Succinycholine: Succinylcholine has no place in pediatric anesthesia. Wads Ames MBBS FRCA

Transcription

1 Succinycholine: Succinylcholine has no place in pediatric anesthesia Wads Ames MBBS FRCA

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3 Food And Drug Administration Created in 1906 Responsible for protecting and promoting public health through the regulation and supervision of food, pharmaceuticals anon. Reserved for emergency intubation / instances where immediate securing of the airway is necessary, e.g., laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible.

4 Side effects Anaphylaxis Hyperkalemia Malignant Hyperthermia Bradycardia Asystole Raised intraocular pressure Phase 2 block

5 Caution in patients with Fractures / muscle spasm fasciculation's causing additional trauma Raises intracranial pressure. Increases intragastric pressure Not short acting if hypokalamia or hypocalcemia. OR.. Reduced Plasma Cholinesterase Activity

6 Reserved for: Emergency intubation / instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible.

7 Pediatric Laryngospasm Complete closure of the larynx caused by external stimulation More common in children Less experienced and non-pediatric anesthetists, increases the incidence of laryngospasm... Hampson-Evans D, Morgan P, Farrar M. Pediatric laryngospasm. Pediatric Anesthesia 2008

8 Caused by firstly, a lack of inhibition of glottic reflexes because of inadequate central nervous system depression and, secondly increased stimuli Causes of stimulation at an inappropriate depth of anesthesia include extubation, secretions or blood irritating the vocal cords, stimulation of the airway by an artificial airway, laryngoscope or suction catheter. Associated with light anesthesia

9 Treatment Pressure on the Laryngospasm notch Pull of Mandible Clear the Airway, administer 100% Oxygen with CPAP. Propofol. Afshan G et al Ped anes 2002 Pre-treat. Propofol or ketamine Hae JP et. Korean J Anesthesiol. 2011

10 What is an RSI? Head Tilt Gastric tube to empty the stomach Pre-oxygenation with 100% oxygen Thiopentone Application of cricoid pressure Succinylcholine Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961

11 If our Goal is emergent intubation, what are the alternatives? Propofol / Intravenous Lidocaine (2mg/kg). Remifentanil/ Propofol Crawford, M et al. Dose-response of remifentanil for tracheal intubation in infants. Anesth Analg 2005 Reversible!

12 (Mivacurium) Benzylisoquinolone Short acting but slow onset. 0.15mg/kg Pretreat 5 mins before the full doseconditions akin to succinylcholine Variable onset Notable side effects

13 Rocuronium Aminosteriod non-depolarizing neuromuscular blocker Small risk of allergic reaction (particularly asthmatics) 1.2mg/kg. Intubation condition akin to Succinycholine.

14 Rocuronium Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically different between succinylcholine and rocuronium when propofol was used. Perry J, lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane database 2008

15 Sugammadex Modified γ cyclodextrin, with a lipophilic core and a hydrophilic periphery Selective relaxant binding agent. Encapsulation of the rocuronium molecule Cardiovascular and autonomic stability. Tolerability profile of sugammadex was generally similar to that of placebo. Safe

16 Sugammadex If Sugammadex was available in the United States, would we be having this conversation.