Pediatric Anesthesia Guidelines for Muscle Relaxants

Introduction to Muscle Relaxants

The American Society of Anesthesiologists recommends succinylcholine as the first-line muscle relaxant for rapid-sequence induction in pediatric anesthesia, with age-specific dosing (1, 2)
The American Academy of Pediatrics suggests that rocuronium at doses >0.9 mg/kg serves as an acceptable alternative when succinylcholine is contraindicated (1, 2)

The American Society of Anesthesiologists recommends succinylcholine for rapid-sequence induction in children, providing the fastest onset and most reliable intubation conditions (1, 2)
The time between loss of consciousness and airway protection must be minimized because apnea duration without hypoxemia is significantly shorter in younger children (1, 2)
In children under 3 years of age, co-administer atropine 0.02 mg/kg to prevent bradycardia or cardiac arrest (3)

The American Society of Anesthesiologists advises against using succinylcholine in primary muscle disorders (myopathies) due to the risk of generalized contraction with rhabdomyolysis (1, 2)
The American Academy of Pediatrics warns that conditions with up-regulation of nicotinic acetylcholine receptors (chronic motor deficits, extensive burns, prolonged critical illness) may cause life-threatening hyperkalemia with succinylcholine (1, 2, 7)
For patients with myasthenia, non-depolarizing muscle relaxants show increased sensitivity and prolonged duration, and atracurium and cisatracurium doses should be reduced by 50-75% (1)

The American Society of Anesthesiologists recommends neuromuscular blockade monitoring in pediatric anesthesia, as residual neuromuscular blockade occurs in 28% of children receiving muscle relaxants (1, 2, 4)
Monitor to train-of-four ratio ≥0.9 before extubation (1)
The allergic risk with muscle relaxants in pediatric populations is low but incompletely characterized (1, 5)