BNF for Children 2011-2012

646 15.1.6 Drugs for reversal of neuromuscular blockade BNFC 2011–201215 Anaesthesiaand is caused by the development of a non-depolarisingblock following the initial depolarising block; edrophonium(section 15.1.6) may be used to confirm the diagnosisof dual block. Children with myasthenia gravis areresistant to suxamethonium but can develop dual blockresulting in delayed recovery. Prolonged paralysis mayalso occur in those with low or atypical plasma cholinesterase.Assisted ventilation should be continued untilmuscle function is restored.SUXAMETHONIUM CHLORIDE(Succinylcholine chloride)Cautions see notes above; hypersensitivity to otherneuromuscular blocking drugs; patients with cardiac,respiratory or neuromuscular disease; raised intraocularpressure (avoid in penetrating eye injury);severe sepsis (risk of hyperkalaemia); interactions:Appendix 1 (muscle relaxants)Contra-indications family history of malignanthyperthermia, hyperkalaemia; major trauma, severeburns, neurological disease involving acute wasting ofmajor muscle, prolonged immobilisation—risk ofhyperkalaemia; personal or family history of congenitalmyotonic disease, Duchenne muscular dystrophy;low plasma-cholinesterase activity (includingsevere liver disease, see below)Hepatic impairment prolonged apnoea may occur insevere liver disease because of reduced hepaticsynthesis of pseudocholinesterasePregnancy mildly prolonged neuromuscular blockademay occurBreast-feeding unlikely to be present in breast milk insignificant amounts (ionised at physiological pH);breast-feeding may be resumed once the motherrecovered from neuromuscular blockSide-effects see notes above; also increased gastricpressure; hyperkalaemia; postoperative muscle pain,myoglobinuria, myoglobinaemia; increased intraocularpressure; flushing, rash; rarely arrhythmias, cardiacarrest; bronchospasm, apnoea, prolonged respiratorydepression; limited jaw mobility; very rarelyanaphylactic reactions, malignant hyperthermia; alsoreported hypertension, hypotension, rhabdomyolysisIndication and doseNeuromuscular blockade (short duration) duringsurgery. By intravenous injectionNeonate 2 mg/kg produces 5–10 minutes neuromuscularblockadeChild 1 month–1 year 2 mg/kgChild 1–18 years 1 mg/kg. By intramuscular injection (onset in 2–3 minutes)Neonate up to 4 mg/kg produces 10–30 minutesneuromuscular blockadeChild 1 month–1 year up to 4–5 mg/kgChild 1–12 years up to 4 mg/kg; max. 150 mgAdministration for intravenous injection, give undilutedor dilute with Glucose 5% or Sodium Chloride0.9%Suxamethonium Chloride (Non-proprietary) AInjection, suxamethonium chloride 50 mg/mL, netprice 2-mL amp = 58p, 2-mL prefilled syringe = £8.45Anectine c (GSK) AInjection, suxamethonium chloride 50 mg/mL, netprice 2-mL amp = 71p15.1.6 Drugs for reversal ofneuromuscular blockadeImportantThe drugs in this section should be used by experiencedpersonnel only.AnticholinesterasesAnticholinesterases reverse the effects of the non-depolarising(competitive) neuromuscular blocking drugssuch as pancuronium, but they prolong the action ofthe depolarising neuromuscular blocking drug suxamethonium.Edrophonium has a transient action and may be used inthe diagnosis of suspected dual block due to suxamethonium.Atropine (section 15.1.3) is given beforeor with edrophonium to prevent muscarinic effects ofedrophonium; it is also used in the diagnosis of myastheniagravis (section 10.2.1).Neostigmine has a longer duration of action thanedrophonium and is used specifically for reversal ofnon-depolarising (competitive) blockade. It acts withinone minute of intravenous injection and its effects lastfor 20 to 30 minutes; a second dose may then benecessary. Glycopyrronium or alternatively atropine(section 15.1.3), given before or with neostigmine, preventbradycardia, excessive salivation, and other muscariniceffects of neostigmine.EDROPHONIUM CHLORIDECautions section 10.2.1; atropine should also be givenContra-indications section 10.2.1Pregnancy section 10.2.1Breast-feeding section 10.2.1Side-effects section 10.2.1Indication and doseBrief reversal of non-depolarising neuromuscularblockade. By intravenous injection over several minutesChild 1 month–18 years 500–700 micrograms/kg (after or with atropine)Myasthenia gravis section 10.2.1Edrophonium (Non-proprietary) AInjection, edrophonium chloride 10 mg/mL, net price1-mL amp = £19.50NEOSTIGMINE METILSULFATE(Neostigmine methylsulphate)Cautions section 10.2.1; glycopyrronium or atropineshould also be givenContra-indications section 10.2.1Renal impairment section 10.2.1Pregnancy section 10.2.1