Excellent intubating conditions with remifentanil–propofol and either low-dose rocuronium or succinylcholine

Abstract

Purpose The shortest time to tracheal intubation, the best intubating conditions, and the shortest duration of muscle paralysis are achieved with succinylcholine. During a lidocaine-remifentanil-propofol induction of anesthesia, we compared intubating conditions 90 s after administering low-dose rocuronium (0.3 mg Á kg -1 ) with intubating conditions 60 s after administering succinylcholine 1.5 mg Á kg -1 . Methods The randomized double-blind study included 184 healthy adult patients scheduled for elective surgery. Anesthesia was induced in all patients with lidocaine 1.5 mg Á kg -1 , remifentanil 2 lg Á kg -1 , and propofol 2 mg Á kg -1 administered over 30 s. In one group, rocuronium 0.3 mg Á kg -1 was administered before the induction sequence, and in the other group, succinylcholine 1.5 mg Á kg -1 was administered after the induction sequence. Laryngoscopy was attempted 90 s after rocuronium administration and 60 s after succinylcholine administration. Intubating conditions were assessed as excellent, good, or poor on the basis of ease of laryngoscopy, position of the vocal cords, and reaction to insertion of the tracheal tube and cuff inflation. Results There were 92 patients per group. In the rocuronium group, intubating conditions were excellent in 83 patients (90%), good in 8 (9%), and poor in 1 (1%), not significantly different from the intubating conditions in the succinylcholine group, which were excellent in 88 patients (96%), good in 3 (3%), and poor in 1 (1%) (P = 0.3). Conclusion During a lidocaine-remifentanil-propofol induction of anesthesia, rocuronium 0.3 mg Á kg -1 administered before the induction sequence provides intubating conditions comparable to those achieved with succinylcholine 1.5 mg Á kg -1 administered after the induction sequence. RésuméObjectif La succinylcholine permet de re´aliser l'intubation trache´ale dans les plus courts de´lais, avec les meilleures conditions d'intubation et la dure´e la plus courte de paralysie musculaire. Au cours d'une induction de l'anesthe´sie avec lidocaı¨ne-re´mifentanil-propofol, nous avons compare´les conditions d'intubation 90 sec apre`s avoir administre´du rocuronium a`faible dose (0,3 mgÁkg -1 ) aux conditions d'intubation 60 sec apre`s avoir administre´de la succinylcholine a`1,5 mgÁkg -1 . Méthode Au total, 184 patients adultes sains devant subir une chirurgie non urgente ont pris part a`cette e´tude randomise´e en double aveugle. L'anesthe´sie a e´te´induite chez tous les patients avec de la lidocaı¨ne (1,5 mgÁkg -1 ), du re´mifentanil (2 lgÁkg -1 ) et du propofol (2 mgÁkg -1 ) administre´s sur une pe´riode de 30 sec. Dans un groupe, du rocuronium (0,3 mgÁkg -1 ) a éte´administre´avant la

How low can you go? Lowest effective dose of neuromuscular blocking agent for tracheal intubation

“…Perhaps; however, to paraphrase Mark Twain, ''rumours of succinylcholine's demise appear to be greatly exaggerated.' ' Nevertheless, in this issue of the Journal, Siddik-Sayyid et al 4 present an alternative to succinylcholine facilitated tracheal intubation, which some clinicians may find attractive and which, at its worst, provides the direction for additional clinical studies. Siddik-Sayyid et al performed the following induction-intubation sequence.…”

“…Siddik-Sayyid et al 4 are not the first to suggest that administering a non-depolarizing neuromuscular blocker before induction of anesthesia shortens the ''intubating interval''. The method has been called the ''timing principle''.…”

“…To what extent should we embrace the Siddik-Sayyid et al 4 technique in our day-to-day practice? The intubation scores that they report are certainly impressive and comparable to those following succinylcholine.…”

“…» Peut-être en est-il ainsi ; toutefois, pour paraphraser Mark Twain, « les rumeurs concernant la mort de la succinylcholine semblent être très exagérées.» Quoi qu'il en soit, dans ce numéro du Journal, SiddikSayyid et coll. 4 présentent une alternative à la succinylcholine pour l'intubation trachéale, et certains cliniciens pourraient être séduits par cette technique ; même si ce n'était pas le cas, cette étude ouvre la voie et donne une orientation possible à d'autres études cliniques. Siddik-Sayyid et coll.…”

“…4 ne sont pas les premiers à émettre l'hypothèse que l'administration d'un curare avant l'induction de l'anesthésie réduise « l'intervalle d'intubation ». La méthode a été nommée le « principe de synchronisation ».…”