A presentation by Antti Väänänen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Should we abandon
succinylcholine and sodium
pentothal in GA cesarean
delivery?
Antti Väänänen, MD, Ph.D. SSAI diploma in obstetric anesthesia
Helsinki University Central Hospital /Women’s hospital

2. Conflicts of interest
• None
• Sole employer: Helsinki University Central Hospital

3. Data derived from: Staikou C et al., Minerva Anesthesiol. 2014; 80(3): 347-54.

4. ”past performance is no guarantee of future
success…”
• Sodium pentothal has a long track record in obstetric anesthesia
• First published report: Le Breque FC 1938; New Engl. J. Med. 219:
954.
• Standard practice by the late 1950’s

6. Pentothal pros and cons for CS
Good
• Long track record
• Easy to stick with the current
”standard practice”
• No local vascular irritation upon
successful IV administration
• Predictable effect
Not so good
• Crosses the placenta
• from ”<12 min rule” to under 4
minutes for ID-time
• Commercial availability?
• Toxic upon extravasation
• Precipitates with MANY drugs
• Injection solution needs to be
prepared prior to use

7. Why pentothal? UK survey Sept 2011:
• Historical reasons 37 %
• Reduced risk of awareness 31 %
• Better infant outcome 13 %
• Better hemodynamic stability 12 %
N=691 UK obstetric anesthetists
Murdoch H et al., IJOA 2013 22: 31-5.

8. Why sodium thiopentothal?
UK survey Sept 2011:
Murdoch H et al., IJOA 2013 22: 31-5.
15 % would definitely
44 % would probably
support change to
PROPOFOL
• Historical reasons 37 %
• Reduced risk of awareness 31 %
• Better infant outcome 13 %
• Better hemodynamic stability 12 %
N=691 UK obstetric anesthetists

9. How about propofol instead?
• The first studies about propofol induction for CS emerged in the late
1980’s1,2
• Major concerns:
• Insufficient maternal sedation (recall)3
• Excessive infant sedation (low apgar points)4
• Maternal hypotension after induction
1Valtonen M et al., Anaesthesia 1989; 44: 758-62; 2Moore J et al., Anesthesia 1989; 44: 753-7.
3Celleno D et al., J Clin Anesth. 1993; 5: 284-8; 4Celleno D et al., Br J Anaesth. 1989; 62: 649-54.

10. Awareness/recall
• Initial concern with propofol (2.4 mg/kg) based on EEG studies ->
sodium pentothal (5 mg/kg) was considered superior for CS1
• Propofol induction (2.5 mg/kg) vs. sodium pentothal (5 mg/kg) +
sevoflurane maintainance gives lower BIS readings2
• 80% of obstetric anesthesia litigation claims for CS under GA due to
awareness during surgery in UK3
• Prospective study of awareness during GA CS (N=1095), insidence of
awareness 2 cases (both with sodium pentothal!)4
1Celleno D et al., J Clin Anesth. 1993; 5: 284-8; 2Mercan A et al., M. Eastern J Anaesthesiol. 2012; 21: 699-704;
3Ashpole and Cook Anaesthesia 2010; 65: 529-30; 4Paech MJ et al., IJOA 2008; 17: 298-303.

11. Haemodynamics
• Compared to propofol sodium pentothal induction results in:
• Greater haemodynamic responses during intubation1,2
• Higher plasma catecholamine levels2
• No difference in the insidence of hypotension1-3
1Mercan A et al., M. Eastern J Anaesthesiol. 2012; 21: 699-704; 2Gin T et al., BJA 1993; 70: 311-6;
3Valtonen M et al., Anaesthesia 1989; 44: 758-762.

12. Infant outcome?

13. Sodium pentothal – what is the benefit?
• For the parturient:
• Awareness/recall: No clear benefit from pentothal
• Haemodynamics: Propofol may be better
• For the newborn:
• Transient neonatal depression may be evident at 1 min age after propofol
induction
• Facilities to monitor the newborn and assist the ventilation are needed no
matter which induction / anesthesia agent is used
• For the anesthetist:
• None

14. Is it time to trash succinylcholine?

15. Succinylcholine a.k.a. suxamethonium
• The side-effects of succinylcholine
• (Too) short duration of action for CS (all)
• Muscle pain / myalgia (appr 50 %)
• Masseter spasm (<1%)1
• Bradycardia/hypotension
• Allergic reactions (1:7500)
• France: /100.000 vials sold: ROC 13.8, SUX 13.3, CIS 0.42
• Hyperkalemia
• Prolonged effect (plasma choline-esterase deficiency)
• Malignant hypertermia (rare)
1 Schwartz L et al., Anesthesiology 1984; 61:772-775, 2 Tacquard C et al., Acta Anesth. Analg. Scand. 2017; 61: 290-
299

16. Rationale for using succinylcholine
• ”Golden standard”1
• Rapid on-set of action
• Good or excellent intubating conditions2
• 1 mg/kg in 60 s
• ”Rapid” recovery of neuromuscular function
• after 1 mg/kg 210-540 s3
• marked and unpredictable individual variation!
1Hodges RJ et al., Br J Anesth. 1959; 31: 152-163; 2 Sluga M et al., Anesth Analg. 2005; 101: 1356-1361; 3Heier T et al.,
Anesthesiology 2001; 94:754-759.

17. Obstetric anesthetist’s pitfalls with SUX
• Increased oxygen consumption due to pregnancy1
• Succinylcholine increases oxygen consumption2
• In non-obstetric patients SpO2 fell to 92 % in 283 s after succinylcholine while
after rocuronium the similar time delay was 329 s3
1McClelland SH et al., Anaesthesia 2009; 64:371-377.; 2 Taha SK et al., Anaesthesia 2010; 65: 358-361; 3Tang L et al.,
Acta Anesthesiol Scand. 2011; 55:203-208.

18. Could rocuronium replace succinylcholine?
• Rocuronium is the only potential option for succinylcholine during
rapid sequence intubation
• Upon introduction of specific reversal agent (sugammadex) rapid
reversal of neuromuscular block is possible
• Concerns:
• Onset time
• Placental transfer
• Allergic reactions

19. Onset time for rocuronium vs succinylcholine
• At 0.6 mg/kg the onset is markedly slower compared to SUX 1 mg/kg1
• Similar onset time as with SUX when rocuronium used at higher dose
1(-1.2 mg/kg)2
• Increased cardiac output (as seen during late pregnancy) may benefit
the onset time of rocuronium3
1Abouleish E et al., Br J Anaesth. 1994; 73:336-341; 2 Williamson et al., Acta Anaesthesiol Scand. 2011; 55: 694-699;
3Han et al., Anaesthesia 2008; 63: 856-860.

20. Stourac et al., Anesth. Analg. 2016; 122:1536-1545.

21. Time from induction to intubation and
relaxation onset time
Stourac et al., Anesth. Analg. 2016; 122:1536-1545.

22. Intubation conditions
Stourac et al., Anesth. Analg. 2016; 122:1536-1545.

23. Newborn outcome
?
?
✔
✔
✔
✔

24. Conclusions
• Succinylcholine CAN be replaced by rocuronium at 1 mg/kg
• However:
• Pain during injection of rocuronium must be dealt with
• A high dose (1 mg/kg) is needed to achieve the speed and quality of
succinylcholine induced muscular paralysis
• Placental transfer rate of high dose rocuronium will need to be determined
• The effect rocuronium at 1 mg/kg will last longer than the operation and likely
require reversal of the neuromuscular block by an expensive medicine

25. Background and figure pixamania.com - no copyright claimed