Optimal Dose of Succinylcholine for Rapid Sequence Induction

In This Article

Abstract and Introduction
Background
Methods
Results
Discussion
Conclusions
References

Abstract and Introduction

Abstract

Background: The evidence base for the widely accepted standard regimen of succinylcholine for rapid sequence induction (1.0 mg kg^{− 1}) remains unclear.

Methods: We performed a systematic review and meta-analysis of randomized trials comparing any succinylcholine regimen with the standard regimen (1.0 mg kg^{− 1}) and reporting on intubating conditions and/or apnoea times. Results were expressed as absolute risk differences (ARD) for dichotomous data and mean differences (MD) for continuous data.

Results: We retrieved six trials with relevant data of 864 patients (ASA 1 or 2, aged 18–65 years, body mass index < 30 kg m^{− 2}). Four regimens (0.3, 0.4, 0.5, 0.6 mg kg^{− 1}) were compared with 1.0 mg kg^{− 1} in at least three trials each, and three (0.8, 1.5, 2 mg kg^{− 1}) in one each. With 0.3 to 0.5 mg kg^{− 1}, the likelihood of excellent intubating conditions was significantly decreased (ARD − 22% to − 67%). With 0.3 and 0.4 mg kg^{− 1}, but not with 0.5, 0.6, 0.8, 1.5 and 2.0 mg kg^{− 1}, the likelihood of unacceptable intubating conditions was significantly increased (ARD + 22% and + 32%, respectively). With 2.0 mg kg^{− 1}, but not with 0.8 or 1.5 mg kg^{− 1}, the likelihood of excellent intubating conditions was significantly increased (ARD + 23%). Apnoea times were significantly shorter with regimens ≤0.8 mg kg^{− 1} (MD − 1.0 to − 3.4 min) but were not reported with 1.5 or 2.0 mg kg^{− 1}.

Conclusions: With succinylcholine regimens ≤0.5 mg kg^{− 1}, excellent intubating conditions are less likely and apnoea times are shorter, compared with 1 mg kg^{− 1}. With 0.3 and 0.4 mg kg^{− 1}, unacceptable intubating conditions are more common. Succinylcholine 1.5 mg kg^{− 1} does not produce more often excellent conditions compared with 1 mg kg^{− 1}, while 2.0 mg kg^{− 1} does, but the database with these regimens is weak and apnoea times remain unknown. Limited information size and strong statistical heterogeneity decrease the certainty of the evidence.

Table 1. Characteristics of included trials
Trial	Country	Experimental regimens [mg kg^{− 1}] (number of patients)	PM	Medications for induction	Rapid Sequence Induction	Cricoid pressure	Adverse effects	Intubation failures
El Orbany 2004	USA	0.3 (n = 23) 0.4 (n = 23) 0.5 (n = 23) 0.6 (n = 23) 1.0 (n = 23)	Yes	Fentanyl 1.5 μg kg^{− 1} Propofol 2 mg kg^{− 1}	Modified	nr	nr	7 with succinylcholine 0.3 mg kg^{− 1}; 2 with succinylcholine 0.4 mg kg^{− 1}
Luo 2014	China	0.3 (n = 60) 0.5 (n = 60) 1.0 (n = 60)	No	Sevoflurane	True*	nr	"No complications such as cough, laryngospasm, or bronchial spasm attributable to the study"	None
Naguib 2003	Saudi Arabia	0.3 (n = 50) 0.5 (n = 50) 1.0 (n = 50)	Yes	Fentanyl 2 μg kg^{− 1} Propofol 2 mg kg^{− 1}	True	nr	"Each patient was followed up for any adverse affects". Results nr.	None
Naguib 2006	USA	0.3 (n = 30) 0.5 (n = 30) 1.0 (n = 30) 1.5 (n = 30) 2.0 (n = 30)	No	Fentanyl 2 μg kg^{− 1} Propofol 2 mg kg^{− 1}	True	nr	"Each patient was monitored for any adverse event". Results nr.	None
Prakash 2012	India	0.4 (n = 23) 0.6 (n = 23) 1.0 (n = 23)	No	Fentanyl 2 μg kg^{− 1} Propofol 2 mg kg^{− 1}	True	yes	Adverse events were recorded and no episodes of laryngospasm, bronchospasm, masseter spasm, generalized rigidity were observed	None
Taxak 2013	India	0.4 (n = 50) 0.6 (n = 50) 0.8 (n = 50) 1.0 (n = 50)	Yes	Meperidine 1 mg kg^{− 1} Propofol 2 mg kg^{− 1}	Modified	nr	nr	nr