From the Guidelines
For laryngospasm occurring after neostigmine reversal, a dose of succinylcholine at 1 mg.kg-1 intravenously is recommended. This dose is based on the most recent and highest quality study available, which suggests that suxamethonium (succinylcholine) 1 mg.kg-1 intravenously can provide cord relaxation, permitting ventilation, re-oxygenation, and intubation if necessary 1. The administration of succinylcholine should be immediate, as laryngospasm can rapidly lead to hypoxemia.
Some key points to consider when administering succinylcholine in this context include:
- The presence of neostigmine, which inhibits acetylcholinesterase and may prolong the effect of succinylcholine by slowing its metabolism
- The need for immediate action to relieve airway obstruction and prevent hypoxemia
- The importance of monitoring oxygen saturation and ventilation, and being prepared for full airway management if the laryngospasm does not resolve quickly
- Alternative approaches, such as deepening anesthesia with propofol or applying positive pressure with jaw thrust, may be considered as initial management, but succinylcholine remains the recommended treatment for severe laryngospasm 1.
In addition to administering succinylcholine, it is also important to:
- Call for help and apply continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask
- Consider Larson’s manoeuvre to help relieve laryngospasm
- Be prepared to administer atropine to treat bradycardia, and to consider a surgical airway in extremis 1.
From the Research
Dose of Succinylcholine for Laryngospasm after Neostigmine Administration
- There are no research papers to assist in answering this question directly, as the provided studies focus on the reversal of neuromuscular blockade using neostigmine and sugammadex, rather than the treatment of laryngospasm with succinylcholine after neostigmine administration.
Reversal of Neuromuscular Blockade
- Neostigmine is commonly used to reverse neuromuscular blockade, with a recommended dose of 0.05 mg/kg 2.
- Sugammadex is an alternative reversal agent that can be used at a dose of 2 mg/kg for moderate neuromuscular blockade and 4 mg/kg for deep neuromuscular blockade 2.
- A half-dose of sugammadex (1 mg/kg) can be used after neostigmine to prevent residual neuromuscular blockade 3.
Optimum Dose of Neostigmine
- The optimum dose of neostigmine to reverse shallow neuromuscular blockade with rocuronium and cisatracurium is 40 μg/kg 4.
Atropine Dose during Reversal
- Different doses of atropine (0.01,0.015, and 0.02 mg/kg) can be used during reversal of neuromuscular blockade, with the lower dose (0.015 mg/kg) associated with less tachycardia 5.