What are the guidelines for the use of succinylcholine (a neuromuscular blocking agent) in intubation of patients (pts)?

Guidelines for Succinylcholine Use in Intubation

Either rocuronium or succinylcholine can be used for rapid sequence intubation (RSI) when there are no contraindications to succinylcholine, with the choice depending on specific patient factors. 1

Indications and Dosing

• Succinylcholine is indicated as an adjunct to general anesthesia to facilitate tracheal intubation and provide skeletal muscle relaxation during surgery or mechanical ventilation 2
• Standard adult dosing for intubation is typically 1.0 mg/kg IV, though studies suggest 0.6 mg/kg may provide comparable intubation conditions with faster recovery 3, 4
• Pediatric dosing varies by age: <1 month: 1.8 mg/kg, 1 month to 1 year: 2.0 mg/kg, 1-10 years: 1.2 mg/kg, >10 years: 1.0 mg/kg 5
• Atropine should be administered before intubation in children aged 28 days to 8 years, particularly in those with septic shock, hypovolemia, or when succinylcholine is used 1

Advantages of Succinylcholine

• Rapid onset (typically 30-60 seconds) and short duration of action (typically 5-10 minutes), making it valuable for RSI 6, 3
• Provides excellent intubating conditions in most patients within 60 seconds 7
• Faster recovery of spontaneous respiration compared to non-depolarizing agents, which may be critical in "can't intubate, can't ventilate" scenarios 3, 4

Contraindications and Precautions

• Absolute contraindications include:

  • History of malignant hyperthermia 5, 2
  • Patients immobilized for more than 3 days 5
  • Duchenne muscular dystrophy and other myopathies 5
  • Hyperkalemia or conditions predisposing to hyperkalemia 2

• Use with extreme caution in:

  • Patients with electrolyte abnormalities 2
  • Patients with digitalis toxicity 2
  • Acute phase following major burns, multiple trauma, or extensive denervation of skeletal muscle 2
  • Upper motor neuron injury 2
  • Patients with chronic abdominal infection, subarachnoid hemorrhage, or conditions causing degeneration of central and peripheral nervous systems 2
  • Patients suspected of being homozygous for the atypical plasma cholinesterase gene 2

Rocuronium as an Alternative

• Rocuronium (0.9-1.2 mg/kg IV) is the recommended alternative when succinylcholine is contraindicated 8, 1
• No significant difference between rocuronium and succinylcholine in obtaining excellent intubation conditions 1
• Rocuronium's longer duration of action (30-60 minutes) is its main disadvantage compared to succinylcholine 1
• When using high-dose rocuronium (≥0.9 mg/kg), consider having sugammadex available for reversal if needed 8

Safety Considerations

• Succinylcholine should only be administered after unconsciousness has been induced to prevent patient distress 2
• A sedative-hypnotic induction agent must be administered before succinylcholine to prevent awareness during paralysis 8
• Only those skilled in airway management should administer succinylcholine, and facilities for tracheal intubation and ventilation must be immediately available 2
• Risk of hyperkalemia increases over time in patients with burns, trauma, or denervation, typically peaking 7-10 days after injury 2
• Succinylcholine administration has been associated with acute onset of malignant hyperthermia, particularly with concomitant administration of volatile anesthetics 2

Common Pitfalls to Avoid

• Failing to identify contraindications to succinylcholine before administration 2
• Using excessive doses (1.0 mg/kg) when smaller doses (0.5-0.6 mg/kg) may provide acceptable intubation conditions with faster recovery 3, 4
• Not having atropine available to manage potential bradycardia, especially in pediatric patients 1, 5
• Inadequate pre-oxygenation before RSI, which can lead to rapid desaturation during the apneic period 8
• Not ensuring full neuromuscular blockade before attempting intubation, which can increase the risk of aspiration 8

By following these guidelines and considering patient-specific factors, clinicians can optimize the use of succinylcholine for intubation while minimizing associated risks.