Succinylcholine Dosing for Rapid Sequence Induction in a 60-Year-Old Male
Administer succinylcholine 1.0–1.5 mg/kg IV for rapid sequence induction in this patient. 1, 2, 3
Primary Recommendation
The European Society of Anaesthesiology and Intensive Care (ESAIC) strongly recommends succinylcholine 1–2 mg/kg IV for rapid sequence intubation in adults, based on moderate-quality evidence, because it provides complete glottic relaxation within approximately 60 seconds—the fastest onset of any neuromuscular blocker. 1, 2, 3
The standard adult intubation dose is 1.0 mg/kg IV, which represents the established benchmark for rapid airway control. 2, 4
For emergency situations requiring optimal intubating conditions, doses up to 1.5 mg/kg may be used, as this range (1.0–1.5 mg/kg) ensures complete glottic relaxation and prevents laryngospasm during intubation attempts. 3, 4
The FDA-approved dosing range for adults is 0.3–1.1 mg/kg, with an average dose of 0.6 mg/kg; however, for rapid sequence induction specifically, the 1.0 mg/kg dose remains the gold standard. 4
Why This Dose Matters for a 60-Year-Old
Age 60 years places this patient at higher risk for postoperative delirium and anesthesia-induced hypotension, but this does not alter the succinylcholine dose—it affects maintenance anesthetic management instead. 1
The 1.0 mg/kg dose produces neuromuscular blockade in approximately 1 minute, with maximum blockade persisting for about 2 minutes and recovery occurring within 4–6 minutes. 4
Never use reduced doses (<1.0 mg/kg) in rapid sequence induction scenarios, as inadequate glottic relaxation increases the risk of difficult intubation, repeated attempts, and aspiration—particularly dangerous in emergency situations. 3
Evidence Comparing Different Doses
While research has explored lower doses to shorten recovery time, the clinical reality favors standard dosing:
Doses of 0.3–0.5 mg/kg produce acceptable (not excellent) intubating conditions in only 30–92% of patients, with significantly higher rates of unacceptable conditions. 5, 6, 7
A 2020 meta-analysis confirmed that succinylcholine regimens ≤0.5 mg/kg result in less frequent excellent intubating conditions and more common unacceptable conditions compared with 1.0 mg/kg. 7
Doses of 1.5–2.0 mg/kg increase the likelihood of excellent conditions (80–87% vs. 63% with 1.0 mg/kg), but the clinical benefit is marginal and comes at the cost of prolonged paralysis. 8, 7
The 0.6 mg/kg dose produces identical intubation conditions to 1.0 mg/kg with faster recovery (5.8 vs. 8.6 minutes to 50% twitch recovery), but this dose is only validated in elective, fasted ASA 1–2 patients—not emergency scenarios. 6
Absolute Contraindications (Use Rocuronium Instead)
Do not use succinylcholine if the patient has: 2
- Personal or familial history of malignant hyperthermia
- Skeletal muscle myopathies (e.g., Duchenne or Becker muscular dystrophy)
- Acute phase of injury (24 hours to 7–10 days) after major burns, extensive trauma, denervation, upper motor neuron injury, or spinal cord injury
- Prolonged immobilization (>3 days)
- Any neuromuscular disease predisposing to acetylcholine receptor upregulation
If any contraindication exists, use rocuronium 0.9–1.2 mg/kg instead, with sugammadex immediately available for reversal. 1, 2, 9
Critical Safety Requirements
Dantrolene must be immediately available wherever succinylcholine is used, as malignant hyperthermia can occur even without prior family history. 2
Continuous ECG monitoring from induction until at least 2 minutes post-intubation is mandatory to detect bradycardia or dysrhythmias. 2
Never administer repeat doses of succinylcholine after failed intubation; use a non-depolarizing agent for subsequent paralysis to avoid Phase II block and prolonged paralysis. 2, 3
If cardiac arrest occurs after succinylcholine administration, immediately suspect hyperkalemia and treat with calcium (gluconate or chloride), insulin + glucose (0.1 U/kg with 400 mg/kg glucose), sodium bicarbonate, and hyperventilation. 2
Common Pitfalls to Avoid
Underdosing in emergency situations: Using <1.0 mg/kg to "reduce side effects" compromises intubating conditions and increases aspiration risk. 3
Assuming negative family history excludes malignant hyperthermia: Patients may develop MH after multiple uneventful prior anesthetics. 2
Failing to have reversal agents ready: When using the alternative rocuronium, sugammadex must be immediately available; when using succinylcholine, dantrolene must be on hand. 2, 9