The Optimal Dose of Succinylcholine for Rapid Sequence Induction

A Systematic Review and Meta-analysis of Randomized Trials

Alessandro Putzu; Martin R. Tramèr; Maxim Giffa; Christoph Czarnetzki


BMC Anesthesiol. 2020;20(54) 

In This Article


Succinylcholine, also known as suxamethonium, has been introduced into anaesthesia practice in the early 1950s.[1] Still today, it remains one of the most commonly used neuromuscular blocking agents for rapid sequence induction (RSI) because of its fast onset and short duration of action.[2] The "cannot intubate, cannot ventilate" scenario is a threat of airway management. Therefore, clinicians are inclined to administer the minimally effective dose of succinylcholine that is meant to provide excellent intubating conditions but that provokes only a short apnoea time. The widely recommended standard intubating regimen of succinylcholine has been 1.0 mg kg− 1, although the scientific basis of that specific regimen remains unclear.[3] Indeed, a dose of 1.0 mg kg− 1 corresponds to almost four times the ED95, which is unusual for a neuromuscular blocking agent.[4,5]

We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the optimal regimen of succinylcholine for RSI. In this context, the optimal regimen was defined as the mg per kg bodyweight regimen that provided the highest likelihood of excellent intubating conditions, the lowest risk of unacceptable intubating conditions, and the shortest apnoea time compared with the gold standard regimen. As 1.0 mg kg− 1 has been reported to be the gold standard in this context,[3] we compared all alternative, experimental regimens with that gold standard regimen.