To the Editor:—

I read with interest the editorial by Donati and Guay, 1who comment about an accompanying paper that examined the use of intramuscular rapacuronium in children. 2Although they correctly note that this study shows the limitations of intramuscular administration of nondepolarizing neuromuscular blocking agents, they also include what I believe to be some unfortunate recommendations regarding the treatment of laryngospasm. For laryngospasm that occurs with mask induction without previous intravenous access, they seem to recommend against administering intramuscular succinylcholine. To support this recommendation, they quote an earlier study, which states that “In an already asphyxiated child, the 3 or 4 min required for maximum relaxation after 4 mg/kg [succinylcholine] argues against its use.”3Rather, they advocate attempting to gain intravenous access (using for example the femoral route) and perhaps administering propofol. This suggestion contradicts the advice of anesthesia texts 4and recent reviews 5,6and is contrary to the clinical experience of most pediatric anesthesiologists, including myself. Although surprisingly little research is extant regarding the treatment of laryngospasm, case reports and experience both show that even small doses of succinylcholine suffice to quickly relieve laryngospasm, and that “maximum relaxation” is not required. 7In fact, the reference quoted by the editorial says in the next sentence that “Nevertheless, clinical experience with intramuscular succinylcholine in children has been that airway control after laryngospasm is achieved in less time than the time to maximum depression [of the twitch response].”3Furthermore, as shown by the excellent work of Dr. Donati et al. , 8the onset of neuromuscular blockade is generally more rapid at the larynx compared with the peripheral muscles, a factor advantageous in the treatment of laryngospasm. In contrast, under the best of circumstances (and a blue child does not represent the best of circumstances), the establishment of intravenous access for the administration of drugs to treat laryngospasm requires a minimum of several seconds, seconds which are precious in this situation.

I fully appreciate the risks of succinylcholine. However, a balanced approach to its risk and benefits must be maintained, and we must not succumb to a sort of “sux-o-phobia” aided and abetted by pharmaceutical manufacturers eager to supplant its use with their newer products. My parents, both pediatric anesthesiologists with more than 60 yr of experience between them, taught me that intramuscular succinylcholine (administered with atropine to avoid cholinergic side effects) quickly relieves laryngospasm in children. My own experience and that of my colleagues has proven them correct. Given the potential for catastrophic injury if severe laryngospasm is not rapidly treated, we should not recommend the abandonment of an effective therapy, especially when measures of questionable practicality and unknown efficacy (e.g. , propofol) are substituted. I fear that removing this valuable tool from our armamentarium could result in harm to our little ones.

Donati F, Guay J: No substitute for the intravenous route. A nesthesiology 2001; 94: 1–2
Denman WT, Kaplan RF, Goudsouzian NG, Uejima T, Barcelona SL, Cote CJ, Ginsberg B, Hannallah RS: Intramuscular rapacuronium in infants and children. A nesthesiology 2001; 94: 3–7
Liu LMP, DeCook TH, Goudsouzian NG, Ryan JF, Liu PL: Dose response to intramuscular succinylcholine in children. A nesthesiology 1981; 55: 599–602
Berry FA: Neonatal anesthesia, Clinical Anesthesia, 3rd edition. Edited by Barash PG, Cullen BF, Stoelting RK. Philadelphia, Lippincott–Raven, 1997, pp 1091–114
Seah TG, Chin NM: Severe laryngospasm without intravenous access: A case report and literature review of the non-intravenous routes of administration of suxamethonium. Singapore Med J 1998; 39: 328–30
Cook DR: Can succinylcholine be abandoned? Anesth Analg 2000; 90 (suppl 5): S24–8
Chung DC, Rowbottom SJ: A very small dose of suxamethonium relieves laryngospasm. Anaesthesia 1993; 48: 229–30
Donati F, Meistelman C, Plaud B: Vecuronium neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis. A nesthesiology 1991; 74: 833–7