholinesterase drugs, such as neostigmine. Anticholinesterase drugs may not always be effective.
Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
NIFEdipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Norethindrone: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Norethindrone; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Norgestimate; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Norgestrel: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Olmesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Olopatadine; Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
OnabotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Oral Contraceptives: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Oxytocin: (Moderate) Concomitant use of succinylcholine and oxytocin may prolong neuromuscular blockade.
Pancuronium: (Major) If succinylcholine is used before pancuronium, delay pancuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of pancuronium and increase its duration of action. If a small dose of pancuronium is given at least 3 minutes before administration of succinylcholine, in order to reduce the incidence and intensity of succinylcholine-induced fasciculations, this dose may induce a degree of neuromuscular block sufficient to cause respiratory depression in some patients.
Paromomycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Phenelzine: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of phenelzine; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Physostigmine: (Contraindicated) Physostigmine is contraindicated in patients receiving succinylcholine due to reduced plasma cholinesterase activity and prolonged neuromuscular blockade.
Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Plazomicin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
Prednisolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Prednisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Prilocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Prilocaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Pyridostigmine: (Moderate) Pyridostigmine does not antagonize, and may prolong, the Phase I block of succinylcholine. If given before succinylcholine is metabolized by cholinesterase, pyridostigmine may prolong rather than shorten paralysis. Depending on the dose and duration of succinylcholine administration, the characteristic depolarizing neuromuscular block (Phase I block) may change to a block with characteristics superficially resembling a non-depolarizing block (Phase II block). When this diagnosis is confirmed with a peripheral nerve stimulator, it may sometimes be reversed with anticholinesterase drugs, such as pyridostigmine. Anticholinesterase drugs may not always be effective.
Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
Relugolix; Estradiol; Norethindrone acetate: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
RimabotulinumtoxinB: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Rivastigmine: (Moderate) A synergistic effect may be expected when succinylcholine is given concomitantly with a cholinesterase inhibitor, such as rivastigmine.
Rocuronium: (Major) If succinylcholine is used before rocuronium, delay rocuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. The median duration of action of rocuronium 0.6 mg/kg administered after succinylcholine 1 mg/kg when T1 (defined as 3 twitches of train-of-four) returned to 75% of control was 36 minutes (range: 14 to 57, n = 12) vs. 28 minutes (range: 17 to 51, n = 12) without succinylcholine.
Ropivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Segesterone Acetate; Ethinyl Estradiol: (Moderate) Plasma cholinesterase activity may be diminished by chronic administration of oral contraceptives; consider the possibility of prolonged neuromuscular block after administration of succinylcholine in patients with reduced plasma cholinesterase activity. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sevoflurane: (Moderate) Additional monitoring or a dosage reduction may be required for some patients during concomitant use of succinylcholine and sevoflurane. Concomitant use may prolong neuromuscular blockade and increase the risk for hyperkalemia and malignant hyperthermia.
Sodium Sulfate; Magnesium Sulfate; Potassium Chloride: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Spironolactone; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Stiripentol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of stiripentol and succinylcholine. CNS depressants can potentiate the effects of stiripentol.
Streptomycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Telmisartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Terbutaline: (Moderate) Concomitant use of succinylcholine and terbutaline may prolong neuromuscular blockade.
Tetracaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Thalidomide: (Moderate) Use succinylcholine with caution in patients taking thalidomide due the risk of additive bradycardia.
Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Thiotepa: (Moderate) Concomitant use of succinylcholine and thiotepa may prolong neuromuscular blockade. It has been theorized that this is caused by the anticholinesterase activity of anticancer drugs such as thiotepa.
Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Tobramycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Torsemide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Triamcinolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Triamterene; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Vecuronium: (Major) If succinylcholine is used before vecuronium, delay vecuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. With succinylcholine as the intubating agent, use initial vecuronium doses of 0.04 to 0.06 mg/kg with inhalation anesthesia and 0.05 to 0.06 mg/kg with balanced anesthesia. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of vecuronium and its duration of action.
Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction. Succinylcholine, a depolarizing neuromuscular blocking agent, produces skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate. Like ACh, it activates the receptor and causes membrane depolarization. Because succinylcholine is resistant to degradation by acetylcholinesterase, it remains bound to the receptor and thereby inhibits repolarization, resulting in an extended duration of neuromuscular blockade. Depolarization results in fasciculation of the skeletal muscles and muscle paralysis. Neuromuscular transmission is inhibited until succinylcholine is degraded by pseudocholinesterase. The paralysis after succinylcholine administration is selective. Initially, paralysis involves the levator muscles of the face and muscles of the glottis. Paralysis consecutively involves the intercostals, the diaphragm, and all other skeletal muscles. Muscle tone generally returns in the reverse order. Succinylcholine has no direct effect on the uterus, myocardium, or other smooth muscle structures. Succinylcholine does, however, stimulate both autonomic ganglia and muscarinic receptors, which may affect cardiac rhythm.
Succinylcholine can be administered intravenously or intramuscularly. Succinylcholine is highly ionized and has low lipid solubility; it is rapidly distributed into the extracellular space. Succinylcholine is rapidly hydrolyzed by plasma cholinesterase to succinylmonocholine, a metabolite which possesses clinically insignificant depolarizing neuromuscular blocking properties. Succinylmonocholine is further hydrolyzed to succinic acid and choline. Up to 10% of a succinylcholine dose is excreted unchanged in the urine.
Plasma cholinesterase activity may be diminished in patients with genetic abnormalities of plasma cholinesterase, malignant tumors, infections, burns, anemia, decompensated heart disease, peptic ulcer, severe hepatic or renal dysfunction, or myxedema. In addition, chronic administration of drugs that antagonize plasma cholinesterase (e.g., oral contraceptives, glucocorticoids, monoamine oxidase inhibitors, cyclophosphamide) may decrease cholinesterase activity and increase duration of neuromuscular blockade.
Affected cytochrome P450 isoenzymes and drug transporters: none
-Route-Specific Pharmacokinetics
Intravenous Route
After administration of succinylcholine 0.3 to 1.1 mg/kg IV in adults, neuromuscular blockade occurs in approximately 1 minute, maximum blockade may persist for about 2 minutes, after which recovery takes place within 4 to 6 minutes. Patients with low pseudocholinesterase concentrations may experience longer durations of action.
Intramuscular Route
Onset of paralysis occurs in approximately 2 to 3 minutes after intramuscular administration. Patients with low pseudocholinesterase concentrations may experience longer durations of action.
-Special Populations
Hepatic Impairment
Plasma cholinesterase activity may be reduced in patients with severe hepatic disease, which may result in prolonged neuromuscular blockade.
Renal Impairment
Plasma cholinesterase activity may be reduced in patients with severe renal disease, which may result in prolonged neuromuscular blockade.
Pediatrics
Children
Children have a larger extracellular fluid compartment resulting in a larger Vd compared to adults; extracellular fluid constitutes approximately 20% of body weight at 6 years compared to 16% of body weight in adulthood. Because of differences in Vd, children often require more succinylcholine on a mg/kg basis than adolescents and adults (but less than neonates and infants).
Neonates and Infants
Neonates and infants have a larger extracellular fluid compartment resulting in a larger Vd compared to other populations; extracellular fluid constitutes approximately 45%, 30%, 20%, and 16% of body weight at birth, 2 months, 6 years, and adulthood, respectively. Because of their larger Vd, neonates and young infants often require larger doses on a mg/kg basis. Developmental differences in the neuromuscular junction during the first 2 months of life may also influence the pharmacokinetics of succinylcholine in this population. In general, immature acetylcholine receptors result in greater variability of neuromuscular blockade response. In addition, the immature receptor has a smaller single-channel conductance that opens for a longer time than the mature receptor, allowing the immature muscle to be more easily depolarized. Though neonates and infants have fewer acetylcholine receptors compared to other populations, the immature receptor has a greater affinity for succinylcholine.