Post-Suxamethonium Muscle Pains after Vitamin C Pretreatment: An Observational Study

Lalit Gupta; Gaurav Dwivedi; Kapil Choudhary

doi:10.4103/mamcjms.mamcjms_46_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 8 | Issue : 3 | Page : 240-244

Post-Suxamethonium Muscle Pains after Vitamin C Pretreatment: An Observational Study

Lalit Gupta¹, Gaurav Dwivedi², Kapil Choudhary¹
¹ Department of Anaesthesia and Critical Care, Maulana Azad Medical College and Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India
² Santosh Medical College, Ghaziabad, India

Date of Submission	11-Aug-2022
Date of Acceptance	25-Aug-2022
Date of Web Publication	07-Dec-2022

Correspondence Address:
Lalit Gupta
Associate Professor, Department of Anaesthesia and Critical Care, Maulana Azad Medical College and Lok Nayak hospital, Bahadur Shah Zafar Marg, New Delhi-110002
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/mamcjms.mamcjms_46_22

Abstract

Background: Succinylcholine has been extensively used for endotracheal intubation because of its ultrashort duration of action, quick onset with complete and predictable paralysis. However, the occurrence of some side effects like post injection fasciculations, postoperative myalgia, and increase in serum potassium levels limits its use in some situations like burns, myopathies, and myoglobinuria. For attenuation of these effects, many drugs have been studied but with limited success. Aims and objectives: To evaluate the role of vitamin C on attenuation of post-suxamethonium myalgia and increase in serum potassium levels. Materials and methods: Seventy-five females of American Society of Anaesthesiologists grade I and II and aged 20 to 50 years undergoing general anesthesia for various short surgical procedures were randomly allocated into three groups. Induction of anesthesia was performed with injection thiopentone 5 mg/kg body weight and suxamethonium 50 mg in all three groups. In group I, no drug was administered before induction of anesthesia. In group II, 500 mg tablet of vitamin C was administered twice orally a day before and on the day of surgery half an hour before induction of anesthesia. In group III, vitamin C 500 mg was administered intravenously in 50 ml saline half an hour before induction of anesthesia. The absence or presence of muscle pains and fasciculations were noted and if present, then their severity was also estimated. Serum potassium levels were measured in the venous samples collected just before induction and at 5-minute interval after the administration of suxamethonium. Patients were observed for myalgia on postoperative days 1, 2, and 3. Results: The patients receiving vitamin C had a little reduction in the incidents but marked reduction in severity of muscle pains and fasciculation. Furthermore, the administration of vitamin C markedly delayed the onset of muscle pains. There was no effect of vitamin C pretreatment on serum potassium levels. Conclusion: Pretreatment with vitamin C 500 mg may be useful in reduction of severity of post- suxamethonium myalgia.

Keywords: fasciculations, myalgia, potassium, pretreatment, vitamin c

How to cite this article:
Gupta L, Dwivedi G, Choudhary K. Post-Suxamethonium Muscle Pains after Vitamin C Pretreatment: An Observational Study. MAMC J Med Sci 2022;8:240-4

How to cite this URL:
Gupta L, Dwivedi G, Choudhary K. Post-Suxamethonium Muscle Pains after Vitamin C Pretreatment: An Observational Study. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 1];8:240-4. Available from: https://www.mamcjms.in/text.asp?2022/8/3/240/362895

Introduction

Succinylcholine is considered as the one of the best drug for providing ideal intubation conditions for short surgical processes and for rapid sequence induction. However, its utility is sometimes questioned because of untoward side effect of postoperative myalgia. Although postoperative myalgia is a minor adverse effect but it may sometimes be very distressing experience for the patient in the postoperative period especially in daycare procedures.

The incidence of succinylcholine induced myalgia has been reported from 1.5% to 89% in literature. The most common coated figure is approximately 50%, while the duration of discomfort is highly variable from 2 to 3 days to a week.^[1] This myalgia usually appears on the first day of surgery and is most commonly described by patient as pain like unaccustomed degree of physical exercise and is usually located in areas of neck, shoulder, and arms.

The first attempt to reduce the incidence and severity of postoperative myalgia associated with suxamethonium was pretreatment with Gallamine in year 1954. Since than a variety of regimens has been tried but with limited success.^[2],[3] The most common practice is to administer a sub paralyzing those of non-depolarizing neuromuscular blocker a few minutes before succinylcholine with the aim of decreasing both the visible fasciculations and postoperative myalgia.^[3] Although much has been said about this technique but controversy still exists about the agent of choice for pretreatment, the optimal dose, and that ideal timing between pretreatment and succinylcholine administration.

High dose of vitamin C has been found to be beneficial in alleviating the pain and stiffness experienced after heavy exercise. This benefit of vitamin C maybe because of its action in maintaining the endothelial lining of capillaries thus preventing damage or rupture of muscle fibers and promoting the detoxification of metabolites as an antioxidant.^[4] Previous studies evaluating role of vitamin C for reduction of postoperative myalgia have found minimal reduction to no reduction of postoperative myalgia.^[] However, none of these evaluated the role of vitamin C pretreatment on changes in serum potassium levels after succinylcholine. Recent evidence has attributed the anti-nociceptive action of vitamin C to its antioxidant, neuroprotective, and neuro-modulatory properties.^[9] The present study was undertaken to evaluate the role of vitamin C on post-suxamethonium muscle pains, fasciculations, and serum potassium levels.

Material and Methods

After approval of Institutional ethics committee and written informed consent, Seventy-five females of American Society of Anaesthesiologists grade I and II, aged 20 to 50 years undergoing general anesthesia for minor surgical procedures were randomly allocated into three groups, each consisting of 25 patients. Pregnant and lactating mothers, patients with significant neurological, hepatic or renal dysfunction, and patients susceptible to succinylcholine induced hyperkalemia were excluded from the study. A computer-generated randomization technique was followed to divide the enrolled 75 patients into three groups and sealed opaque envelopes were used for group concealment.

In group I, no drug was administered before induction of anesthesia. In group II, 500 mg tablet of vitamin C was administered twice orally a day before and on the day of surgery half an hour before induction of anesthesia. In group III, vitamin C 500 mg was administered intravenously in 50 ml saline half an hour before induction of anesthesia.

All the patients underwent detailed preanesthesia assessment and investigations as per hospital protocol and were kept nil orally for 6 hours before procedure. Upon arrival of patient in the operation room, basal pulse rate (bpm), blood pressure (mmHg), SpO2 (%) were measured and recorded. Then all the patients were premedicated with glycopyrrolate 0.2 mg IV before induction. Induction of anesthesia was performed with injection thiopentone (2.5% solution) 5 mg/kg body weight and suxamethonium 50 mg in all three groups. Thereafter, all patients received positive pressure ventilation with nitrous oxide and oxygen (6:4) using Bains Circuit with bag and face mask. No volatile anesthetic drug was used as it may interfere with the effect of suxamethonium. Blood samples were taken before induction and 5 minutes after administration of suxamethonium in all the three groups and were analyzed for serum potassium level. Another observer blinded to group allocation noted the presence and severity of muscle fasciculations. Patients were discharged 4 hours after recovery and were followed at 12, 24, and 48 hours post-surgical procedure for the presence and severity of muscle fasciculations and muscle pain.

Assessment of muscle pain

All the patients were interviewed by same observer on 1st, 2nd, and 3rd postoperative days for occurrence and severity of postoperative myalgia. Any history of muscle pain except in the immediate vicinity of operation, injection site, and low backache in dilatation and curettage was taken into account. History of muscle pain or stiffness was classified as mild, moderate, or severe as below:

Mild: Patients complained of pain usually at one site and patients were not troubled by this.

Moderate: Patients complained of pain usually at more than one site or the patients had pain at one site and the pain was troublesome possibly requiring analgesic therapy.

Severe: Pain at more than one site and severe with definitive analgesic therapy. Patients experiencing moderate to severe myalgia were injected with Inj. Paracetamol 1 g, as rescue analgesia.

The presence and severity of muscle fasciculations were observed as follow: ^[10]

Fasciculations: incidence and severity:

The fasciculations were first recorded as:

Absent
Present
1. Mild: Facial grimace, finger tremor, forearm rotation.
2. Moderate: Visible displacement of head or a whole limb.
3. Severe: Vigorous movements seen in the trunk and limb.

Statistical analysis

The observations recorded in both the groups were tabulated and statistical analysis was carried out using Epi-data statistical software. The observations were subjected to statistical analysis t test (for rate of difference between the means of the samples). P < 0.05 was considered as statistically significant.

Results

All the three groups were similar with regards to age, weight, and height of the patients, baseline pulse rate, and blood pressure readings. The patients underwent minor surgical procedures (biopsy of skin lesions, colposcopy and cervical biopsy, endometrial ablation procedure, endometrial biopsy, hysteroscopy, incision and draining of abscesses Loop Electrosurgical Excision Procedure (LEEP removes abnormal cells from the cervix), and polyp removal) and the incidence of procedures was similar between three groups.

Muscle pain: incidence and severity

The incidence and severity of muscle pain were significantly lower after administration of vitamin C in groups II and III (44% each), as compared to group I (72%, P < 0.05) ([Table 1]). Eighteen patients in group I had post-suxamethonium muscle pains as compared to 11 each in group II and III (P < 0.05) ([Table 1]). None of the study patients experienced severe fasciculations while the incidence of moderate muscle pain was significantly high in group I (48%) compared to groups II and III (12% in both, P < 0.05). None of the patients in group II and group III experienced post succinylcholine muscle pains at 12 hours as compared to eight patients (3 mild, 5 moderate) in group I ; P < 0.05. Eighteen patients (6 mild, 12 moderate) in group I, 11 (8 mild, 3 moderate) in group II and III each experienced post succinylcholine muscle pains at 24 hours. Twelve patients (2 mild, 10 moderate) in group I, 11 (8 mild, 3 moderate) in group II and III each experienced post succinylcholine muscle pains at 24 hours.

Table 1 Incidence of and severity of post-suxamethonium pain and fasciculations.

Click here to view

Muscle fasciculation: incidence and severity

Twenty four patients in group I had post-suxamethonium fasciculations as compared to 21 each in group II and III ([Table 1]). The severity of fasciculations was comparable between the three groups (P > 0.05); with majority of patients experiencing mild fasciculations in all groups and none experienced severe fasciculations.

Changes in serum potassium levels:

The preinduction mean serum potassium levels were comparable between the three groups; P > 0.05 ([Table 2]). There was statistically significant rise in serum potassium levels from preinduction levels at 5 minute in all the three groups (P < 0.001); with the rise being maximum in group II (0.83 ± 0.07) compared to Group I (0.66 ± 0.07) and III (0.64 ± 0.05).

Table 2 Changes in serum potassium concentration.

Click here to view

Discussion

The present study demonstrates that vitamin C administration (oral or intravenous) was significantly effective in decreasing the incidence and severity of muscle pains. The occurrence of muscle pain was delayed in groups receiving oral or intravenous vitamin C. There was no effect of vitamin C administration on the incidence and severity of muscle fasciculations and attenuation of rise in potassium levels after succinylcholine administration.

Vitamin C has been observed to be safe and effective adjuvant therapy for many painful conditions. It has been observed to exhibit analgesic properties in some clinical conditions thus potentially improving patient’s quality of life in postoperative period. It not only decreases the requirement of opioid analgesia in postoperative period but also diminishes the deleterious effects of opioids, thus can be of very immense importance in postoperative succinylcholine induced myalgia.^[11] It is well accepted that vitamin C is essential for the proper formation of collagen and intercellular material. This property of vitamin C might help in stabilizing the muscle cell wall against the mechanical damage caused by strenuous exercise or suxamethonium.

The incidence of muscle pain in our study after vitamin C administration was 44% compared to 72% in control group. The incidence of muscle pain in our study after vitamin C administration is high compared to previous studies observing an incidence varying from 12% to 20%^[] and is considerably lower than 89% observed by Wood et al.^[8] The difference in incidence may be explained by the difference in patient population, the pain perception of population studied, and variation in doses of vitamin C, thiopentone, and succinylcholine used. Also, the incidence and severity of muscle fasciculations were high in all groups (84% each in groups II and III) as compared to 96% incidence in the control group (group I). The observations of Bourne et al.^[12] and Currie^[13] attributing post-suxamethonium muscle pain as a sequel of fasciculations could account for high incidence of muscle pain in this study. Also, the incidence and severity of muscle fasciculations observed after succinylcholine due to activation of terminal part of motor axons could not be effectively reduced by vitamin C pretreatment in our study.

Despite high incidence of muscle pain in control and study group; the incidence and severity of muscle pain in group II and III receiving oral/intravenous vitamin C was reduced (by 28%) as compared to the control group I. These findings are similar to observations of other authors observing reduction in incidence and severity of muscle pain with vitamin C administration (by 24.5–44%)^[6],[7] and in contrast to the observations of Wood et al.⁸ observed no change in the severity of post-suxamethonium pain after 10 g vitamin C received peri-procedurally.

Vitamin C pretreatment was not effective in preventing the rise of serum potassium (0.64–0.83 meq/l) observed in our study. Our findings are similar to established observation of transient rise in 0.5–1 meq/l in first 3–5 minutes following succinylcholine. The rise in potassium levels after administration of succinylcholine has been attributed to depolarization and transient potassium efflux by nicotinic receptors. The rise is significant in certain pathological conditions and further studies are required to evaluate whether vitamin C is useful in those conditions to prevent significant rise in potassium levels by virtue of its membrane stabilizing property.

Limitations of the study

The present study has several limitations. Firstly, it was single blinded study with the patient not being blinded to the treatment group. Though, the observer assessing muscle pain and fasciculations was blinded to the treatment group, the possibility of non-blinding of patient to study group influencing results cannot be ruled out. Secondly, vitamin C was administered only before procedure and not post-procedure in our study.

The compliance of patient in post-procedure period can be a concern due to various factors including surgical and anesthetic techniques and keeping this in mind, we restricted to pre-procedural vitamin C in our study.

Thirdly, our study is limited by its small sample size and further multicentric studies with large sample size might prove to be useful in evaluating the role of vitamin C. Future studies should endeavor to ascertain the following aspects: measurement of vitamin C concentrations at baseline and following intervention to determine if specific patient groups respond, determination of the optimal route of administration (i.e., enteral or parenteral), the optimal dose and frequency of vitamin C administration (for best dose to decrease myalgia), and the potential mechanisms of action of vitamin C.

Conclusion

We conclude that pretreatment with vitamin C before suxamethonium injection might be effective in decreasing the incidence and severity of muscle pains. There was no effect of vitamin C administration on the incidence and severity of muscle fasciculations and attenuation of rise in potassium levels after succinylcholine administration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ali AH. Neuromuscular block and its antagonism: clinical aspects. In: Nunn JF, Utting JE, Brown BR, eds. General Anaesthesia. 5th ed. London: Butterworths 1989 164–84.
2.	O’Sullivan EP, Williams NE, Calvey TN. Differential effects of neuromuscular blocking agents on suxamethonium-induced fasciculations and myalgia. Br J Anaesth 1988; 60: 367–71.
3.	Pinchak AC, Smith CE, Shepard LS, Patterson L. Waiting time after non-depolarizing relaxants alter muscle fasciculations response to succinylcholine. Can J Anaesth 1994; 41: 206–12. https://doi.org/10.1007/BF03009832
4.	Syed IH. Muscle stiffness and vitamin C. Br Med J 1966; ii: 304.
5.	Moorty ASR, Dhanraj VJ. Vitamin C and postsuxamethonium muscle pains. Ind J Anaesth 1973; 21: 123.
6.	Singh P, Kocher SK, Singh G. Role of Vitamin C in the prevention of post-suxamethonium muscle pains. Ind J Anaesth 1976; 24: 255.
7.	Gupta SR, Savant NS. Post suxamethonium pains and vitamin C. Anaesthesia 1971; 26: 436.
8.	Wood JB, Attwood EC, Wood BM, Dowling RMB, Bradley BF.Vitamin C and post-suxamethonium pains. Anaesthesia 1977; 32: 21.
9.	Hung KC, Lin YT, Chen KH et al. The effect of perioperative vitamin c on postoperative analgesic consumption: a meta-analysis of randomized controlled trials. Nutrients 2020; 12: 3109.
10.	Yun MJ, Kim YH, Go YK et al. Remifentanil attenuates muscle fasciculations by succinylcholine. Yonsei Med J 2010; 51: 585–89.
11.	Carr AC, McCall C. The role of vitamin C in the treatment of pain: new insights. J Transl Med 2017; 15: 77.
12.	Bourne JG, Collier HOJ, Somers CF. Succinylcholine, a muscle relaxant of short action, Lancet 1952; 1: 1225.
13.	Currie TT. Subcostal pain following controlled respiration. Br Med J 1953; 1: 1032.