IM rocuronium for laryngospasm

[deleted59964]

and now for something not COVID related.

has anyone given IM rocuronium for laryngospasm in pediatric anesthesia for children with contraindications to sux?
there is an article that describes time to twitch suppression and time to good intubation conditions in infants and children, but that's about all I can find.

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[Mman]

I have heard of it but not done it myself

 

[deleted59964]

ive drawn in up a few times as my emergency plan, when doing a gas induction without IV access in a child with a contraindication to sux - but havent needed it.

 

[Arch Guillotti]

I have heard of it but not done it myself

Same here.

 

[Arch Guillotti]

Same here.

 

[Mman]

ive drawn in up a few times as my emergency plan, when doing a gas induction without IV access in a child with a contraindication to sux - but havent needed it.

have considered it a few times, but the question to me is always how contraindicated the sux actually is. Sometimes we avoid it more out of theoretical concerns whereas if a kid is hypoxic and dying in front of me I'm not sure I wouldn't just push the sux if Roc wasn't working fast enough.

 

[ambiturner]

Never for OR laryngospasm, but I’ve used it following accidental extubation in a 2 month old who was impossible to mask and had also lost their IV (PICU mess). Was able to mask in about 10 seconds and was able to intubate within 2 minutes, but as the kid was so young could have possibly rammed the tube through with nothing.

Also have used IM roc/ketamine combo for cardiac inductions and it typically takes about 10-15 seconds for the child to stop moving.

 

[kidthor]

Also have used IM roc/ketamine combo for cardiac inductions and it typically takes about 10-15 seconds for the child to stop moving.

Same here.

 

[MirrorTodd]

Never for OR laryngospasm, but I’ve used it following accidental extubation in a 2 month old who was impossible to mask and had also lost their IV (PICU mess). Was able to mask in about 10 seconds and was able to intubate within 2 minutes, but as the kid was so young could have possibly rammed the tube through with nothing.

Also have used IM roc/ketamine combo for cardiac inductions and it typically takes about 10-15 seconds for the child to stop moving.

Because they're paralyzed or because they're stoned out?

 

[ambiturner]

Because they're paralyzed or because they're stoned out?

They need to be masked so paralyzed, but the ketamine may very well take action first.

 

[deleted59964]

Never for OR laryngospasm, but I’ve used it following accidental extubation in a 2 month old who was impossible to mask and had also lost their IV (PICU mess). Was able to mask in about 10 seconds and was able to intubate within 2 minutes, but as the kid was so young could have possibly rammed the tube through with nothing.

Also have used IM roc/ketamine combo for cardiac inductions and it typically takes about 10-15 seconds for the child to stop moving.

for your 2m old was there a reason not to use IM sux? being able to bag is what its all about - so thats a win.
IM roc/ketamine ... what age group and why? interesting, thanks

 

[ambiturner]

for your 2m old was there a reason not to use IM sux? being able to bag is what its all about - so thats a win.
IM roc/ketamine ... what age group and why? interesting, thanks

Biggest factor was probably availability in the unit, they don’t keep sux around but the child didn’t have any contraindications other than a slightly higher K.

I personally don’t do a lot of IM roc/ketamine but had attendings that liked to for cardiac pathology sensitive to afterload and myocardial depression in kids under 18 mo-2 yrs. Typically still orally premedicated. I always thought it was a bit tenuous as they invariably got tachycardic and cried but never saw anyone code with it so I guess no harm no foul.

 

[MikeMerk-MtS]

have considered it a few times, but the question to me is always how contraindicated the sux actually is. Sometimes we avoid it more out of theoretical concerns whereas if a kid is hypoxic and dying in front of me I'm not sure I wouldn't just push the sux if Roc wasn't working fast enough.

Agreed. If the contraindication is just the child at risk for hyperkalemia with an undiagnosed dystrophy then the ASA recommends giving succ to protect the airway. However, if it's for MH then obviously that's a different story. I haven't used it but believe that studies have shown it's an alternative if using at like 1-2 mg/kg IM but onset is still gonna take a hell of a long time... which isn't ideal in laryngospasm. So I guess if you have that scenario where you have a kid with MH and is in laryngospasm without an IV... that's a toughy.

 

[Arch Guillotti]

Agreed. If the contraindication is just the child at risk for hyperkalemia with an undiagnosed dystrophy then the ASA recommends giving succ to protect the airway. However, if it's for MH then obviously that's a different story. I haven't used it but believe that studies have shown it's an alternative if using at like 1-2 mg/kg IM but onset is still gonna take a hell of a long time... which isn't ideal in laryngospasm. So I guess if you have that scenario where you have a kid with MH and is in laryngospasm without an IV... that's a toughy.

Use 4 mg/kg.

 

[nimbus]

Anyone else hear it works fastest if injected under the tongue? Was told that by a couple of pediatric anesthesiologists but couldn’t find any references.

 

[MikeMerk-MtS]

Use 4 mg/kg.

I've seen both 1-2 mg/kg and 4 mg/kg quoted in literature... maybe we split the difference at 3 mg/kg?

Reference:
-Intramuscular Rocuronium in Infants and Children. Dose-ranging and Tracheal Intubating Conditions L M Reynolds 1, M Lau, R Brown, A Luks, D M Fisher: "Deltoid injections of rocuronium, 1,000 micrograms/kg in infants and 1,800 micrograms/kg in children, rapidly permit tracheal intubation in infants and children, despite a light plane of anesthesia."

 

[deleted162650]

Anyone else hear it works fastest if injected under the tongue? Was told that by a couple of pediatric anesthesiologists but couldn’t find any references.

I’ve heard the same. Also heard that if you’re gonna give it IM, you should give it in 2-4 different spots to speed the absorption. Not sure if that would even make a clinically relevant difference.

 

[WholeLottaGame7]

Also remember if you're already starting to brady down, you might need a few chest compressions to get the CO up to circulate the drug (whichever route you administer it).

I've talked about it as a backup but have never had to do it. Would probably give at least 2mg/kg.

 

[MirrorTodd]

Also remember if you're already starting to brady down, you might need a few chest compressions to get the CO up to circulate the drug (whichever route you administer it).

I've talked about it as a backup but have never had to do it. Would probably give at least 2mg/kg.

You mean you cant just do the ole Pulp Fiction trick?

 

[Mman]

Agreed. If the contraindication is just the child at risk for hyperkalemia with an undiagnosed dystrophy then the ASA recommends giving succ to protect the airway. However, if it's for MH then obviously that's a different story. I haven't used it but believe that studies have shown it's an alternative if using at like 1-2 mg/kg IM but onset is still gonna take a hell of a long time... which isn't ideal in laryngospasm. So I guess if you have that scenario where you have a kid with MH and is in laryngospasm without an IV... that's a toughy.

for the sake of discussion, what exactly is the MH risk? I mean it's not like many 3 year olds have a personal history of MH. For a kid you are either talking about a family history of MH (in which case you probably wouldn't be masking them down with sevo in the first place and would already have an IV) or a condition which puts them at increased risk of MH (but even that isn't a guarantee they would have a crisis).

 

[MikeMerk-MtS]

for the sake of discussion, what exactly is the MH risk? I mean it's not like many 3 year olds have a personal history of MH. For a kid you are either talking about a family history of MH (in which case you probably wouldn't be masking them down with sevo in the first place and would already have an IV) or a condition which puts them at increased risk of MH (but even that isn't a guarantee they would have a crisis).

OP never gave an age so that was a generality. But yes, 3 year olds like 30 year olds are at risk for MH. Plenty of 3 year olds who have had multiple surgeries before so it would apply to both personal or family history. Some people also don’t have a family history available (adoption).

 

[Mman]

OP never gave an age so that was a generality. But yes, 3 year olds like 30 year olds are at risk for MH. Plenty of 3 year olds who have had multiple surgeries before so it would apply to both personal or family history. Some people also don’t have a family history available (adoption).

I am aware that there can be kids "at risk" for MH. I'm saying that phrase can mean something different. Let's just say I wouldn't hesitate to use succinylcholine on a kid dying of hypoxia from laryngospasm because they might have a 5% chance of MH.

 

[MikeMerk-MtS]

I am aware that there can be kids "at risk" for MH. I'm saying that phrase can mean something different. Let's just say I wouldn't hesitate to use succinylcholine on a kid dying of hypoxia from laryngospasm because they might have a 5% chance of MH.

Right. But because MH is autosomal dominant if they were actually at risk then you might think twice.

 

[Mman]

Right. But because MH is autosomal dominant if they were actually at risk then you might think twice.

That kinda implies you are saying they are "at risk" because they have a parent with documented MH. Maybe it was their mom's aunt that had suspected MH but nobody in the family has been tested so this kid's risk is far lower than 50%. Personally I'd rather treat a hypothetical MH crisis than sign a death certificate for hypoxic arrest.

But this sort of situation gets so far down the rabbit hole that almost nobody has ever had to do it. I mean in my personal experience the odds of even using IM succinylcholine in a normal pediatric patient are well under 1/1000. How many MH susceptible kids is any person going to take care of in their career to get to the point of needing IM roc?

 

[deleted59964]

there are other CI to sux...
hyperkalaemia in wheelchair/bed bound kids for example

 

[deleted59964]

i know it’s rare generally.
but if you do a lot of complex peds it happens from time to time that you have a child that you would plan not to give sux

 

[deleted59964]

Anyone else hear it works fastest if injected under the tongue? Was told that by a couple of pediatric anesthesiologists but couldn’t find any references.

i wouldn’t inject sux in the tongue, would rather keep some cpap on.

would inject in the deltoid, and then massage it. key is to give it before bradycardia starts as once CO drops IM absorption drops

 

[Arch Guillotti]

i wouldn’t inject sux in the tongue, would rather keep some cpap on.

would inject in the deltoid, and then massage it. key is to give it before bradycardia starts as once CO drops IM absorption drops

give it with atropine.

 

[deleted59964]

give it with atropine.

or adrenaline

 

[Arch Guillotti]

or adrenaline

IM?

 

[HalO'Thane]

Haven’t had to give it for acute laryngospasm but I feel a lot less nervous about needing to use it now that we have Suggamadex. 16 mg/kg should reverse just about any dose of Roc for even the quickest procedure, such as ear tubes.

As for potential contraindications to Sux, probably the ones that would make me most nervous are burn patients in babies and young children. They may have limited access for line placement due to the burns and dressing, potential inhalation injury, and I have sometimes seen difficulty with ventilation due to the dressings and binders being wrapped too tight around the chest. Fortunately not all burn patients come to the operating room but the ones that do seem to be sick as hell.

 

[deleted59964]

IM?

yep - it works for anaphylaxis - it works for other indications too

 

[deleted9493]

I do it all the time in neonatal/infant open heart cases just to free me up to start getting access...1 mg/kg in each deltoid. Laryngospasm breaks a lot sooner than total muscle relaxation. That can take several minutes, as others have pointed out.

 

[Mman]

i know it’s rare generally.
but if you do a lot of complex peds it happens from time to time that you have a child that you would plan not to give sux

We have all taken care of kids you didn't want to give sux to. I'm asking how often do you have one of those patients and end up down the rabbit hole of not having an IV and having severe laryngospasm that you need to treat with IM roc? I'm assuming it's rare enough that it is unlikely even a peds only anesthesiologist would need to do it more than once in a career (if that).

My ballpark guess was that you need IM sux less than 1/1000 peds mask inductions. The percent of kids you are trying to avoid sux on has to be <1% overall, but I suppose maybe 10% in some surgical populations. So that'd be between a 1/10,000 and 1/100,000 chance of needing it.

 

[deleted59964]

We have all taken care of kids you didn't want to give sux to. I'm asking how often do you have one of those patients and end up down the rabbit hole of not having an IV and having severe laryngospasm that you need to treat with IM roc? I'm assuming it's rare enough that it is unlikely even a peds only anesthesiologist would need to do it more than once in a career (if that).

My ballpark guess was that you need IM sux less than 1/1000 peds mask inductions. The percent of kids you are trying to avoid sux on has to be <1% overall, but I suppose maybe 10% in some surgical populations. So that'd be between a 1/10,000 and 1/100,000 chance of needing it.

I'm not disagreeing with you.

I've given IM sux twice -- both times in semi electively in unwell infants that had difficult IV access
I've had IM roc as my plan because of CI to sux and no IV a few times
I've never given IM roc -- hence the thread.

by the way, at those odds - there is a reasonable chance that someone who reads the thread will need to use it at some point in their career.