Succinylcholine Injection Uses, Dose, Side Effects | DrugsAtlas India
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DRUG NAME: Succinylcholine
Therapeutic Class: Neuromuscular Blocking Agent
Subclass: Depolarising Neuromuscular Blocker
Specialty: Anaesthesiology
Schedule (India): H
Route(s): Intravenous (IV), Intramuscular (IM - emergency use when IV access unavailable)
Formulations Available in India:
| Formulation | Strength |
| Injection | 50 mg/mL in 2 mL ampoule (100 mg) |
| Injection | 50 mg/mL in 10 mL vial (500 mg) |
INDICATIONS + DOSING — FOR CLINICIAN USE ONLY
Primary Indications (Approved / Standard in India)
❖ Rapid Sequence Intubation (RSI) / Facilitation of Tracheal Intubation
Intravenous Route (Preferred):
| Parameter | Recommendation |
| Starting dose | 1–1.5 mg/kg IV bolus |
| Titration | Not applicable — single bolus administration |
| Usual maintenance dose | Not applicable for RSI (single dose procedure) |
| Maximum dose | 2 mg/kg (higher doses may be required with concurrent volatile anaesthetics) |
Pharmacokinetic Parameters:
- Onset: 30–60 seconds
- Duration: 5–10 minutes
Clinical Notes:
- Pre-treatment with defasciculating dose of non-depolarising agent (e.g., vecuronium 0.01 mg/kg or rocuronium 0.06 mg/kg) may reduce fasciculations and postoperative myalgias
- Atropine pre-treatment (0.01–0.02 mg/kg IV) recommended in children and when repeat doses anticipated to prevent bradycardia
Intramuscular Route (Only when IV access unavailable):
| Parameter | Recommendation |
| Starting dose | 3–4 mg/kg IM |
| Titration | Not applicable |
| Usual maintenance dose | Not applicable |
| Maximum dose | 150 mg per injection |
Note: IM route has slower onset (2–3 minutes) and is reserved for emergency situations when IV access cannot be established. Monitor for delayed recovery and arrhythmias.
❖ Short Surgical Procedures Requiring Brief Muscle Relaxation
| Parameter | Recommendation |
| Starting dose | 1–1.5 mg/kg IV bolus |
| Titration | Not applicable |
| Usual maintenance dose | 0.3–0.6 mg/kg IV if additional relaxation required |
| Maximum dose | Total cumulative dose guided by clinical response; avoid prolonged or repeated infusions |
Clinical Notes:
- Suitable only for procedures lasting <10 minutes
- Continuous infusion not recommended due to Phase II block risk and tachyphylaxis
- Repeat doses carry higher risk of bradycardia and hyperkalaemia
Secondary Indications — Adults (Off-label, if any)
| Indication | Status |
| Electroconvulsive therapy (ECT) | Specialist use — may be used for brief muscle relaxation during ECT; standard RSI dosing applies |
| Laryngospasm (refractory) | Emergency use — 0.1–0.5 mg/kg IV or 4 mg/kg IM if IV access unavailable |
Note: These uses are within specialist anaesthesia/psychiatry practice and not routine off-label applications.
PAEDIATRIC DOSING (Specialist Only)
Primary Indications (Approved / Standard in India)
❖ Tracheal Intubation / RSI in Paediatric Patients
Intravenous Route:
| Age Group | Dose | Notes |
| Neonates (<1 month) | 2 mg/kg IV | Higher dose required due to larger volume of distribution |
| Infants (1–12 months) | 2 mg/kg IV | Pre-treat with atropine 0.02 mg/kg IV to prevent bradycardia |
| Children (1–12 years) | 1–2 mg/kg IV | Atropine pre-treatment recommended |
| Adolescents (>12 years) | 1–1.5 mg/kg IV | Adult dosing applies |
Intramuscular Route (Emergency only — when IV inaccessible):
| Age Group | Dose | Maximum |
| All paediatric ages | 3–4 mg/kg IM | 150 mg |
Mandatory Monitoring:
- Continuous ECG monitoring (bradycardia risk higher in children)
- Pulse oximetry
- End-tidal CO₂ monitoring
- Observe for arrhythmias
Safety Statement:
- Use permitted in all paediatric age groups under anaesthesiologist supervision only
- CRITICAL WARNING: Avoid in children with undiagnosed myopathy (Duchenne muscular dystrophy) — risk of fatal hyperkalaemia and rhabdomyolysis
- Routine screening for neuromuscular disease history mandatory before administration
Secondary Indications — Paediatric (Off-label, if any)
Not recommended — Continuous infusion or repeated doses carry unacceptable risk of hyperkalaemia and rhabdomyolysis, particularly in patients with occult myopathies.
RENAL ADJUSTMENT
| Renal Function | Recommendation |
| Mild to moderate impairment | No dose adjustment required |
| Severe impairment (eGFR <30 mL/min) | Use with caution; monitor serum potassium before administration |
| Haemodialysis | Avoid if pre-dialysis potassium elevated; ensure potassium <5.0 mEq/L before use |
Note: Succinylcholine is hydrolysed by plasma pseudocholinesterase; not dependent on renal excretion. However, chronic kidney disease patients may have baseline hyperkalaemia, increasing risk of succinylcholine-induced cardiac arrhythmias.
HEPATIC ADJUSTMENT
| Hepatic Function | Recommendation |
| Mild impairment (Child-Pugh A) | No dose adjustment required |
| Moderate impairment (Child-Pugh B) | Use with caution; monitor for prolonged paralysis |
| Severe impairment (Child-Pugh C) | Use with caution; reduced pseudocholinesterase synthesis may prolong duration of action significantly |
Note: Patients with severe liver disease, malnutrition, or cirrhosis may have reduced plasma pseudocholinesterase levels leading to prolonged neuromuscular blockade. Ensure ventilatory support available.
CONTRAINDICATIONS
- Personal or family history of malignant hyperthermia
- Known or suspected pseudocholinesterase deficiency (inherited or acquired)
- Hypersensitivity to succinylcholine
- Hyperkalaemia or conditions predisposing to hyperkalaemia
- Penetrating eye injuries (raises intraocular pressure)
- Skeletal muscle myopathies (especially Duchenne muscular dystrophy in children)
- Denervation injuries or prolonged immobilisation (>72 hours) — upregulation of extrajunctional acetylcholine receptors
- Burns (>48 hours post-injury up to several months)
- Upper motor neuron lesions, stroke with hemiplegia (>48 hours)
- Spinal cord injury with paralysis (>48 hours)
- Severe crush injuries (>48 hours)
CAUTIONS
- Conditions increasing hyperkalaemia risk: Chronic kidney disease, burns (early phase), crush injuries, neuromuscular diseases, prolonged ICU immobility
- Repeat dosing: Increased bradycardia risk, especially in children; pre-treat with atropine
- Increased intraocular pressure: Use with caution in glaucoma (not absolute contraindication if globe intact)
- Increased intracranial pressure: Fasciculations may transiently raise ICP
- Increased intragastric pressure: Risk of regurgitation; mitigated by cricoid pressure during RSI
- Postoperative myalgias: More common in young ambulatory patients; consider defasciculating dose
- Prolonged infusion: Risk of Phase II (desensitisation) block; avoid continuous infusion
- Atypical pseudocholinesterase: Prolonged paralysis (may last hours); maintain ventilation until recovery
PREGNANCY
| Parameter | Information |
| Risk category | Generally safe for short-term use during emergency airway management |
| Overall safety | Not teratogenic; minimal placental transfer due to quaternary ammonium structure |
| Preferred alternatives | Succinylcholine remains preferred agent for obstetric RSI due to rapid onset and short duration |
| When may be used | Emergency caesarean section, failed intubation protocols, obstetric RSI |
| Monitoring | Maternal oxygenation; fetal heart rate monitoring post-procedure |
Note: Reduced plasma pseudocholinesterase activity in late pregnancy may slightly prolong duration of action.
LACTATION
| Parameter | Information |
| Compatibility | Compatible with breastfeeding |
| Drug levels in milk | Negligible — rapid hydrolysis in plasma; quaternary ammonium structure limits transfer |
| Preferred alternatives | Not applicable — succinylcholine is the agent of choice when indicated |
| Infant monitoring | Not required; no interruption of breastfeeding necessary |
ELDERLY
| Parameter | Recommendation |
| Starting dose | 1 mg/kg IV (lower end of adult range) |
| Titration | Not applicable |
| Slower titration needed | Not applicable (single bolus agent) |
| Extra risks | Reduced pseudocholinesterase activity; increased sensitivity to bradycardia; prolonged duration of action possible |
| Monitoring | Continuous ECG; ensure full recovery of neuromuscular function before extubation |
Note: Avoid repeat dosing in elderly. Ensure adequate ventilatory support during prolonged recovery.
MAJOR DRUG INTERACTIONS
| Interacting Drug/Class | Interaction | Recommendation |
| Volatile anaesthetics (halothane, sevoflurane, isoflurane, desflurane) | Trigger for malignant hyperthermia when combined with succinylcholine | Avoid combination in patients with MH risk; have dantrolene available |
| Cholinesterase inhibitors (neostigmine, pyridostigmine, physostigmine, rivastigmine) | Inhibit succinylcholine metabolism → Prolonged paralysis | Avoid or reduce succinylcholine dose significantly |
| Organophosphate/carbamate insecticides | Irreversible cholinesterase inhibition → Extremely prolonged paralysis | Contraindicated; identify exposure history |
| Aminoglycoside antibiotics (gentamicin, amikacin, tobramycin) | Potentiate neuromuscular blockade | Use with caution; prolonged paralysis possible |
| Cyclophosphamide (high-dose) | Reduces pseudocholinesterase levels | Avoid or anticipate prolonged action |
| Metoclopramide | Inhibits plasma cholinesterase | Monitor for prolonged paralysis |
| Ecothiopate eye drops | Irreversible cholinesterase inhibition | Discontinue 2–4 weeks before surgery if possible |
MODERATE DRUG INTERACTIONS
| Interacting Drug/Class | Interaction | Recommendation |
| Beta-blockers | Enhanced bradycardia risk | Pre-treat with atropine; ECG monitoring |
| Calcium channel blockers (verapamil, diltiazem) | Additive bradycardia and hypotension | Monitor closely |
| Magnesium sulfate | Potentiates neuromuscular blockade | Common in obstetrics; reduce dose and monitor carefully |
| Lithium | May prolong neuromuscular blockade | Monitor; anticipate longer recovery |
| Quinidine, procainamide | Potentiate blockade | Monitor recovery closely |
| Non-depolarising neuromuscular blockers (defasciculating doses) | Reduce fasciculations but may require higher succinylcholine dose | Increase succinylcholine to 1.5–2 mg/kg if defasciculation used |
| Diuretics (furosemide, thiazides) | Electrolyte disturbances may increase arrhythmia risk | Check potassium before administration |
COMMON ADVERSE EFFECTS
- Muscle fasciculations
- Postoperative myalgias (especially in young ambulatory patients)
- Transient hyperkalaemia (0.5–1 mEq/L rise)
- Bradycardia (especially with repeat doses or in children)
- Transient increase in intraocular pressure
- Transient increase in intragastric pressure
- Mild histamine release (flushing, rash)
- Jaw rigidity (masseter muscle spasm — may herald malignant hyperthermia)
SERIOUS ADVERSE EFFECTS
| Adverse Effect | Clinical Action |
| Malignant hyperthermia |
EMERGENCY: Discontinue all triggering agents; administer dantrolene 2.5 mg/kg IV immediately (repeat as needed up to 10 mg/kg); active cooling; ICU admission mandatory
|
| Severe hyperkalaemia with cardiac arrhythmias/arrest | Immediate CPR if arrest; calcium chloride/gluconate IV; insulin + glucose; sodium bicarbonate; haemodialysis if refractory |
| Prolonged paralysis (pseudocholinesterase deficiency) | Maintain mechanical ventilation until full recovery; sedation during prolonged paralysis; fresh frozen plasma may shorten recovery |
| Rhabdomyolysis | Aggressive IV fluids; monitor creatine kinase, renal function, urine myoglobin |
| Cardiac arrest (children with undiagnosed myopathy) | Immediate resuscitation; treat hyperkalaemia; high mortality |
| Anaphylaxis | Standard anaphylaxis management; adrenaline, fluids, airway support |
MONITORING REQUIREMENTS
Baseline:
- Serum potassium (mandatory in renal impairment, burns, trauma, prolonged immobility)
- History of neuromuscular disease (personal and family)
- History of malignant hyperthermia (personal and family)
- Pseudocholinesterase assay if history of prolonged paralysis in patient or relatives
During Administration:
- Continuous ECG monitoring
- Pulse oximetry
- End-tidal CO₂ (capnography)
- Peripheral nerve stimulator (if available)
- Core temperature monitoring (for MH detection)
Post-Administration:
- Confirm full recovery of neuromuscular function (head lift ≥5 seconds, adequate tidal volume)
- Ventilatory adequacy before extubation
- Monitor for residual weakness
BRANDS AVAILABLE IN INDIA
| Brand Name | Manufacturer |
| Scoline | Samarth Life Sciences |
| Myorelax | Samarth Life Sciences |
| Sucon | Neon Laboratories |
| Suxoflex | Emcure Pharmaceuticals |
| Succicure | Themis Medicare |
| Anectine | Aspen (limited availability) |
PRICE RANGE (INR)
| Product | Approximate Price (INR) |
| Succinylcholine 100 mg/2 mL ampoule | ₹25 – ₹60 |
| Succinylcholine 500 mg/10 mL vial | ₹80 – ₹150 |
NLEM Status: Included in NLEM 2022 — NPPA price control applicable
Note: Available in government hospitals and district health facilities. Cold chain storage required (2–8°C).
CLINICAL PEARLS
- Gold standard for RSI: Succinylcholine remains the preferred agent for rapid sequence intubation when no contraindications exist due to fastest onset and shortest duration among all neuromuscular blockers
- Rocuronium as alternative: In patients with contraindications to succinylcholine, rocuronium (1.2 mg/kg) with sugammadex reversal provides comparable intubating conditions
- Atropine pre-treatment: Essential in children and when repeat doses are anticipated; dose 0.01–0.02 mg/kg IV
- Myopathy screening in children: Always enquire about motor developmental milestones and family history before administration; undiagnosed Duchenne muscular dystrophy is a life-threatening contraindication
- Never use for infusion: Phase II block and tachyphylaxis develop with prolonged administration; succinylcholine is a single-bolus agent only
- Storage requirement: Refrigerate at 2–8°C; stable at room temperature for limited period (check manufacturer guidelines)
TAGS
Succinylcholine; suxamethonium; neuromuscular blocker; depolarising; RSI; rapid sequence intubation; airway management; anaesthesia; hyperkalaemia risk; malignant hyperthermia; NLEM India
VERSION
RxIndia v0.2 — 03 Feb 2026
REFERENCES
- CDSCO (Product approval and labelling information)
- Indian Pharmacopoeia
- NLEM 2022
- AIIMS Anaesthesia Protocols
- API Textbook of Medicine
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics
- Indian Society of Anaesthesiologists Guidelines
- Manufacturer’s Product Inserts (India-registered products)
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Clinical Responsibility
This platform is designed strictly for healthcare professionals. Data provided is synthesized from authoritative pharmacological sources and clinical registries. Do not use for consumer medical decisions. Always verify critical dosing and contraindications with official institutional protocols and peer-reviewed journals.
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