How should succinylcholine be approached in patients with ESRD?

In patients with end-stage renal disease (ESRD), succinylcholine should be approached with caution and is typically avoided due to its association with a significant risk of hyperkalemia. Succinylcholine is a depolarizing neuromuscular blocker that causes an influx of potassium into the extracellular space by stimulating nicotinic receptors at the neuromuscular junction. In patients with ESRD, the kidneys are unable to adequately excrete potassium, which can lead to dangerously elevated serum potassium levels, especially after the administration of a drug that induces potassium release like succinylcholine.

In the context of intubation needs, while succinylcholine may be the preferred agent in patients with normal renal function due to its rapid onset and quick offset, this advantage does not outweigh the potential life-threatening complication of hyperkalemia in ESRD patients. Therefore, its use is contraindicated in this population.

Monitoring potassium levels, adjusting the dosage, or considering alternate agents does not mitigate the inherent risks associated with the drug's mechanism in these patients. Consequently, avoiding succinylcholine in patients with ESRD is the safest and most clinically advisable approach.