A systematic review and meta-analysis of the use of succinylcholine to facilitate tracheal intubation in neonates

Abstract

Use of succinylcholine in neonates is surrounded by many controversies. The need to review this topic stems from the fact that though there is an abundance of information, but there are divergent views regarding its use in neonates. We have analyzed the incidence of intubation attempts, bradycardia, and hemodynamic changes in clinical settings.The authors conducted a meta-analysis and systematic literature search to ascertain the risks and benefits of using succinylcholine in neonatal intubation by conducting a review in the online databases of PubMed, Cochrane, Scopus, Embase, Elsevier, and Google scholar. The combination of keywords used for the search included “Succinylcholine,” “succinylcholine” AND “neonates,” “neonates” AND “difficult airway,” “neuromuscular blockers” AND “neonates,” and “non-depolarizing neuromuscular blockers” AND “neonates”. The severe adverse reactions associated with use of succinylcholine include bradycardia, asystole, hyperkalemia, and apnea. The number of attempts required for intubation was significantly lower in the patients receiving succinylcholine as compared to those who did not receive succinylcholine. Evidence suggests that conscious awake intubation leads to adverse physiological responses in neonates. The main recommended indications for using succinylcholine include emergency intubation in laryngospasm, full stomach, difficult airway, absent intravenous access, and controlled endotracheal intubation in the neonatal intensive care unit. Hence, the use of succinylcholine can be rationally accepted after considerations of the pre-operative clinical status of the neonate and risk-benefit ratio with more research further to build up strong evidence for the most appropriate agents for use in neonatal patients.

Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

“…Table 4 summarizes the recommended doses for the sedatives and anesthetics discussed in this document, according to indication and gestational age. These data are based on the literature ( 12 , 13 , 36 , 44 – 49 , 51 – 53 , 68 , 69 , 71 , 81 , 83 , 84 , 90 , 94 , 101 – 110 ). Whenever possible, drugs should be started at a low dose and titrated by small increments so that the minimal effective dose can be administered.…”

Administration of paediatric intranasal sedation

“…The use of an appropriate device such as the LMA ® mucosal atomizer device (MAD) would probably have delivered the intranasal medication much better. It is also worth mentioning that the US Food and Drug Administration (FDA) has issued a black box warning for utilizing succinylcholine in children and therefore administration of such drug as part of the anaesthetic protocol, when alternatives could easily have been opted for, is rather perplexing 12 , 13 . The mean peak plasma concentration of dexmedetomidine (C max ) to achieve acceptable sedation is 0.54±0.17 ng/cc which was achieved by administration of 2-3 μg/kg of dexmedetomidine intranasally in some studies 7 .…”