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55]

Original Article

Determination of optimal dose of succinylcholine

to facilitate endotracheal intubation in pregnant
females undergoing elective cesarean section
Mohd Asim Rasheed,
ABSTRACT
Urmila Palaria,
Umesh K. Bhadani1, Aims: The study was carried out to find the optimal dose of succinylcholine for pregnant
Abdul Quadir2 females, undergoing elective cesarean section under general anesthesia, in order to achieve
Department of Anaesthesiology, excellent intubation conditions for a successful endotracheal intubation.
Government Medical College, Materials and Methods: One hundred and twenty pregnant females aged between 20 and
Haldwani, Uttarakhand, Department 35 years were randomly allocated into 4 groups of 30 patients each. Group I received Inj.
1

of Anaesthesiology, Sharda Medical succinylcholine 0.5 mg/kg, Group II received 0.6 mg/kg, Group III received 1.0 mg/kg, and
College, Greater Noida, 2Department of Group IV received 1.5 mg/kg intravenously. The response to ulnar nerve stimulation at the wrist
Anaesthesiology, JNMCH, Aligarh, India was recorded using the peripheral nerve stimulator. Grading of intubation conditions was done
60 s after Inj. succinylcholine administration. Peak effect, peak time, and duration of absent
respiratory movement (apnea time) was noted.
Statistical Analysis: One-way analysis of variance (ANOVA) with post hoc analysis (Bonferroni
test) has been applied to see significance among groups for continuous variables and the
Chi-square test was performed for categoric variables. SPSS v 16 was used for statistical
analysis for the study.
Results: Peak effect achieved was similar with 0.6, 1.0, and 1.5 mg/kg. There was no statistically
significant difference (P >0.05) in the time taken to achieve the peak effect (peak time) between
1.0 and 1.5 mg/kg. Apnea time was 242.7 ± 7.1 s with 1.0 mg/kg and 377.7 ± 28.9 s with
1.5 mg/kg (P < 0.001). Intubating conditions were poor with 0.5 mg/kg, good with 0.6 mg/kg,
and excellent with 1.0 and 1.5 mg/kg.
Address for correspondence:
Dr. Mohd. Asim Rasheed, Conclusion: The dose of 1.0 mg/kg of succinylcholine produces excellent intubation conditions
Department of Anaesthesiology, in pregnant females similar to the conventional dose of 1.5 mg/kg and is associated with a
Government Medical College, Haldwani, significantly shorter duration of action.
Uttarakhand, India.
E-mail: drmohdasim@gmail.com Key words: Caesarean section, intubation conditions, pregnancy, succinylcholine

INTRODUCTION esophageal intubation, and failure to ventilate.[2,3] Failed end

tracheal intubation is more common in pregnant females
(incidence: 1:300 versus 1:2000 for all females) and is one of
M ost general anesthesia-related deaths occur due to
hypoxemia when difficulty in securing airway is
encountered. [1] The most commonly occurring adverse
the major causes of maternal morbidity and mortality.[4]

There are several physiologic alterations during pregnancy that

respiratory events are failure to intubate, failure to recognize
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DOI:
10.4103/2249-4472.104733
pose a challenge to the anesthesiologist in terms of a successful
tracheal intubation during general anesthesia. Pregnant females
have high chances for regurgitation and aspiration of gastric
contents.[5,6] Respiratory physiology is also altered in pregnant
females leading to increase in tidal volume, minute ventilation
volume, and oxygen consumption.[7-9] There occur changes in the
upper airway, chest wall, static lung volumes, and gas exchange.[10]
Thus succinylcholine is an ideal neuromuscular blocker in
pregnant females because it provides an excellent intubation

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Rasheed, et al.: Optimal dose of succinylcholine in cesarean section
conditions along with a short duration of apnea, although it has
been observed that the duration of action of succinylcholine
is significantly longer in pregnant women as compared with
nonpregnant women.[11] Serum cholinesterase activity decreases
30% during pregnancy and remains depressed during the
postpartum period.[12] Therefore, a higher proportion of females
may be expected to show increased sensitivity (prolonged apnea)
to succinylcholine when pregnant than when nonpregnant. This
finding assumes great significance in the scenario of “cannot
intubate, cannot ventilate,” especially in pregnant females who
are at more risk for sudden oxyhemoglobin desaturation than
a nonpregnant female because of various respiratory changes
and hormonal alterations.
Therefore, the objective of our study was to find out the
optimal dose of succinylcholine for getting the best intubation
conditions in pregnant females undergoing cesarean section.
MATERIALS AND METHODS
This prospective, randomized study was approved by the ethical
committee of Government Medical College, Haldwani. After
obtaining written informed consent, 120 pregnant females of
ASA grade I aged between 20 and 35 years, posted for elective
cesarean section over a period of 11 months were selected.
Females with cardiac, hepatic, pulmonary, and renal disease
were excluded from the study. Females with neuromuscular
disease or those taking medications known to interfere with
neuromuscular transmission were also excluded from the
study with the help of history taking and clinical investigations.
Females with a documented or family history of abnormal
response to succinylcholine, with a history of difficult intubation
during previous surgery or with modified Mallampati grades
III and IV were also excluded from the study. Actual body
weight of the females was taken for the calculation of the dose
of succinylcholine to be administered.
Random allotment of pregnant females into various groups
was done by asking them to pick a sealed envelope containing
cards specifying the dose to be given.
Females in Group I received Inj. succinylcholine 0.5 mg/kg.
IV, Group II received dose of 0.6 mg/kg IV, Group III received
1.0 mg/kg IV, and Group IV received the dose of 1.5 mg/kg IV.
In the operating theater, the patients were monitored with an
electrocardiogram, pulse oximetry, and noninvasive blood
pressure monitoring using multichannel monitor (Drager
model no. ms 18986 E539U). All females were premeditated
with ranitidine 1 mg/kg IV and metoclopramide 0.15 mg/kg IV.
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2012 / Vol 2 | Issue 2
Patients were preoxygenated with 100% oxygen through a
facemask for more than 3 min. Anesthesia was then induced
with thiopentone sodium (5 mg/kg IV). After loss of eyelash
reflex, we calibrated our peripheral nerve stimulator (TOF
Watch S Organon IPXO CE 0543). The designated dose of
succinylcholine (volume of the injection being 10 mL in each
group) was then administered to the patient via a free running
IV line on the contralateral arm. The patient was unaware of
the dose to be administered as this was a single-blinded study.
A size 3 Macintosh blade was used for the laryngoscopy in
each case. One minute after succinylcholine administration,
laryngoscopy and tracheal intubation was performed by an
anesthesiologist with more than 2 years of experience, who
was unaware of the dose of succinylcholine administered and
tracheal intubation conditions were graded using Copenhagen
Consensus Conference Criteria [Table 1].
If tracheal intubation proved impossible because of inadequate
relaxation, respiration was supplemented by a face mask and
the patient was given a supplemented dose of 0.5 mg/kg of
succinylcholine, and another attempt was made 1 min later. These
patients who received supplemental dose were excluded from the
study. Correct tracheal tube placement was confirmed by EtCO2
measurement and bilaterally equal air entry on auscultation.
After proper placement and confirmation of endotracheal
tube by capnograph, cesarean section was started to keep the
induction-delivery time as short as possible. Maintenance of
anesthesia was done with FiO2 of 0.5 (with nitrous oxide) in
0.6% isoflurane. The patient’s lungs were ventilated to target
EtCO2 concentration of 35–40 mmHg using open circuit with
fresh gas flow of 8 L/min.
Following parameters were recorded using a peripheral nerve
stimulator:
1. Peak effect (maximal twitch depression achieved)
2. Peak time (time taken to achieve peak effect)
Table 1: Copenhagen consensus conference criteria
Criteria Intubation conditions
Clinically acceptable Clinically
unacceptable
Excellent Good Poor
Ease of laryngoscopy Easy Fair Difficult
(Jaw relaxation)
Vocal cord Position Abducted Intermediate Closed
Vocal cord movement None Moving Closed
Airway reaction None Diaphragm Sustained
Movement of limbs None Slight Vigorous
Intubation conditions: Excellent = all criteria are excellent Good = All criteria
either good or even if one is good and rest excellent Poor = The presence of a
single criterion graded as poor
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Rasheed, et al.: Optimal dose of succinylcholine in cesarean section

Duration of absence of respiratory effort (apnea time) was
recorded as the time taken from the correct placement of the
endotracheal tube until the appearance of patient’s first respiratory
effort as shown by the first visible reservoir bag movement.
Statistical analysis
One-way analysis of variance (ANOVA) with post hoc analysis
(Bonferroni test) has been applied to see significance among
groups for continuous variables and the Chi-square test was
performed for categoric variables. SPSS v 16 was used for
statistical analysis for the study.
RESULTS
Of the 120 patients who underwent randomization, all the
patients agreed to participate in the study. The baseline
characteristics of the patients in the 4 groups were similar [Table 2].
Comparison of peak effect (maximal twitch depression achieved)
and peak time (time taken to achieve peak effect) is compared
in Table 3. Peak time (mean ± SD) was 78.3 ± 3.8 s in Group I
(0.5 mg/kg); 69 ± 4.0 s in Group II (0.6 mg/kg); 59.7 ± 1.8 s in
Group III (1.0 mg/kg); and 59.7 ± 3.1 s in Group IV (1.5 mg/kg).
The difference of peak time between group IV (1.5 mg/kg) and
Group III (1.0 mg/kg) was statistically insignificant (P = 1)
[Table 3], whereas it was statistically significant (P value
< 0.001) between Group IV (1.5 mg/kg) and Group II
(0.6 mg/kg) and between Group IV (1.5 mg/kg) and Group
I (0.5 mg/kg). Peak time was inversely related to the dose of
succinylcholine given. Maximal twitch depression achieved
was 96% with the dose of 0.5 and 0.6 mg/kg but all pregnant
females achieved full muscular relaxation with the dose of
1.0 and 1.5 mg/kg.
Intubation conditions were graded and the results are
shown in Table 3. In females receiving the dose of 0.5 mg/
kg, 13 females were graded as poor (vocal cord was closed
in 7 females and 6 females had movement of limbs), 12
were graded as good, and 5 were graded as having excellent
intubation conditions.
With 0.6 mg/kg, 11 females were graded as having good and 19
were graded as having excellent intubation condition, whereas
all the females receiving the dose of 1.0 and 1.5 mg/kg were
graded as having excellent intubation condition.
(Out of 23 females having good intubation conditions,
21  females had slight movement of the limbs especially
lower limbs and 2 had vocal cord in intermediate position
due to which they were graded as having good intubation
condition.)
The mean apnea time was recorded and is shown in Table 4. In
Group I (0.5 mg/kg), the apnea time (mean ± SD) was 162.1 ± 7.6 s;
in Group II (0.6 mg/kg) it was 215.6 ± 20.3 s; in Group III

Table 2: Distribution of females in the study according to age (years), height (cm), and weight (kg)
Characteristics Succinylcholine dose P value
Group I 0.5 mg/kg Group II 0.6 mg/kg Group III 1.0 mg/kg Group IV 1.5 mg/kg
(n = 30) (n = 30) (n = 30) (n = 30)
Age ( years) 24.9 ± 3.5 24.5 ± 2.9 25.8 ± 4.1 26.6 ± 4.1 0.13*
Weight (kg) 56.8 ± 6.7 58.7 ± 5.3 60.0 ± 6.4 59.7 ± 7.3 0.23*
Height (cm) 152.8 ± 4.6 152.8 ± 4.6 152.8 ± 4.6 152.8 ± 4.6 0.17*
Values are in means (SD), *One-way analysis of variance (ANOVA)

Table 3: Peak time, peak effect, and intubation condition during laryngoscopy according to copenhagen
consensus conference criteria
Variables Succinylcholine dose P value
Group I 0.5 mg/kg Group II 0.6 mg/kg Group III 1.0 mg/kg Group IV 1.5 mg/kg
(n = 30) (n = 30) (n = 30) (n = 30)
Peak time (s) 78.3 ± 3.8 69.0 ± 4.0 59.7 ± 1.8 59.7 ± 3.1 0.001a
Apnea time (s) 162.1 ± 7.6 215.6 ± 20.3 242.7 ± 7.1 377.7 ± 28.9 0.001a
Peak effect (in %) 96 96 100 100
Intubation condition
Excellent 05 (16.7%) 19 (63.3%) 30 (100%) 30 (100%) 0.001b
Good 12 (40.0%) 11 (36.7%) 0 (0%) 0 (0%)
Poor 13 (43.3%) 0 (0%) 0 (0%) 0 (0%)
Values are in means (SD), or numbers (%), aOne-way analysis of variance (ANOVA), b2 test, Statistical significant accepted when P value is <0.05

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Rasheed, et al.: Optimal dose of succinylcholine in cesarean section
Table 4: Mean apnea time
Group I Group II Group III Group IV
Mean apnea time 162.1 ± 7.6 215.6 ± 20.3 242.7 ± 7.1 377.7 ± 28.9
(s) ± S.D.
Statistical significance accepted when P value is < 0.001
(1.0 mg/kg) it was 242.7 ± 7.1 s, and in Group IV (1.5 mg/kg)
the apnea time was 377.7 ± 28.9 s.
DISCUSSION
Succinylcholine is a unique drug in anesthetic practice,
primarily because of its pharmacodynamic profile. Although
rocuronium has rapid onset of action similar to succinylcholine
when given in the dose of 0.9 and 1.2 mg/kg, it is associated
with long duration of action.[13] Recently it was found that
despite its very short duration of action, functional recovery
of succinylcholine takes a longer time after the conventional
dose of 1.0 mg/kg in a healthy adult human being.[14]
Therefore, finding the optimal dose of succinylcholine during
general anesthesia for cesarean section is of paramount
importance: firstly, because of various physiologic and anatomic
changes during pregnancy; and secondly, because most of the
general anesthesia-related deaths in pregnancy is because of
hypoxemia and airway catastrophe.[15,16]
Although succinylcholine has a short duration of action
because of its rapid hydrolysis by plasma cholinesterase,
it was found that the critical oxyhemoglobin desaturation
occurred before return to an unparalyzed state following
1 mg/kg intravenous dose.[17] They found that 0.6 mg/kg
dose was ideal in terms of providing excellent intubation
conditions as well as keeping the apnea time as short as
possible to prevent any oxyhemoglobin desaturation. In
addition, succinylcholine produced desaturation below
80% in 50% of females receiving conventional dose of
1.5 mg/kg.[18]
The present study was aimed at finding the optimal dose of
succinylcholine, in pregnant females undergoing cesarean
sections, so as to produce excellent intubation conditions, and
at the same time producing an apnea time as short as possible
to prevent oxyhemoglobin desaturation in cases of cannot-
ventilate and cannot-intubate scenario.
The results of our study show that satisfactory tracheal
intubation conditions in pregnant females could be achieved
1 min after succinylcholine administration, with doses much
less than the traditionally recommended dose of 1.5 mg/kg
and the dose of 0.6 mg/kg do not always provide the satisfactory
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2012 / Vol 2 | Issue 2
intubation condition as produced in a normal healthy
nonpregnant female and male patients.
We selected four groups in our study to determine the optimal
dose required for intubation; 1.5 mg/kg was the traditionally
recommended dose and 0.6 mg/kg was the dose as suggested
for normal healthy nonpregnant female and male patients and
1.0 mg/kg was taken as a group because the dose calculation
was easy. Although the difference between 0.5 and 0.6 mg/kg
was small it nevertheless found whether intubation was possible
with such small doses or not.
The present study also recorded the peak time and peak effect
of various doses of succinylcholine using the peripheral nerve
stimulator.
Peak time (time taken to achieve peak effect) was not
statistically significant between groups IV and III, whereas it
was statistically significant (P value < 0.001) between groups
IV and II and between groups IV and I.
The peak effect (maximal twitch depression achieved) was
recorded and was found to be 96% in groups I and II, whereas
it was 100% in groups III and IV. We recorded apnea time from
the time of placement of tracheal tube until the first visible
movement in the reservoir bag. When compared statistically, we
found that there was statistically significant difference (P value
< 0.001) between the apnea time in groups IV and III. Similarly,
the apnea time between groups IV and II and between groups
IV and I was also statistically significant (P value < 0.001).
Intubation conditions were compared in 4 groups using
Copenhagen consensus conference criteria. In females receiving
the dose of 0.5 mg/kg, intubation condition was graded as poor
and with 0.6 mg/kg, intubation condition was graded as good,
whereas all the females receiving the dose of 1.0 and 1.5 mg/kg
were graded as having excellent intubation condition.
When compared statistically, we found that the difference
in intubation conditions were not statistically significant
between groups IV and III, whereas the difference in intubation
conditions were statistically significant between groups IV
and II and between groups IV and I (P value < 0.001). There
was also a statistically significant difference in intubation
conditions between groups III and II between groups III and
I and between groups II and I (P value < 0.001). Naguib et al.
had found that the calculated dose of succinylcholine (and
their 95% confidence intervals) required to achieve excellent
intubation conditions in 50% and 80% of nonpregnant females
and male patient at 60 s to be 0.39 (0.29–0.51) mg/kg and 1.6
(1.2–2.0) mg/kg, respectively.[19]
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Rasheed, et al.: Optimal dose of succinylcholine in cesarean section
We have not taken the body mass index (BMI) of the pregnant
females into consideration in our study as a high BMI is a
weak predictor for difficult and failed tracheal intubation.[20]
Thus we cannot comment on the dose and intubation
conditions in obese females, although it has been found
that for complete neuromuscular paralysis and predictable
laryngoscopy conditions, succinylcholine 1 mg/kg total body
weight was appropriate in morbidly obese females with BMI
of >40 kg/m2.[21]
We found that the dose of 0.5 and 0.6 mg/kg did not often
result in satisfactory intubation conditions at 60 s, and therefore
cannot be recommended for routine endotracheal intubation
in pregnant females. The conditions after 0.6 mg/kg were
clinically acceptable, although not ideal, whereas the intubation
conditions after 1.0 mg/kg were identical to those obtained
after 1.5 mg/kg dose.
The effectiveness of small doses of succinylcholine in
achieving adequate tracheal intubation conditions 60 s after
administration has been reported previously but they were not
appreciated because there was no clearly defined relationship
between the apnea time and oxyhemoglobin desaturation.[22,23]
Although in our study the onset of action was dose dependent,
there was no statistically significant difference between 1.0 and
1.5 mg/kg groups. This suggests that there is no benefit in terms
of peak time in giving doses of succinylcholine larger than
1.0 mg/kg in pregnant females.
All the doses administered produced nearly complete abolition
of the twitch response. The peak effect was 100% in groups
III and IV.
The apnea time, was also dose dependent. It increased with
the increase in dose of succinylcholine. It was 242.7 ± 7.1 s
with 1.0 mg/kg (Viby-Mogensen had reported an apnea time
of 348 min with the dose of 1 mg/kg in nonpregnant female
and male patients.[24] The apnea time increased to 377.7 ± 28.9
seconds with the dose of 1.5 mg/kg which was statistically
significant (P value < 0.001).
In our study we found that respiration began in most of
the pregnant females, even before any muscular activity at
the thumb, as recorded by the peripheral nerve stimulator.
Although initial spontaneous and regular breathing may
not reflect full functional recovery, this may still prevent
oxyhemoglobin desaturation that would ensue if the patient
remained apneic.
This study had few limitations. Firstly, the apnea time which
was measured as the first visible reservoir bag movement after
90
muscular relaxation was sometime effected by the pressure,
which was applied on the abdomen by the surgeon. This
limitation was removed by asking the surgeon to remove the
pressure from the abdomen temporarily to determine the
accuracy of reservoir bag movement.
Secondly, the duration of absence of respiratory effort (apnea
time) was not very accurate for it was measured in between the
IPPV given to the patient but the inaccuracy was reduced by
diligent observation by the same observer in each case.
Thus, we can say that succinylcholine in the dose of 1.0 mg/kg
provides excellent intubation conditions similar to the
conventional dose of 1.5 mg/kg and is associated with shorter
apnea time.
Alternatively, the more rapid return of neuromuscular function
after smaller doses of succinylcholine could negatively affect
intubation conditions by narrowing the window of opportunity
for successful tracheal intubation.
CONCLUSION
The dose of 1.0 mg/kg of succinylcholine produces excellent
intubation conditions during pregnancy, and is associated with
a shorter apnea time as compared with the conventional dose
of 1.5 mg/kg.
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Cite this article as: Rasheed MA, Palaria U, Bhadani UK, Quadir A.
Determination of optimal dose of succinylcholine to facilitate endotracheal
intubation in pregnant females undergoing elective cesarean section. J Obstet
Anaesth Crit Care 2012;2:86-91.
Source of Support: Nil, Conflict of Interest: No.
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