Article

Retrospective assessment of succinylcholine use in acute stroke care: What are the risks?

Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128 2119

This was likely due to the fact that medical students are still selecting a specialty. Those interested in pursuing EM should spend more time in this environment to understand the schedule and demands of the field.

Career satisfaction strongly correlates with not waking up often once

asleep, regular bedtime sleep routine, avoiding stimulant use, avoiding medication sleep aides, exercise, good diet, and not eating poorly on night shift. To prevent waking once asleep provide a schedule to those who may attempt to contact you. Turn electronic devices off or to “Do Not Disturb” to prevent interruptions. Sleeping in a dark, cool, and quiet room is also more conducive for sleep. White noise machines or ear plugs may be warranted depending on where you live. Going to bed at the same time and waking at the same time are unrealistic for those practicing EM but by keeping similar bedtime routines despite being on varying shifts improve sleep hygiene. Reading a book is a frequent bedtime routine; however, E-Readers have the ability to suppress melatonin making it difficult to fall asleep. To wake up it’s recommended to use a bright light source to stimulate ones’ wake cycle. Wearing sunglasses can assist in regulating light exposure when leaving a night shift in preparation for sleep. Stimulant use and medi- cated sleep aides are not recommended as there are side effects such as inability to fall asleep when needed and impairED decision making. Exercise and healthy diet have been shown to improve overall health including improving sleep and shiftwork tolerance. shift workers should attempt to get Regular exercise upon waking and avoiding exer- cise prior to bed. One’s diet should include high protein meals upon waking and moving to complex carbs before sleeping to improve one’s sleep cycle.

Physicians with the highest career satisfaction felt that burnout could be prevented through appropriate amount of time off between shifts and schedule flexibility. Flipping from nights to days is exhausting and appropriate time for recovery is key to adjusting. Flexibility of schedule is also important in having a life beyond the ER. For longevity it’s recommended shorter shifts (i.e. 8 s), fewer night shifts, and incen- tives for nocturnists. Circadian rhythm is less affected when working 1- 2 isolated nights. Assigning shifts in a forward rotation (morning, afternoon, evening) is better tolerated. In preparation for evening shift, napping (i.e. anchor sleep) is recommended for easier shift transition.

There appears to be no difference in career satisfaction among male and female medical students; however, there was among residents and attendings. As of 2013, 27% of EM boarded doctors and 37% of EM resi- dents-in-training were women. This will likely evolve over the next de- cade as more women enter into EM. The level of career satisfaction on the resident and attending level will hopefully improve as work-life bal- ance (i.e. family dynamics, childcare, and pregnancy) are addressed with wellness initiatives.

In effort to maintain physician wellness we recommend implementing a regular bedtime routine, avoiding stimulant use, avoiding medicinal sleep aides, healthy diet both on day and night shifts, regular exercise after waking up from sleep, and efforts to prevent frequent waking and interruptions once going to sleep. To employers and schedulers, we recommend shorter shifts, minimizing flipping schedules, appropriate Recovery time between shifts, and methods to prevent being retained after shifts.

Margaret Mary S. Landel, DO? Samaresh Dasgupta, DO, MHA, FACEP

Inspira Health Network, 1505 West Sherman Avenue, Vineland, NJ 08360,

United States

?Corresponding author.

E-mail address: [email protected] (M.M.S. Landel).

15 August 2017

https://doi.org/10.1016/j.ajem.2018.03.045

Retrospective assessment of succinylcholine use in acute stroke care: What are the risks?

Dear Sir,

Airway management remains an important part of acute stroke care, as patients with stroke can require endotracheal intubation for reasons including decreased level of consciousness, airway compromise, and hypoxia. Succinylcholine is usually the preferred paralytic agent for ur- gent endotracheal intubation but caution is recommended in some stroke patients due to risk for serum potassium increases and resultant arrhythmia or cardiac arrest. This risk appears highest 48-72 h follow- ing stroke and persists for weeks to years [1]. Experts, however, suggest safety within 48 h based on data from another disease state other than stroke. We feel this is problematic as there is information demonstrating increases in nicotinic acetylcholine receptors within 24 h of stroke. Succinylcholine-mediated increases in serum potassium occur when succinylcholine binds nicotinic acetylcholine receptors and stroke pa- tients could be at increased risk during the first treatment day [1,2]. We, therefore, performed a retrospective, cohort study in stroke pa- tients administered succinylcholine at a 472-bed comprehensive stroke center, which was given an exemption by our Institutional Review Board. The primary outcome was the proportion with serum potassium values of 5 mEq/L or more within 30 min of succinylcholine administra- tion. The secondary outcome was the proportion of patients with ar- rhythmia or cardiac arrest within 30 min of succinylcholine administration. These outcomes were selected based on the observation that succinylcholine-mediated serum potassium increases occur within minutes of administration but then rapidly resolve.

Sixty-seven consecutive stroke patients who were not hyperkalemic prior to succinylcholine administration were identified via a query of the electronic medical record between April 2017 and November 2017. The average age +- standard deviation (SD) was 58.8 +-

20.5 years. The population was generally male (40/67, 59.7%) and had hemorrhagic stroke (46/67, 68.7%). The average +- SD succinylcholine dose was 1.43 +- 0.41 mg/kg and most administrations occurred within the first 48 h (62/67, 92.5%). Five patients (5/67, 7.5%) received the medication N48 h following stroke; these patients received succinylcho- line on average +- SD 4.4 +- 1.1 days after stroke. Sixty-four patients (64/ 67, 95.5%) had serum potassium documented prior to succinylcholine administration and 18 patients (18/67, 26.9%) had a serum potassium documented within 30 min following succinylcholine administration. The average +- SD potassium prior to succinylcholine was 4.0 +-

0.4 mEq/L and the average +- SD potassium documented within 30 min of succinylcholine was 3.9 +- 0.5 mEq/L. No patient had a docu- mented serum potassium >=5 mEq/L within 30 min of succinylcholine administration (0/18, 0%) and no patient developed an arrhythmia or cardiac arrest within 30 min of administration (0/67, 0%).

Succinylcholine has been shown to produce excellent intubation conditions when compared to non-depolarizing agents but is avoided in some stroke patients due to concerns of arrhythmia or cardiac arrest secondary to serum potassium increases [3]. The largest previous refer- ence was presented by Cooperman and included 37 patients with neu- romuscular disease but only six with stroke [4]. The author, unfortunately, did not document if any stroke patient developed serum potassium increases or arrhythmia/cardiac arrest following suc- cinylcholine and we find it difficult to interpret this study. Endotracheal intubation generally occurs within the first week following stroke pre- sentation and is usually secondary to a medical emergency, such as neu- rologic deterioration [5]. Our results support the current suggestion that succinylcholine is safe within 48 h of stroke and further suggest poten- tial safety when used within the first week. This is potentially advanta- geous, as it would allow for earlier neurologic re-assessment when compared to non-depolarizing agents. We, however, cannot make a strong conclusion due to several study limitations and further research is needed to confirm our findings before application in clinical practice.

2120 Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128

Though we plan to continue this assessment, we implore other authors to investigate the safety of succinylcholine within one week of stroke as we feel it could have a significant impact in the initial management of many stroke patients.

Sources of support

None.

Name of organization and date if article has been presented.

None.

Jenna Fancher, PharmD? Gregory Meola, PharmD, BCCCP Robert Seabury, PharmD, BCPS, DABAT Department of Pharmacy, United States

?Corresponding author.

E-mail address: [email protected] (J. Fancher).

William Paolo, MD

Department of Emergency Medicine, United States

20 March 2018

https://doi.org/10.1016/j.ajem.2018.03.047

References

  1. Martyn J, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states. Anesthesiology 2006;104(1):158-69. https://doi.org/10.1097/00000542- 200601000-00022.
  2. Huggins R, Kennedy W, Melroy M, Tollerton D. Cardiac arrest from succinylcholine- induced hyperkalemia. AJHP 2003;60:694-7.
  3. Tran D, Newton E, Mount V, et al. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia 2017;72(6):765-77. https:// doi.org/10.1111/anae.13903.
  4. Cooperman L. Succinylcholine-induced hyperkalemia in neuromuscular disease. JAMA 1970;213(11):1867-71.
  5. Grotta J, Pasteur W, Khwaja G, Hamel T, Fisher M, Ramirez A. Elective intubation for Neurologic deterioration after stroke. Neurology 1995;45(4):640-4. https://doi.org/ 10.1212/wnl.45.4.640.

    Incorporating phenobarbital into your symptom-based benzodiazepine alcohol withdrawal protocol in the emergency department

    Dear Reader,

    Alcohol withdrawal carries a large burden on the healthcare industry. Approximately 8 million people are affected by Alcohol use disorders, with up to 50% experiencing Withdrawal symptoms. 5% of those may require treatment in the emergency department (ED) or intensive care unit (ICU) to control symptoms including seizures or Delirium tremens [1,2]. Current Mainstays of treatment include benzodiazepines, with Alternative agents such as barbiturates, propofol, and anti-adrenergic agents being used as second or third line agents.

    Benzodiazepines bind and stimulate the ?-aminobutyric acid (GABAA) receptors, hyperpolarizing the neurons with a Chloride ion influx thus producing slowed neurotransmision similar to alcohol [3]. Due to recent drug shortages, including all intravenous (IV)

    benzodiazepines, it has been necessary to utilize second and third line agents, which clinicians are much less familiar with and less well stud- ied for safety and efficacy [4,5].

    Phenobarbital (PB), a barbiturate producing prolonged signaling

    of GABAA activity, has shown promise in treating acute alcohol withdrawal in small studies involving ED patients [3]. Similar to benzo- diazepines, PB has reduced Severity assessment scores, reduced ICU admission rates, and shown no increase in adverse effects, such as need for mechanical ventilation [6-8]. Due to its slight Pharmacokinetic differences with benzodiazepines, longer time of onset, prolonged Duration of action, and concern for respiratory depression, PB has been used less frequently than benzodiazepines in the treatment of alcohol withdrawal.

    Due to the aforementioned benzodiazepine shortage, institutions are scrambling to implement alternative treatment protocols, most to include PB. Successful incorporation of PB into a previously established benzodiazepine based treatment protocol requires several key compo- nents. At our institution, a multidisciplinary working group including emergency medicine (EM) and internal medicine physicians, EM nurse managers, and EM clinical pharmacists met frequently to coordi- nate the process.

    As demonstrated by the paucity of evidence, standardized dosing of phenobarbital for the treatment alcohol withdrawal does not exist. Literature describes doses ranging from 100 mg IV/PO to 10 mg/kg IV [6-8]. Based on clinical experience, our working group members identi- fied a range between 260 mg IV and 650 mg IV as single doses, repeating every 15-60 min as needed according to our Severity of Ethanol With- drawal Scale (SEWS) scoring assessments prior to benzodiazepine ad- ministration (Fig. 1) [9,10]. For example, a patient presenting in severe withdrawal, would receive PB 650 mg IV once, then receive lorazepam IV doses thereafter based on their severity scores. A patient with moder- ate scoring withdrawal, would receive PB 260 mg IV once, then loraze- pam thereafter.

    Incorporation into our electronic medical record (eMR) system allowed for a nurse driven protocol that was easy to follow and accessible for timely assessments and treatments. Based on standard- ized timing of nursing assessments, nurses were allowed to score and administer PB according to the established protocol prior to benzodiazepines in patients presenting with mild, moderate, and severe withdrawal. This required development of hospital policies and extensive nursing education to ensure a safe medication use process.

    Due to the risks of oversedation because of pharmacokinetic differ- ences in PB, quality assurance analysis was completed weekly to iden- tify any trends in Intubation rates, as well as changes in hospital and ICU admissions.

    Between June 1st, 2017 and July 30th, 2017, our 75-bed ED (~80,000 adult patients seen annually), saw just over 320 patients who were treated with our SEWS protocol. A pre-post analysis compared results from a benzodiazepine only to a PB plus benzodiazepine SEWS protocol. A convenience sampling of 76 patients from each group were extracted and matched according to initial withdrawal severity. Our primary ob- jectives were to assess intubation rates, admission rates to the floor vs. ICU, and length of stay.

    Comparing benzodiazepine only to PB plus benzodiazepines, intubation rates were 1% vs 2% [p = 0.56]; rates of overall admission were 41% vs 50% [p = 0.25]; rates of admission to the ICU was 8% vs 8% [p = 0.53]; and rates of floor admission were 21% vs 30% [p = 0.53]. ED and ICU length of stay between benzodiazepine only vs. PB plus benzodiazepines were 8.4 vs. 10.3 h [p = 0.014], and 52 vs 78 h [p = 0.87] respectively. Additional analysis revealed significant reduc- tions in diazepam equivalents between the benzodiazepine only vs PB plus benzodiazepine groups, 181.8 mg vs 99.8 mg [p = 0.04] respectively.

    Our experience shows that a multidisciplinary approach to implementing PB into a nursing driven benzodiazepine based alcohol

Leave a Reply

Your email address will not be published. Required fields are marked *