Increases in Intracranial Pressure from Succinylcholine

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Abstract
Whether succinylcholine causes an increase in intracranial pressure (ICP) in patients with brain lesions is uncertain and, if increased ICP does occur, its pathophysiology remains unknown. The authors investigated both the effect of succinylcholine on ICP and its modification with prior neuromuscular blockade by measuring ICP (subarachnoid bolt) in 13 consecutive patients with brain tumors who received succinylcholine both before and after complete neuromusuclar blockade with vecuronium. Anesthesia was induced with thiopental, 6 mg .cntdot. kg-1 iv, and nitrous oxide, 70% in oxygen, while ventilation was controlled (PaCO2 = 37.2 mmHg .+-. .17 SE). Succinylcholine, 1 mg .cntdot. kg-1 iv, was administered and ICP, heart rate (HR), and blood pressure (BP) were recorded until normal twitch tension was restored. Complete neuromuscular blockade was then established with vecuronium, 0.14 mg .cntdot. kg-1 iv; 3 min later, succinylcholine, 1 mg .cntdot. kg-1 iv, was repeated. The resulting changes in ICP, HR, and BP were recorded for 3 min. Following the first dose of succinylcholine, mean ICP increased from 15.2 mmHg .+-. 1.3 SE to 20.1 mmHg .+-. 2.0 SE (P < 0.05), with five of the patients sustaining increases in ICP of 9 mmHg or greater. In contrast, when succinylcholine was given after vecuronium-induced paralysis, no patient developed an increase in ICP greater than 3 mmHg (P < 0.05 compared with the incidence of ICP .gtoreq. 9 mmHg observed after the first dose of succinylcholine). A second group of six patients received two doses of succinylcholine according to the same protocol but without an intervening dose of vecuronium. These patients sustained increased ICP after both doses of succinylcholine. The authors conclude that increases in ICP may be induced by succinylcholine in patients with compromised intracranial compliance and the possibility of such an increase should be considered in their anesthetic management. While the exact mechanism of this phenomenon remains unknown, the results indicate that complete neuromuscular blockade with vecuronium prevents succinylcholine-induced increases in ICP.

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