To the Editor:—  We read with interest the article of Naguib et al.  1and the Editorial View of Donati 2regarding optimal succinylcholine dose used for intubation. In their article, Naguib et al.  1conclude that the recommended dose of 1 mg/kg succinylcholine for intubation at 60 s may be excessive and that reducing the dose to 0.56 mg/kg would provide same intubating conditions in 95% of patients with normal airway anatomy and allow a more rapid return of spontaneous respiration.

In our opinion, patients with normal airway anatomy, as those included in the study of Naguib et al. , 1are not the challenging cases to anesthesiologists. They can easily be intubated even with a reduced dose of succinylcholine, and it is indifferent whether return of spontaneous respiration in these patients is rapid or slow. However, patients who are muscular, are obese, or have abnormal airway anatomy and parturients undergoing cesarean delivery present a challenge to anesthesiologists during intubation. Profound and intense muscular relaxation is necessary to obtain an optimal/best attempt at intubation in these patients, and we question whether this can be achieved using a reduced dose of 0.56 mg/kg succinylcholine. Finally, if a difficult intubation is anticipated before initiation of general anesthesia, we would be prone to follow the American Society of Anesthesiologists algorithm for difficult intubation rather than using a reduced dose of succinylcholine with a presumption that it would allow a more rapid return of spontaneous respiration in case of failure to intubate.

Naguib M, Samarkandi A, Riad W, Alharby SW: Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045–9
Donati F: The right dose of succinylcholine. Anesthesiology 2003; 99:1037–8