Pediatric Anesthesia Induction Guidelines

Muscle Relaxants for Induction

The American Society of Anesthesiologists recommends succinylcholine as the first-line muscle relaxant for rapid sequence induction in children, with age-appropriate dosing: <1 month: 1.8 mg/kg, 1 month to 1 year: 2.0 mg/kg, 1-10 years: 1.2 mg/kg, >10 years: 1.0 mg/kg 1, 2
Use of a rapid-onset muscle relaxant is strongly recommended for rapid sequence induction in children, with succinylcholine being the expert choice 3, 1
When succinylcholine is contraindicated, rocuronium at doses >0.9 mg/kg is recommended as an alternative 3, 2
The choice between succinylcholine and rocuronium should consider the desired duration of muscle relaxation, risk of difficult intubation, and presence of neuromuscular disease 1

Succinylcholine is contraindicated in cases of primary muscle damage or up-regulation of nicotinic acetylcholine receptors at the motor end plate 3
In patients with specific muscle disorders, succinylcholine can induce generalized contraction with rhabdomyolysis 4
Monitoring of neuromuscular blockade is warranted in pediatric anesthesia, as residual neuromuscular blockade is estimated at 28% in children receiving muscle relaxants 3
The duration of apnea without hypoxemia is shorter in younger children, necessitating rapid airway protection after loss of consciousness 1, 2
In children with upper respiratory infections, preoperative inhaled salbutamol may reduce perioperative respiratory adverse events 6

Sugammadex is useful for reversing rocuronium effects but may not be approved for use in children in all regions 2, 7
The risk of anaphylaxis with muscle relaxants should be considered, though it is generally low 3, 7
Doses of opioid or hypnotics that allow tracheal intubation without a muscle relaxant are high and have significant hemodynamic effects 3, 2