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Suxamethonium is safe in safe hands; mivacurium should also be considered
  1. ASRAR RASHID, Specialist Paediatric Registrar
  1. MICHAEL WATKINSON, Consultant Neonatologist
  1. Neonatal Unit
  2. Birmingham Heartlands Hospital
  3. Bordesley Green, Birmingham B9 5SS
  4. email: Drasrar{at}
  5. Neonatal Unit
  6. Birmingham Heartlands Hospital

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Editor—We thank Whyteet al 1 for detailing the premedication policies for intubation in United Kingdom neonatal units. There is a wide disparity in both the type and dosage of drugs.

Whyte et al 1 mention that, as a muscle relaxant, suxamethonium, has important safety benefits. It has a very rapid onset and offset of action, and therefore there is a “get out clause” for the difficult intubation or intubation by an inexperienced operator. However, other considerations need to be taken into account when suxamethonium is used.

Firstly, intravenous premedication is contraindicated in conditions known to be associated with difficult intubations, such as the Pierre Robin sequence. Further, suxamethonium is a depolarising muscle relaxant and can therefore cause sinus bradycardia. Atropine can be given in an attempt to avoid this.

Suxamethonium causes depolarisation at the neuromuscular junction, rarely leading to hyperkalaemic induced cardiac arrest.2 Undiagnosed myopathic conditions were found in a number of affected children, and paediatric licensing for this drug was therefore removed in the United States. However, no other very rapidly acting drug has been manufactured, and, because of its popularity, suxamethonium was reinstated. Before its use, a detailed family history for myopathic conditions must be taken.

In our neonatal unit, we have started to use fentanyl, an opioid, with mivacurium as the muscle relaxant.3 The disadvantage of mivacurium is that it is only a rapidly acting muscle relaxant.4 Its major advantage is that it is a non-depolarising muscle relaxant and therefore carries no risk of life threatening arrythmias. The routine use of atropine is not necessary.

We agree that a randomised trial needs to be undertaken to prove that premedication has the desirable end point of reducing neonatal morbidity, particularly intraventricular haemorrhage.


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