To The Editor

The recommendation to limit intermediate-acting non-depolarizing neuromuscular blockers (IANDNMB’s) to rapid sequence when succinylcholine is contraindicated, or cases of 60-90 minutes or less, reported in an ASA meeting session summary by Dr. Mark P. Fritz (APSF Newsletter, Winter 1994-95) goes in the right direction, but not far enough. It is actually quite easy to almost totally eliminate these costly drugs from anesthesia practice while enhancing safety.

I use the following guidelines:

1. Only intubate when necessary.

2. Unless contraindicated, use succinylcholine for all intubations.

3. Administer judicious incremental doses of relaxant to achieve the required surgical relaxation (you’d be surprised how little is needed for many procedures!). Do not base doses of NMB on the twitch ratio but on the surgical situation.

4. Do not paralyze a patient for personal convenience, and if feasible, assist rather than control respiration.

5. Use succinylcholine infusions for cases under 60 minutes and use pancuronium, curare, or metocurine for longer cases.

Using these common-sense guidelines for some 20 years, I have avoided or minimized:

1. The “can’t intubate, can’t ventilate” scenario.

2. Awake, paralyzed patients.

3. Ventilator induced hypotension.

Not only is this a safer, more reasonable practice than the ubiquitous exclusive use of IANDNMB’s, but the average relaxant costs are under $5.00 per case versus the $20-50 (or more) range I frequently see now!

Steven S. Kron M.D. New Britain, CT