Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a “standard of care.”

Background and objective: The aim was to determine if the intravenous administration of sufentanil or clonidine before the induction of anaesthesia could obtund the increase of intraocular pressure associated with rapid-sequence induction.

Methods: Thirty-two ASA I—II patients with no history of eye illness scheduled for elective non-ophthalmic surgery were randomly assigned to receive either sufentanil 0.05 µg kg−1 i.v. (Group A, n = 15) or clonidine 2 µg kg−1 i.v. (Group B, n = 17) prior to induction. General anaesthesia was induced with thiopental (5 mg kg−1) followed by succinylcholine 1 mg kg−1 to facilitate tracheal intubation. The general anaesthetic technique was standardized in both groups. Intraocular pressure was measured using the Schioetz tonometer just before the succinylcholine administration (t0), just before tracheal intubation (t1) and immediately after intubation (t2). Mean arterial pressure and heart rate were recorded at the same time intervals.

Results: Intraocular pressures were similar in both groups at t0, but the sufentanil group had significantly lower values compared with the clonidine group just before (t1) and immediately after tracheal intubation (t2).

Conclusions: Sufentanil is effective in blunting the increase in intraocular pressure caused by rapid-sequence induction with succinylcholine, while clonidine did not seem to have any effect in intraocular pressures just before (t1) and just after (t2) intubation.

Background and objective: The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation.

Methods: All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme.

Results: Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68–80] 95% CI versus 55% [45–65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 ± 3.2 vs. 4.1 ± 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01).

Conclusions: The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

Muscle relaxants are given as part of a rapid-sequence induction to facilitate tracheal intubation. Among all the muscle relaxants available, succinylcholine is the only one with a fast (≅1 min) onset and a fast recovery. Therefore it is still the most frequently used muscle relaxant for rapid-sequence induction despite its well-known side-effects. The short duration of action of succinylcholine is, however, no substitute for aggressive airway management in the case of an unexpectedly difficult intubation in order to prevent life-threatening hypoxia. A preoperative assessment of the airway is mandatory in any patient and may indicate the need for using intubation techniques without a muscle relaxant. Rocuronium in large doses (i.e. ≥1 mg kg−1) is an alternative to succinylcholine in a classical rapid-sequence setting under relatively light anaesthesia. With respect to rapid tracheal intubation, the timing and priming principles offer little advantage over the use of rocuronium in doses of 0.6 mg kg−1 in combination with an appropriate induction technique (i.e. including an opioid) or over the use of larger doses of rocuronium (≥1.0 mg kg−1) under relatively light anaesthesia, and may even be potentially harmful.

In contrast to rocuronium, the use of rapacuronium in a rapid-sequence setting has been associated with dose-dependent respiratory side-effects that limit its usefulness in doses higher than 1.5 mg kg−1 for this indication.

The choice of hypnotics and opioids for rapid-sequence induction, and the use of premedication, is influenced by the choice of the muscle relaxant. Anaesthetic agents have a major influence on the quality of intubation when rapid-sequence induction is achieved without a muscle relaxant. Premedication is important, along with a high dose of propofol (2.5 mg kg−1 or more) and a short-acting opioid such as alfentanil (30–40 μg kg−1) or remifentanil (up to 4 μg kg−1). It has also been demonstrated that i.v. lidocaine can improve intubating conditions. When a muscle relaxant is used, the choice of the anaesthetic agents depends on the onset of action of the relaxant. With a rapid-acting compound such as rocuronium at a dose of 0.6 mg kg−1, the hypnotic agents need to be supplemented with only a small dose of opioids, e.g. alfentanil 10–20 μg kg−1. When succinylcholine, rocuronium 1.0 mg kg−1 or rapacuronium 1.5 mg kg−1 are used, excellent intubating conditions may be obtained by relatively smaller doses of hypnotic agents even without opioids; however, haemodynamic and intraocular pressure changes are better controlled when small doses of opioids are administered.

Neuromuscular blocking agents are used as adjuvants in day case anaesthesia to facilitate tracheal intubation and/or surgery. Although the majority of day case procedures are performed without the use of neuromuscular blocking agents, there are procedures, such as laparoscopic surgery, microsurgery, open eye surgery, some ear, nose and throat procedures and some paediatric procedures, which may require neuromuscular blockade. The characteristics of an ideal neuromuscular blocking agent for day case surgery are a short onset, a short clinical duration and a short recovery time, with or without reversal. It should also lack histamine release, provide haemodynamic stability, and be competitively priced. This paper reviews the neuromuscular blocking agents currently available and used, such as succinylcholine and mivacurium, low doses of an intermediate-acting neuromuscular block, such as rocuronium and the recently introduced rapacuronium. Their advantages and disadvantages are described and discussed, with special reference to the needs of day case surgery. Rapacuronium offers certain benefits compared with the currently available neuromuscular blocking agents for day care anaesthesia.

It has been estimated that more than 60% of all paediatric surgery is performed on a day case basis. The benefits of this type of surgery in children include reduced costs, avoidance of the stress of hospitalization and less disruption to family life. The growth of day surgery in children has been facilitated by the development of non-depolarizing neuromuscular blocking agents characterized by short and intermediate duration of action and fewer side-effects. The more rapid onset and shorter duration of action of non-depolarizing neuromuscular blocking agents in children should facilitate the use of these agents in place of succinylcholine for day case procedures.

Background and objective In the present study, we investigated the combination of etomidate and s-ketamine with regard to its suitability for modified rapid-sequence induction using rocuronium for muscle relaxation.

Methods In a prospective, randomized and double-blinded study, 90 patients were assigned to one of three groups for induction of anaesthesia in combination with etomidate (0.3 mg kg−1) and muscle relaxation with rocuronium (0.6 mg kg−1). The groups were as follows: (a) control, i.e. placebo; (b) fentanyl, fentanyl (1.5 μg kg−1); (c) ketamine, s-ketamine (0.5 mg kg−1). Tracheal-intubating conditions after 1 min were classified as excellent, good or poor. During the induction of anaesthesia, arterial pressure and heart rate were measured every 60 s.

Results Intubating conditions were best using etomidate and s-ketamine (23 excellent, 7 good, 0 poor) compared with the control (8, 16, 6 respectively) and fentanyl groups (7, 21, 2 respectively) (P < 0.01). While heart rate and arterial pressure remained stable in the control and fentanyl groups during induction, both significantly increased in the ketamine group (P < 0.01).

Conclusions The combination of etomidate and s-ketamine for anaesthesia induction produces mostly excellent intubating conditions after 60 s using only 0.6 mg kg−1 of rocuronium. This combination of drugs may be a useful alternative, if succinylcholine needs to be avoided, for modified rapid-sequence induction.