# Prefilled Succinylcholine



## NomadicMedic (Oct 4, 2010)

Hi all:

One agency I work part time stocks our RSI kits with succinylcholine in 200mg preloads. I was asking about the difference between preloads and vials and was told that the preloaded Sux will last longer without refrigeration and is cheaper than the vials.

I mentioned this to the MSO at my primary agency and he was very interested, especially if it lasts longer than the vials. However, it seems that our supplier has a shortage of Sux. Our current order is on backorder, and they've never heard of preloads.

So, is anyone here using prefilled succinylcholine, and if so, can you fill me in on likes/dislikes? Also, a PM with the supplier would be great.

Thanks.


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## abckidsmom (Oct 4, 2010)

I don't know, but in our area, the shortage of succ has lead them to suspend the RSI program until they figure out a different way.  This is a 10 county region in central VA.  Probably under 3 dozen medics are affected, but it's a significant shortage.


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## Aidey (Oct 4, 2010)

Succs is one of the meds that is currently in short stock....along with nearly every other major emergency medicine.


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## usalsfyre (Oct 4, 2010)

Roccuronium FTW....


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## NomadicMedic (Oct 4, 2010)

I understand that Sux is in short supply everywhere, but eventually we'll be able to get some...

I agree that Roc is a good substitute, but our RSI protocols specifically call for induction with Sux, unless it's contraindicated. 

However this post is about the sux preloads. Is anyone using them? If so, do they last longer then the vials without refrigeration?


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## MrBrown (Oct 5, 2010)

Suxamethonium along with morphine, ketamine and vecuronium are kept in authorised Officers' hip pouches and stored in the fridge when not in use.


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## usalsfyre (Oct 5, 2010)

n7lxi, apparently they will last 45 days past what they would otherwise if I'm reading this right. You might contact the company rep for your area, but it seems like it might get a bit expensive if this is all your buying from them. 

http://www.capspharmacy.com/succinylcholine-syringe-prefilled-anesthesia-service-sux-CAPS.html


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## NomadicMedic (Oct 10, 2010)

Found them at Ameridose. Now, I've got to see if I can order a small batch for us.


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## curt (Oct 10, 2010)

Unfortunately, Georgia's a restrictive state when it comes to EMS. It's just a crappy state for EMS in general, considering it's got the 3rd lowest wages for EMS out of all 50 states with salaries averaging about 11k for EMT-I and 22K for Medic. Don't come here. Anyway, RSI's a big no-no here, ranking right up there with assassination of political figures and uttering the word "shenanigans". Wish I could dispense some advice, but I can only dispense with useless attention whoring.


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## Flight-LP (Oct 11, 2010)

n7lxi said:


> I agree that Roc is a good substitute, but our RSI protocols specifically call for induction with Sux, unless it's contraindicated.



Then you need to get your protocols changed! For one, there is a big semantic error that can land you in the courtroom. You are not "inducing" with the paralytic, you are paralyzing. You induce sedation and a state optimal for intubation with the benzo, analgesic, and/or barbituate. 

I have never seen Sux work longer in prefilled form and it certainly isn't less expensive. Regardless how it is supplied, remember it is still a depolarizing agent and thus by its pharmacodynamics will typically be very short acting.

When you truly look at the contraindications of Sux and the narrow therapeutic window of who can actually receive it in the population of your patient's requiring RSI/RSA, an intermediate non-depolorizing NMBA such as Rocuronium really starts to make sense. 

I haven't used Sux in years and never plan on using it again. Keep your eyes open though, there is another depolorizing NMBA in the works that allegedly eliminates the massive K+ dump. Should that be the case, it'll be worth looking into.


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## inacornfield (Oct 12, 2010)

The drug information resource Lexi-Comp has the following statement on their monograph for succinylcholine:

"Manufacturer recommends refrigeration at 2°C to 8°C (36°F to 46°F) and may be stored at room temperature for 14 days; however, additional testing has demonstrated stability for ≤6 months unrefrigerated (25°C) (Ross, 1988; Roy, 2008)"

Full citation for the 2008 Roy article:
Roy JJ, Boismenu D, Mamer OA, et al, “Room Temperature Stability of Injectable Succinylcholine Dichloride,” Int J Pharm Compound, 2008, 12(1): 83-85.

Another citation:
 Adnet, et al. Stability of succinylcholine solutions stored at room temperature studied by nuclear magnetic resonance spectroscopy.  Emerg Med J 2007;24:168-169
"If a 10% loss of potency is considered acceptable, then the 20 and 50 mg/ml succinylcholine solutions can be stored in emergency resuscitation carts at room temperature for 8.3 and 4.8 months, respectively."

I showed the monograph and sources to the pharmacy director at the hospital at which I intern and as a result we adjusted the expiration time for succs at room temp from 30 days to 90 days, to err on the conservative side.


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## NomadicMedic (Oct 12, 2010)

Flight-LP said:


> Then you need to get your protocols changed! For one, there is a big semantic error that can land you in the courtroom. You are not "inducing" with the paralytic, you are paralyzing. You induce sedation and a state optimal for intubation with the benzo, analgesic, and/or barbituate.



You're correct. However, I was referring to the entire process, RSI, as Rapid Sequence Induction. That is, sedation with Etomidate or Versed followed by a paralytic. I'm sorry if I was unclear.



Flight-LP said:


> I have never seen Sux work longer in prefilled form and it certainly isn't less expensive. Regardless how it is supplied, remember it is still a depolarizing agent and thus by its pharmacodynamics will typically be very short acting.



I think you misunderstood my original post. The Sux that was supplied in a prefill was touted to "last longer when unrefrigerated". That is, the expiration date was further out than those on the vials. Obviously the pharmodynamics of the drug don't change based on if it comes in a vial or a prefilled syringe.

It's my belief that we still continue to use Sux based ONLY on the fact that it's duration of action is very short, and if we as paramedics are unable to secure the airway, the Sux will wear off quickly. But I agree, in my limited experience, Roc is a more than acceptable option for RSI.


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## usalsfyre (Oct 13, 2010)

n7lxi said:


> It's my belief that we still continue to use Sux based ONLY on the fact that it's duration of action is very short, and if we as paramedics are unable to secure the airway, the Sux will wear off quickly.



This is a *MASSIVE* thought process error. An anoxic event of 3-5 minutes will be just as deadly as an anoxic event of 20 minutes or more. If your medics are pushing paralytics with the thought of anything other than "I must secure a way to ventilate this patient by whatever means nessecary" than you are setting up for a fatal event. You are taking that ability away, you must replace it. Not to mention, if you let the sux just wear off your right back to the crappy situation you were in before (if not worse) and 10-15 minutes later into the call. If "well sux is safe because it wears of quick" is how people are thinking, they have no business performing this procedure. N7lxi, please don't take this next statement personally, as I don't know how you approach RSI, but the truth is either know all of your airway options, assessn the need for and be prepared to use them _every time you need to control an airway_, or GTFO. Part of this is assesment as well, there's some airways that just shouldn't be mucked around with in the field.


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## MrBrown (Oct 13, 2010)

*Brown puts on his Stetson and gets his lasoo ready to rein in the cowboys


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## usalsfyre (Oct 13, 2010)

I'm a cowboy? Well, Texas is where I work...


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## swissmedic (Oct 29, 2010)

Hello everyone
I am very impressed about your prefilld syringes. 
Here in SWITZERLAND we have no prefilled drugs, especially for RSI or cardiac arrest it costs too much time and we dosen't have time... 
Does anyone have some packages from the prefilled drugs / syringes for me?
(of course I will pay for the shiping charges). Perhaps your Medical Director like them and order some prefilled syringes a RSI pilotproject???
*<contact information removed>*

Thanks in advanced & best regards 
Matt


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## Chimpie (Oct 29, 2010)

swissmedic said:


> Hello everyone
> I am very impressed about your prefilld syringes.
> Here in SWITZERLAND we have no prefilled drugs, especially for RSI or cardiac arrest it costs too much time and we dosen't have time...
> Does anyone have some packages from the prefilled drugs / syringes for me?
> ...



Are you asking for the drugs or the empty packages?


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## swissmedic (Oct 29, 2010)

Chimpie said:


> Are you asking for the drugs or the empty packages?



Sorry for breaking the rules !!!
Of course I mean the empty package, sorry again 
Matt


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