Can succinylcholine be used in patients with end stage renal disease who are on dialysis? As I see it the key questions are: 1) is the release of potassium that normally occurs after succinylcholine in some way exaggerated in patients with renal failure? 2) Is the hyperkalemia sometimes seen in patients with renal failure a contraindication to succinylcholine? It is clear from the literature that there are two pathophysiologic situations in which succinylcholine is clearly contraindicated because it may produce massive hyperkalemia and another in which hyperkalemia might occur but is uncommon: 1) patients with severe, acute muscle destruction such as burns or crush injuries, 2) patients with large amounts of denervated muscle (regardless of whether it is an upper motor or lower motor nerve injury) and 3) prolonged immobilization. In situations 1 and 2 it has been well demonstrated that even small amounts of succinylcholine can produce large increases in serum potassium and this may lead to cardiac arrest. The effects of prolonged immobilization on succinylcholine are less clear as there are only occasional case reports. However there is one animal study using cast immobilization of a lower extremity that demonstrated increased potassium after succinylcholine at immobilization day 14 plus (Anesthesiology 1991;75:650). With respect to renal failure there is no evidence that there is a change in the sensitivity of the motor endplate to succinylcholine or a change in the number of receptors. There are a few case reports of cardiac arrest after succinylcholine in patients with renal failure; however these reports did not measure potassium either before or after the event. Schow AJ et al retrospectively reviewed the Duke Anesthesiology Electronic Data Base between 1995 and 2001. They identified 38 patients with serum potassium greater than 5.6 mEq/l before the administration of succinylcholine at the induction of anesthesia. There was no documented succinylcholine associated morbidity (Anesth Analg 2002;95:119 – 22). Miller et al. studied 20 patients, 10 with normal renal function undergoing abdominal surgery and 10 in renal failure who presented for renal transplantation. The increase in potassium after succinylcholine was similar in both groups with a maximal increase of 0.7 mEq/l (Anesthesiology, 1972;36:138 – 141). In a subsequent paper Powell DD and Miller R studied the effect of repeat doses of succinylcholine in patients with and without renal failure and showed that both groups had similar increases in serum potassium; the largest increase was 0.6 mEq/l (Anesth Analg 1975;54:746-748). Based on this literature chronic renal failure is not a contraindication to the use of succinylcholine provided that the serum potassium is not acutely elevated and the dose may be repeated as needed.
David S. Smith, M.D, Ph.D.