Management of the airway without the use of neuromuscular blocking agents: the use of remifentanil

Fotopoulou, Georgia; Theocharis, Stamatios; Vasileiou, Ioanna; Kouskouni, Evangelia; Xanthos, Theodoros

doi:10.1111/j.1472-8206.2011.00967.x

Cited by 14 publications

(9 citation statements)

References 88 publications

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“…Our results are largely consistent with those of a previous narrative review, which included adult and paediatric patients; however, we undertook a systematic search, risk of bias and quality assessment of studies [16].…”

Section: Discussionsupporting

confidence: 85%

“…Previous reviews on this topic were published over 10 years ago [15,16] and further studies have been completed since. In light of this, the objective of this systematic review and meta-analysis was to determine the efficacy and safety of remifentanil for providing comparable conditions for tracheal intubation compared with NMB drugs in adult patients.…”

Section: Introductionmentioning

confidence: 99%

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Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis

Santos,

Zheng,

Singhal

et al. 2024

Anaesthesia

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SummaryThere is increasing interest in the use of short‐acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty‐one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5–4.0 μg.kg‐1) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94–1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate‐certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0–4.0 μg.kg‐1) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72–1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate‐certainty of evidence). There was no evidence of an effect between remifentanil (2.0–4.0 μg.kg‐1) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01–13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44–2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low‐certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis

Santos,

Zheng,

Singhal

et al. 2024

Anaesthesia

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“…Intubation without a muscle relaxant is achievable with deep anesthesia or with the combination of propofol and remifentanil. 24–27 However, difficult intubations and adverse hemodynamic events are more frequently related to intubation without muscle relaxants, 25,26 and excellent intubation conditions are more frequent when muscle relaxation is used. 24 …”

Section: Discussionmentioning

confidence: 99%

Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center

Yan

Tanner

Lin

et al. 2013

Anesthesia &Amp; Analgesia

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Background Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting. Methods We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories, and compared these cases to those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same time period (control group), were collected via review of medical records. Results Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (p=0.04, odds ratio 10, 95% confidence interval 1.1 to 482). Tongue or soft tissue bite occurred in two cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure. Conclusion The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.

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“…Several studies have reported the incidence of hypotension and bradycardia after remifentanil use, which may explain our results. [22,23] In addition, there were 3 patients in group 2.0 who had closed vocal cords during the induction period. This seems to be related to the muscle rigidity following a high dose of remifentanil.…”

Section: Discussionmentioning

confidence: 99%

The optimal exhaled concentration of sevoflurane for intubation without neuromuscular blockade using clinical bolus doses of remifentanil

2017

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Background:The aim of this study was to investigate the optimal exhaled sevoflurane concentration that produces adequate endotracheal intubation conditions when sevoflurane is combined with the different bolus doses of remifentanil used in clinical practice.Methods:The patients were randomized to 3 groups (groups 1.0, 1.5, and 2.0), receiving remifentanil bolus doses of 1.0, 1.5, and 2.0 μg/kg, respectively. For each group, the concentration of sevoflurane used for each consecutive patient was increased or decreased using the “up-and-down” method based on the success or failure to achieve adequate conditions for intubation in the previous patient. The remifentanil bolus dose was administered 90 s before intubation and after the target sevoflurane concentration was achieved.Results:In groups 1.0, 1.5, and 2.0, the effective concentration in 50% (EC50) of the sevoflurane concentration required to perform successful intubation was 3.0, 2.0, and 1.29 vol% and the effective concentration in 95% was 3.45, 2.91, and 1.89 vol%, respectively. When sevoflurane was administered for the induction, the increase in heart rate (HR) of group 1.0 was the highest among the groups. The highest number of adverse events occurred in group 2.0, including vocal cord rigidity, hypotension, and bradycardia.Discussion:The EC50 of the sevoflurane concentration was 3.0, 2.0, and 1.29 vol% when it was combined with a bolus dose of remifentanil of 1.0, 1.5, and 2.0 μg/kg, respectively. Of the 3 different bolus doses of remifentanil, the dose of 1.5 μg/kg was least associated with changes in the HR/mean blood pressure during intubation without increasing adverse effects.

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Management of the airway without the use of neuromuscular blocking agents: the use of remifentanil

Cited by 14 publications

References 88 publications

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis

Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center

The optimal exhaled concentration of sevoflurane for intubation without neuromuscular blockade using clinical bolus doses of remifentanil

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