Frequenty Asked Questions

Succinylcholine in pediatrics

Question:

Recently a colleague of mine asked you a question regarding the use of Succ in the peds. population. I had raised this issue with him for a couple of reasons. A # of years ago I attended a peds. ED conference at CHOP in Philadelphia where anesthesia had pulled succ. from their dept. and gave them roc. as felt to be a safer choice. Last year at the ACEP peds conference Tim Ericson stated that succ. is not a good choice as safer agents available. I continue to use succ. as my initial choice unless contraindications exist. What are your thoughts on this point and the recent literature suggesting that atropine is not needed pre succ. in kids as no evidence to support this practice .
Reply:
This is one of those things that does not have specific literature defining or not defining a preference between sux and really the only other choice, rocuronium, in children. Both are used and preferences are personal. The rationale for choosing roc over sux has to do with the perceived safety of the drug given the fact that the FDA warned against the use of the drug in children after a couple of reports of hyperkalemic cardiac arrest following administration of Sux to patients with undiagnosed neuromuscular disease approximately 10-15 years ago. The pediatric anesthesia community at that time rebelled against the FDA’s warning causing a softening of their stance to a caution. The incidence of that rare problem vs any problems that could be encountered because of the long duration of action of Roc vs sux is probably the crux of the issue. I personally use sux and promote it in the airway course in effort to keep things simple because it is recommended in adults. I have absolutely no issue with use of Roc however.
The issue of using atropine or not prior to Sux is another issue which cannot be definitively solved in the literature. Classically it has been used to prevent the bradycardia and even asystole which can accompany a single dose of sux in children. A few recent studies failed to show difference in response to sux with or without atropine in children. Admittedly it would be difficult to prove that the atropine is beneficial, but the absence of evidence is not proof when dealing with very uncommon event. If atropine were a dangerous drug I would be more concerned. I routinely use the drug prior to the administration of sux as well of some of my anesthesia friends (Charlie Cote’, author of a major pediatric anesthesia text, thinks not using it is playing with fire, as he has personally had patients become asystolic after sux without atropine requiring resuscitation.

I hope this has helped.

Bob Luten