Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol

Purpose:The need for muscular relaxation to improve intubating conditions and to reduce the incidence of laryngeal morbidity is still controversial. The aim of this study was to determine the incidence of symptomatic laryngeal injuries (SLI) and of acceptable intubating conditions (including both good and excellent conditions), both with and without cisatracurium during induction of anesthesia, along with moderate doses of remifentanil and propofol. Methods:In this prospective, randomized double-blind equivalence trial, the intubating conditions were compared in 130 ASA I or II female patients. All subjects received remifentanil 2 µg·kg -1 iv and propofol 2.5 mg·kg -1 iv, with either cisatracurium 0.15 mg·kg -1 iv (group Cisatracturium), or saline (group Placebo). Tracheal intubating conditions were assessed with the Copenhagen Score. A systematic screening for postoperative hoarseness and sore throat was performed 24 and 48 hr after anesthesia, followed by a nasofibroscopic examination when laryngeal symptoms persisted at 48 hr.Results: Twenty-four hr after anesthesia, the incidence of postoperative hoarseness and sore throat in the Cisatracurium and Placebo groups was 26.5% and 21.5%, respectively, and 48 hr after anesthesia, the incidence was 7.8% and 6.1%, respectively (P = 0.32 and P = 0.50 between groups, respectively). In the clinically evaluable population, the incidence of SLI, assessed at 48 hr by nasofibroscopy, was equivalent in both groups, 1.6% vs 1.5% in group Placebo and group Cisatracurium, respectively (P < 0.001 for equivalence test), as was the occurrence of acceptable intubating conditions (95.4% vs 100%, P < 0.05 for equivalence test). However, the occurrence of excellent intubating conditions was more frequent in group Cisatracurium than in group Placebo (P = 0.0003). Conclusion:Following induction of anesthesia with propofol and moderate-dose remifentanil, cisatracurium did not confer a higher rate of good-to-excellent conditions for tracheal intubation, nor did muscle relaxation with cisatracurium decrease the rate of SLI after tracheal intubation.

Section: Conclusion : à La Suite D'une Induction De L'anesthésie à L'mentioning

confidence: 99%

Laryngeal injuries and intubating conditions with or without muscular relaxation: an equivalence study

Bouvet

Stoian

Jacquot-Laperrière

et al. 2008

“…The chosen anesthetic regimen, sevoflurane and remifentanil, might have been a reason for the ease of positive pressure ventilation despite the absence of neuromuscular blockade in the NOBLOCK group. Remifentanil is known to facilitate even endotracheal intubation without the aid of neuromuscular blocking agents 7,8 and its ability to profoundly block the nociceptive reaction could have helped to easily tolerate positive pressure ventilation. The chosen induction regimen of propofol 2.5 mg·kg -1 two minutes after remifentanil infusion possibly created a sufficient depth of anesthesia for successful LMA insertion.…”

Section: Me Et Th Ho Od Ds Smentioning

confidence: 99%

Neuromuscular blockade does not change the incidence or severity of pharyngolaryngeal discomfort after LMA anesthesia

Hemmerling

Beaulieu

Jacobi

et al. 2004

P Pu ur rp po os se e: : Positive pressure ventilation using a laryngeal mask airway (LMA) has gained increased popularity. This study examined the influence of neuromuscular blockade on the incidence and severity of pharyngolaryngeal discomfort after positive pressure ventilation using a LMA.M Me et th ho od ds s: : 130 patients were included in this prospective, doubleblind, randomized two-centre study. Anesthesia was induced with remifentanil and propofol and maintained using remifentanil and sevoflurane in 30% oxygen and 70% air. Patients were mechanically ventilated at 15 breaths·min -1 with tidal volumes to maintain PETCO 2 30-40 mmHg. Patients were randomly assigned to receive no neuromuscular blocking agent (NOBLOCK group) or cisatracurium prior to LMA insertion (BLOCK group). Prior to the end of surgery, morphine 3 to 5 mg iv were injected. The ease of insertion of the LMA, cuff pressure, and inspiratory pressure were recorded. Patients were asked immediately after two hours, and 24 hr after surgery to rate sore throat, dysphonia, or dysphagia as absent, minimal, moderate or severe. Continuous and categorical data were compared using t test and Chi-squared test, respectively.

“…Several previous studies reported a similar acceptable decrease in the MAP and HR when using varying amounts of remifentanil (from 0.5 to 5 lgÁkg -1 ) combined with propofol 2.0 or 2.5 mgÁkg -1 . 23,26 In fact, in ASA I and II patients, it has been reported that co-administration of fentanyl (2 or 4 lgÁkg -1 ) with increased doses of propofol (from 2 to 3.5 lgÁkg -1 ) did not exacerbate a decrease of either blood pressure or HR while it attenuated the cardiovascular response to laryngoscopy in comparison with placebo. 19 In the same way, the addition of remifentanil 0.25 or 0.5 lgÁkg -1 to propofol 2.5 mgÁkg -1 was well tolerated and moderated cardiovascular responsiveness to LMA insertion that were present when no opioid was co-administered with propofol.…”

Section: Discussionmentioning

confidence: 99%

Dose optimale de rémifentanil pour l’insertion d’un masque laryngé lors de la co-administration d’une dose standard unique de propofol

Bouvet

Da-Col

Rimmelé

et al. 2010

Purpose This dose-response study aimed to determine the optimal dose of remifentanil combined with propofol 2.5 mgÁkg -1 iv in order to achieve excellent conditions for laryngeal mask airway (LMA TM ) insertion in 95% of adult female patients. Methods Sixty-eight adult premedicated female patients, American Society of Anesthesiologists (ASA) physical status I and II requiring anesthesia for ambulatory surgery, were randomly allocated to one of four remifentanil dose groups (0.25, 0.5, 1, or 2 lgÁkg -1 ). Induction of anesthesia was achieved with one of the four blinded doses of remifentanil infused over 60 sec and simultaneously co-administered with propofol 2.5 mgÁkg -1 iv infused over 45 sec. Insertion of the LMA was attempted 150 sec after the beginning of the induction sequence. Insertion conditions were assessed using a six-category score according to resistance to mouth opening and insertion, swallowing, coughing and gagging, movement, and laryngospasm. A probit analysis was performed to calculate the effective dose for insertion of the LMA in 95% of patients (efficient dose [ED] 95 ). The changes in heart rate (HR) and mean arterial blood pressure (MAP) in response to LMA insertion were recorded and compared as secondary outcome variables. Results The ED 95 of remifentanil was 1.32 (95% confidence interval [CI] 0.99-2.46) lgÁkg -1 . Changes in heart rate and mean arterial pressure were modest and similar over time across groups, with maximum decreases in heart rate and mean arterial pressure \ 30% each during induction of anesthesia. Conclusions The required dose of remifentanil is 1.32 (95% CI 0.99-2.46) lgÁkg -1 to achieve excellent LMA insertion conditions in 95% of patients when co-administered with propofol 2.5 mgÁkg -1 in healthy premedicated female patients undergoing elective ambulatory surgery. RésuméObjectif L'objectif de cette e´tude de dose-re´ponse e´tait de de´terminer la dose optimale de re´mifentanil lors de l'administration conjointe de propofol 2,5 mgÁkg -1 iv afin d'obtenir des conditions excellentes pour l'insertion d'un masque larynge´(LMAÒ) chez 95 % de patientes adultes. Méthode Soixante-huit patientes adultes ASA I et II pre´me´dique´es et ne´cessitant une anesthe´sie pour une chirurgie ambulatoire ont e´te´randomise´es en quatre groupes selon la dose de re´mifentanil (0,25, 0,5, 1 ou 2 lgÁkg -1 ). L'induction de l'anesthe´sie a e´te´re´alise´e avec l'une des quatre doses de re´mifentanil en aveugle perfuse´e sur 60 secondes, administre´e simultane´ment a`du propofol 2,5 mgÁkg -1 iv perfuse´sur 45 secondes. L'insertion du Support was provided solely by institutional sources.