Succinylcholine

ANECTINE

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Pronunciation: sux-in-il-KOE-leen

Succinylcholine ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Succinylcholine ballicule

Succinylcholine ANECTINE mascot mnemonic cartoon — Visual mnemonic: Succinylcholine mascot
**“A nectarine Sucks in a coal line”**
baby blue theme → muscarinic

What it isDepolarizing nicotinic agonist at the neuromuscular junction; rapid-sequence intubation.

Why this oneOnset within a minute and offset within ten, which no nondepolarizing agent matches.

What limits it⚑ Hyperkalemic arrest follows burns, crush injury, denervation or prolonged immobility. It also triggers malignant hyperthermia.

Succinylcholine molecular structure (skeletal formula) — Molecular structure: Succinylcholine

FDA-approved for

rapid-sequence intubation (1952)

Principal riskEndogenous or dietary; no boxed warning applies

Classes and tags

Clinical profile

Therapeutic safety burden3 / 4

Overdose danger4 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryC

Defining liabilityRespiratory paralysis, hyperkalemia and malignant hyperthermia

FDA label

Read the full label on DailyMed ↗

BOXED WARNING Risk of ventricular dysrhythmias, cardiac arrest and death from hyperkalemic rhabdomyolysis in pediatric patients with undiagnosed skeletal muscle myopathy (e.g., Duchenne).

FDA dosing	Population	Start	Target	Max
Neuromuscular blockade / facilitate tracheal intubation (short procedures)	Adults, IV	0.6 mg/kg IV (range 0.3-1.1 mg/kg)	titrate to effect

Renal Undefined

Hepatic Undefined

Reserve pediatric use for emergency intubation; IV bolus in children may cause profound bradycardia/asystole.

Instructions

For IV or IM use only.
Do not administer before unconsciousness is induced (except emergencies).
Pretreat with an anticholinergic (e.g., atropine) to reduce bradyarrhythmias.
Monitor neuromuscular function with a peripheral nerve stimulator when given by infusion.

Available strengths

inj 20 mg/mL
sol 100 mg/5 mL

Contraindications

Known or suspected genetic susceptibility to malignant hyperthermia
Skeletal muscle myopathies
After acute phase of major burns, multiple trauma, extensive denervation, or upper motor neuron injury (severe hyperkalemia risk)

Cautions

MAOIs may diminish plasma cholinesterase activity
Anaphylaxis
Risk of death from medication errors (unintended paralysis)
Hyperkalemia — serious arrhythmias/cardiac arrest
Malignant hyperthermia
Bradycardia (esp. with a second dose)
Increased intraocular pressure

Adverse reactions

Cardiac arrest, arrhythmias, bradycardia, tachycardia
Hyper-/hypotension
Hyperkalemia
Malignant hyperthermia; rhabdomyolysis
Prolonged respiratory depression/apnea
Anaphylaxis

Pregnancy Decades of data show no drug-associated risk; risk of prolonged apnea (plasma cholinesterase decreased ~24%).

Lactation No data on presence in milk; weigh benefits/risks.

Cost

Succinylcholine (ANECTINE)

Strength		#/mo	generic $/unit	CostPlus
20 mg/mL	inj	per unit		not offered

NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Succinylcholine is administered under clinical supervision and dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.

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Memory aids: interaction avatars

butyrylcholinesterase substrate

Box: minimal PK interactions

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Self-check

How does succinylcholine produce neuromuscular blockade?
Depolarizing nicotinic agonism.
What fatal electrolyte event can follow succinylcholine after burns or denervation?
Hyperkalemic arrest.