Succinylcholine pretreatment using gallamine or mivacurium during rapid sequence induction in children: a randomized, controlled study
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M C Theroux1, J B Rose, S Iyengar
1Department of Anesthesiology and Critical Care Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA. mtheroux@nemours.org
Insights
Mivacurium pretreatment effectively reduces succinylcholine-induced increases in serum potassium, myoglobin, and creatine phosphokinase (CPK) in children. This study highlights mivacurium
Area of Science:
- Anesthesiology
- Pediatric Pharmacology
- Clinical Chemistry
Background:
- Succinylcholine is commonly used for rapid sequence induction (RSI) in pediatric anesthesia.
- RSI can lead to undesirable side effects such as fasciculations, myalgias, and elevations in serum potassium, myoglobin, and creatine phosphokinase (CPK).
- Pretreatment with neuromuscular blocking agents is sometimes employed to mitigate these effects.
Purpose of the Study:
- To evaluate the efficacy of gallamine or mivacurium as pretreatment agents before succinylcholine administration in pediatric patients.
- To assess the impact of these pretreatments on reducing fasciculations, postoperative myalgias, and serum levels of potassium, CPK, and myoglobin.
Main Methods:
- A prospective, randomized, double-blinded study was conducted in 45 pediatric patients (ASA physical status I, aged 3-15 years) undergoing emergency surgery.
- Patients received either normal saline, mivacurium (0.03 mg/kg), or gallamine (0.04 mg/kg) 2 minutes prior to RSI with thiopental, fentanyl, and succinylcholine.
- Serum potassium, myoglobin, and CPK levels were measured at various time points. Fasciculations and myalgias were scored.
Main Results:
- Mivacurium pretreatment significantly reduced the increase in serum potassium at 5 minutes, myoglobin at 5 and 15 minutes, and CPK at 24 hours compared to normal saline.
- No significant differences were observed in fasciculation or myalgia scores between the groups.
- Gallamine was not effective in reducing the measured biochemical markers, although a lower dose was used compared to mivacurium.
Conclusions:
- Mivacurium, when administered intravenously 2 minutes before succinylcholine in children, is effective in attenuating the acute rise in serum potassium, myoglobin, and CPK.
- This pretreatment strategy may help minimize the adverse biochemical effects associated with succinylcholine use in pediatric anesthesia.
- Gallamine did not demonstrate similar efficacy in this study at the tested dose.
Study Objective:
To determine if pretreatment with either gallamine or mivacurium before succinylcholine in children is associated with reduction in fasciculations; postoperative myalgias; or serum levels of potassium, creatinine phosphokinase (CPK), and myoglobin.
Design:
Prospective, randomized, double-blinded study.
Setting:
Operating room at a children's hospital.
Patients:
45 ASA physical status IE children, aged 3 to 15 years, scheduled for emergency surgery.
Interventions:
The children received either normal saline 0.5 mL, mivacurium chloride 0.03 mg. kg(-1), or gallamine triethiodide 0.04 mg. kg(-1)2 minutes prior to rapid sequence induction (RSI) using thiopental sodium 5 mg. kg(-1), fentanyl 2 microg. kg(-1), and succinylcholine 2 mg. kg(-1).
Measurements:
Serum potassium concentration (0, 3, 5, 7.5, and 15 min), myoglobin concentration (5 and 15 min), and CPK concentration (0 min and 24 hr). Fasciculation and myalgia were rated on a 0 to 3 score.
Main Results:
There was no difference between groups for fasciculation (p = 0.87) or myalgia score (p = 0.52). The mivacurium group had significantly less increase in potassium at 5 minutes (0.45 vs. 0.0, p = 0.01), myoglobin at 5 minutes (56 vs. 2, p < 0.001), myoglobin at 15 minutes (128 vs. 2.5, p < 0.001), and CPK at 24 hours (399 vs. 138, p < 0.001) following succinylcholine when compared with normal saline. Additionally, we found a significant level of association (p < 0.001) between fasciculation and myoglobin levels and fasciculation and CPK levels (p < 0.001). Gallamine was not effective in reducing the increase of potassium, myoglobin, or CPK. However, the dose of gallamine used for pretreatment was 13 times less than the dose of mivacurium.
Conclusions:
Administration of mivacurium 0.03 mg. kg(-1) intravenously 2 minutes before administration of succinylcholine 2 mg. kg(-1) in children is effective in reducing the increase in serum potassium at 5 minutes, the increase in myoglobin at 5 minutes and 15 minutes, and the increase in CPK at 24 hours.
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