Administration of neuromuscular blocking agents (NMBA) during anesthesia can facilitate endotracheal intubation. This can decrease the incidence of postintubation hoarseness and airway injury.
Short-acting neuromuscular blocking agents are chosen for endotracheal intubation for short procedures (< 30minutes), and neuromonitoring is required soon after intubation. Options include succinylcholine, rocuronium or vecuronium if sugammadex is available for rapid reversal block.
Any short or intermediate acting neuromuscular blocking agents can be applied for endotracheal intubation for long procedures (≥ 30 minutes). Options include succinylcholine, rocuronium, vecuronium, mivacurium, atracurium and cisatracurium. The choice among these NMBA depends on availability, cost and patient parameters that affect drug metabolism.
Intraoperative relaxation can be maintained as necessary with additional dose of nondepolarizing NMBA.
Among all NMBA, Succinylcholine establish the most stable and fastest intubating conditions, thus is considered as the preferred NMBA for rapid sequence induction and intubation (RSII). Alternatives for succinylcholine for RSII include high dose rocuronium (1.2mg/kg which is a 4 X ED95 dose), or avoidance of NMBAs with a high dose remifentanil intubation.