|Year : 2014 | Volume
| Issue : 2 | Page : 106-111
Effect of repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia
Kamakshi Garg1, Neeru Luthra1, Sandeep Sud2, Tej K Kaul1, Namrata1
1 Department of Anesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana, India
2 Ex Senior Resident, Department of Anesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||11-Aug-2014|
House No. 4, Professor Colony, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
Background: Succinylcholine-induced fasciculations and myalgia are common and troublesome for the patients. A few studies have used propofol to minimize succinylcholine-induced fasciculations and myalgia, but none of these have used a repeat bolus dose. Materials and Methods: A prospective, randomized, double blind study was designed to assess the effect of a repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia. Ninety adult patients scheduled for elective surgery under general anesthesia were selected by computer-generated random numbers and allocated to one of the three equal groups randomly. Anesthesia was induced with intravenous injection of propofol 2 mg/kg, followed by administration of succinylcholine 1.5 mg/kg. Immediately after the injection of succinylcholine a repeat bolus of propofol was given as per group. Group I: No repeat dose of propofol; Group II: Repeat propofol bolus of 0.5 mg/kg body weight; Group III: Repeat propofol bolus of 1.0 mg/kg body weight. Muscle fasciculations were observed and graded as nil (0), mild (1), moderate (2), or severe (3). Postoperative myalgia were assessed every 6 hourly for 24 h and then at 48 h and graded as nil (I), mild (II), moderate (III), or severe (IV). Results: The overall incidence of muscle fasciculations was 73 and 33% in Groups II and III, respectively as against 90% in Group I. The incidence of postoperative myalgia was highest (86.67%) in Group I and lowest in Group III (60.0%). Conclusion: The technique of giving repeat bolus dose of propofol immediately after succinylcholine not only decreases the incidence and severity of fasciculations and postoperative myalgia, but also provides hemodynamic stability and satisfactory grade of relaxation for intubation.
Keywords: Muscle fasciculations, post-operative myalgia, succinylcholine chloride
|How to cite this article:|
Garg K, Luthra N, Sud S, Kaul TK, Namrata. Effect of repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia. J Mahatma Gandhi Inst Med Sci 2014;19:106-11
|How to cite this URL:|
Garg K, Luthra N, Sud S, Kaul TK, Namrata. Effect of repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2020 Jul 5];19:106-11. Available from: http://www.jmgims.co.in/text.asp?2014/19/2/106/138429
| Introduction|| |
Fasciculation's and postoperative myalgia are distressing side effects of succinylcholine. The incidence of muscle pain after administration of succinylcholine varies from 0.2 to 89%.  It is postulated that myalgia are secondary to damage produced in muscle by the unsynchronized contraction of adjacent muscle fibers just before onset of paralysis. The damage to muscle has been substantiated by finding myoglobinemia and increase in serum creatine kinase (CK) after succinylcholine administration. Many attempts have been made to control these undesired effects, which include pretreatment with nondepolarizing muscle relaxants,  lignocaine,  calcium gluconate,  diazepam,  etc., with variable results. A thorough search of literature did not show role of decreasing the dose of succinylcholine in reducing fasciculations. Propofol has also been identified to be a better agent than thiopentone sodium to control succinylcholine induced myalgia.  Manataki et al.,  showed that propofol effectively prevented succinylcholine induced myalgia and CK elevation when used as continuous infusion during anesthesia. Some authors have also used higher doses of propofol and suggested that it is more effective in reducing fasciculations and myalgia.  However, using larger doses can lead to hemodynamic variations. The major disadvantage of induction with propofol is the considerable decrement in the systemic arterial blood pressure. A decrease of 26-28% of systolic blood pressure, 19% of diastolic blood pressure, and 11% of mean arterial pressures, without any change in stroke volume and cardiac output, are observed when patients are induced with more than 2.0 mg/kg of propofol. 
Hence, the present study was designed to evaluate the effectiveness of a repeat bolus dose of propofol (total dose equating doses used in other studies) on succinylcholine-induced fasciculations and myalgia.
| Materials and Methods|| |
After clearance from institutional ethical committee, 90 adult patients of American Society of Anesthesiologists (ASA) class I and II, aged between 15 and 60 years, of either sex, scheduled for elective surgery under general anesthesia were selected by computer-generated random numbers. Informed consent was obtained from each patient who participated in the study. Patients having any systemic disease, head injury, raised intraocular and intracranial pressure, renal or hepatic impairment, neuromuscular diseases, burns, shock, or having allergy or contraindication to any of the study drugs were excluded from the study. Patients were randomly allocated into three groups of 30 patients each: No repeat dose of propofol in Group I, repeat dose of 0.5 mg/kg propofol in Group II, and repeat dose of 1.0 mg/kg propofol in Group III. Fasciculations were evaluated by the same investigator, who was unaware of the dose of propofol given to the patients. The arm bearing venous access was covered with a green-colored cotton sheet to prevent the viewing of the independent observer. Monitoring included continuous electrocardiogram (ECG), heart rate (HR), noninvasive blood pressure (NIBP), and pulse oximetry (SpO 2 ). Patients were preoxygenated with 100% oxygen for 3 min. Anesthesia was induced with intravenous injection propofol 2 mg/kg over 60 s followed by injection succinylcholine 1.5 mg/kg. A repeat bolus of propofol was given immediately after giving succinylcholine in the doses as already described. Thereafter, fasciculations were observed and graded as: 0-no fasciculations,1-mild fine fasciculations of the eyes, neck, face or fingers without limb movement, 2-moderate fasciculations occuring on more than two sites or obvious limb movement and 3-vigorous or severe, sustained and widespread fasciculations.
Oral endotracheal intubation was performed after assessing complete muscular relaxation as per Mingus et al.,  i.e. satisfactory-when well relaxed, no patient movement during intubation and vocal cords not moving, fair when minor patient movement or vocal cords moving and poor when obvious patient movement, bucking, or coughing during intubation. Anesthesia was maintained with 60% nitrous oxide in oxygen supplemented with isoflurane, fentanyl, and injection atracurium as required. At the end of the procedure, neuromuscular blocking effect was reversed with injection neostigmine 0.05 mg/kg and injection atropine 0.02 mg/kg and extubation was done. All patients were interviewed by another blinded investigator who was unaware of the dose of induction agent used. Postoperative myalgia were assessed every 6 hourly for first 24 h and then at 48 h in all patients and graded as I No Myalgia (Absence of muscle pain), II-Mild ( Minor stiffness limited to one area of the body), III -Moderate (Muscle pain or stiffness noticed spontaneously by the patient, which may require analgesic therapy) IV-severe (Generalized, severe, or incapacitating discomfort). Pain related to surgical intervention was relieved with injection tramadol 1 mg/kg intravenous (IV). 
Data was analyzed using Microsoft Excel 2010 software. We summarized data as mean ± standard deviation (SD) or number (percentage). Analysis of variance (ANOVA) test was applied for quantitative data and chi-square test for qualitative data. Pearson r correlation was used to correlate the fasciculations and myalgia. P-value < 0.05 was taken as significant. Considering the power analysis to be at least 0.80, 20 patients were required in each group, but to increase the validity of the study a sample size of 30 was selected thus making the power of the study 0.97.
| Results|| |
The demographic data of patients of the three groups were comparable [Table 1]. The overall incidence of muscle fasciculations was 73 and 33% in Groups II and III, respectively as against 90% in Group I (P < 0.05). The grade of fasciculations was observed to be lower (P < 0.05) in Group III followed by that in Group II. The results showed that 66.7% patients in Group III showed 0 grade of fasciculations [Table 2].
In Group I 56.67% of patients had no (grade I) myalgia and 3.33% patients had severe grade IV myalgia [Table 3]. There was no postoperative myalgia (grade I) in 80% of patients in Group II. No patient in this group had grade IV (severe) myalgia. In Group III, immediately after shifting the patients to the postoperative recovery room, 93.33% did not have myalgia (grade I) and none of the patients ever had grade III (moderate) or IV (severe) myalgia [Table 3].
Intergroup comparison showed statistically significant difference in grade I, II, and III myalgia between Groups I, II, and III with P-values = 0.00, 0.016, and 0.002, respectively at all time intervals. Nonsignificant difference in grade IV myalgia was observed between groups as none of the patients of Groups II and III had myalgia and only one patient had grade IV myalgia in Group I.
The observations for mean blood pressure are shown in [Figure 1].
In patients given no repeat dose of propofol (Group I), mean HR persistently increased from baseline value throughout the study period; while the patients given a repeat dose of propofol at 0.5 mg/kg (Group II) recorded an initial increase in mean HR after induction, after repeat bolus dose, and after intubation; following which a decrease in HR was noticed. The patients given a repeat dose of propofol at 1.0 mg/kg (Group III) recorded a persistent fall in HR after induction till the end of study period as shown in [Figure 2].
It was observed that, although there was no significant difference in rescue analgesic demand time interval, but the total dose requirement of rescue analgesic in first 24 h and 25-48 h postoperatively was statistically significant. The number of patients who required no rescue analgesic was 13 (43.33%) in Group III, 10 (33.33%) in Group II, and seven (23.33%) in Group I [Table 4].
|Table 4: Total dose/mg of analgesic in first 24 and 48 h postoperatively |
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| Discussion|| |
Succinylcholine, a depolarizing muscle relaxant, has a unique place in clinical practice because of its quick and excellent muscle relaxation followed by early spontaneous recovery. Unfortunately, its use is associated with muscle fasciculations and postoperative myalgia which are very distressing for the patients. Hartman et al.,  observed that the cause of fasciculations could be the antidromical conduction of axonal depolarizations initiated by succinylcholine binding on prejunctional nicotinic cholinergic receptors. Though the exact underlying pathophysiology still needs to be clarified completely, several mechanisms like increased myoplasmic calcium concentrations, membrane phospholipid degradation, released free fatty acids, and free radicals have been held responsible for muscle damage and postoperative myalgia. ,, To reduce these side effects, various drugs such as nondepolarizing muscle relaxants, , lignocaine,  calcium,  diazepam,  magnesium sulfate,  thiopentone sodium,  gabapentine,  remifentanyl  and propofol  have been researched and have shown variable results. Propofol has an antioxidant effect like a-tocopherol and it accumulates in the biomembranes with an ability to form stable radicals. It inhibits propagation of reactions involving free radicals.  This antioxidant effect of propofol was used by some authors to attenuate postoperative myalgia caused by succinylcholine, but they failed to show any usefulness of propofol in this respect.  They concluded that no statistically significant difference was observed in succinylcholine-induced fasciculations and myalgia when patient was induced with either propofol or thiopentone. Manataki et al.,  proved the effectiveness of propofol in preventing succinylcholine-induced myalgia when used for both the induction and maintenance of anesthesia. They suggested that to maintain effective levels of drug in the serum, a single dose of propofol at induction is not sufficient in preventing postoperative muscle pain. Kararmaz et al.,  suggested that by using high-dose propofol, the incidence and severity of postoperative myalgia is significantly reduced.
Various drugs have been tried to prevent fasciculations and myalgia but these are associated with certain disadvantages. Pretreatment with nondepolarizing drugs can lead to complications like diplopia, a feeling of impending doom, difficulties with breathing and swallowing, and prolonged neuromuscular paralysis. , Remifentanil causes bradycardia when given prior to succinylcholine.  Regular monitoring of serum magnesium and calcium are required when these drugs are given ahead of succinylcholine to reduce its side effects. A thorough search of literature did not show role of decreasing the dose of succinylcholine in reducing fasciculations.
Propofol is a hypnotic agent used frequently for the induction of anesthesia. The peak effect of propofol comes in 90-100 s and the duration of hypnosis is dose dependent. The cardiovascular depressive effects of large doses of propofol is a drawback in clinical use. By prolonging the injection time, the hypotensive effects of propofol may be minimized.  In our study the induction of anesthesia was done over a period of 60 s. After an induction dose of 2.0 mg/kg, we preferred to use a repeat bolus of smaller dose of propofol. Giving a repeat bolus dose instead of using a single large dose also helped us in prolonging the injection time along with making our total study dose comparable with other studies. The mean HR was less in Groups II and III patients as compared to Group I patients. The mean blood pressure was also less in Groups II and III patients. These group of patients recorded a fall in mean blood pressure from baseline after intubation. Except for one patient in Group III none of patients developed hypotension (systolic blood pressure < 90 mmHg) or bradycardia (HR <60/min) in all three groups.
Some authors found that induction of anesthesia with propofol is associated with less myalgia after succinylcholine than when thiopentone is used.  McClymont observed that the incidence of myalgia with use of propofol was lower than that with thiopentone (19 vs 63%) (P < 0.05).  The decrease in muscle tone with propofol induction is attributed not only to central nervous system depression, but it also acts as a block in skeletal muscle sodium channels.  Adequate conditions for tracheal intubation can be achieved with propofol without the use of neuromuscular blockers. 
Kararmaz et al.,  compared the effects of thiopentone 5 mg/kg in Group I, propofol 2 mg/kg in Group II, and propofol 3.5 mg/kg in Group III on succinylcholine-induced fasciculations and myalgia in 90 women who underwent laparoscopy. Severity of fasciculations in Group III was significantly lower than in the other two groups (P = 0.01). Seventy percent of patients had no myalgia in Group III, 39.2% in Group II, and 37% in Group I (P = 0.011). We also found a significant decrease in the incidence of fasciculations and myalgia when higher dose of propofol was used which is in comparison with the results of Kararmaz et al.
Maddineni et al.,  assessed the incidence and severity of muscle pain following administration of 1 mg/kg succinylcholine after induction of anesthesia with either propofol or thiopentone and found no statistically significant difference between groups. This is in contradiction to the results of our study, we used 1.5 mg/kg dose of succinylcholine in all subjects and a significant reduction (P-value < 0.01) was observed in the incidence of myalgia with increasing the of repeat bolus dose of propofol.
It was also observed that, although there was no significant difference in rescue analgesic demand time interval, but the total dose requirement of rescue analgesic in first 24 h and 25-48 h postoperatively was significantly different among groups. Group III patients required less total dose of rescue analgesia in comparison to Groups II and I patients postoperatively which could be attributed to lesser incidence of fasciculation and myalgia in Group III.
| Conclusion|| |
Propofol is an effective drug to reduce succinylcholine-induced fasciculations and myalgia. The most common side effect of propofol during induction of anesthesia is hypotension, which is augmented by the concomitant administration of opioids and if higher doses of propofol are used. None of the patients in our study had hypotension and bradycardia after induction with propofol. Our study demonstrates that a repeat bolus dose of propofol (0.5 and 1.0 mg/kg) given immediately after succinylcholine is effective in decreasing the incidence and severity of fasciculations and postoperative myalgia.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]