We would like to thank Drs. Chidiac, Brinkley, and Henrick for their thoughtful responses to our article. 1The teaching about the use of succinylcholine for surgery to repair an open globe injury remains controversial. The major point of our article was to show that this teaching is based on anecdote rather than complete, well-documented case reports. Although scientific investigation supports the fact that succinylcholine causes contraction of the extraocular muscles, thus increasing intraocular pressure in the intact globe, no study to date has shown that these contractions are of a sufficient magnitude to cause extrusion of the vitreous. Drs. Brinkley and Henrick are quite correct in pointing out that when the globe is open, intraocular pressure is zero. We also agree that their proposed mechanism for the possible extrusion of vitreous is correct. Finally, these authors also agree that the magnitude of contraction has not been shown to cause the vitreous to be extruded. We agree with their call for a randomized, prospective, double-blind study and eagerly look forward to its publication.
Dr. Chidiac clearly misinterpreted our statement “To follow the dictum ‘primum non nocere,’ we thus avoid succinylcholine.” This sentence was meant to explain why anesthesiologists in general may be reluctant to use succinylcholine for anesthetics involving open globe injury. In no way was this a declaration of policy at the Mayo Clinic. We (Drs. Vachon, Warner, and Bacon) agree with the intellectual framework Dr. Chidiac has proposed for the use of succinylcholine in open globe injuries, and all of us continue to use succinylcholine as an agent to facilitate rapid sequence induction in this setting. We intended the article to be a historic review of an interesting story and to stimulate discussion about how principles of evidence-based medicine might be applied to the evaluation of low-frequency events.