1/8/2017 Endotrachealintubationwithoutmusclerelaxantsinchildrenusingremifentanilandpropofol:Comparativestudy

SaudiJAnaesth.2015OctDec9(4):409412. PMCID:PMC4610085
doi:10.4103/1658354X.159465

Endotrachealintubationwithoutmusclerelaxantsinchildrenusing
remifentanilandpropofol:Comparativestudy
FreshtehNaziri,HakimehAlerezaAmiri,MozaffarRabiee,NadiaBanihashem,FarhadMohammadNejad,ZibaShirkhani,and
SedighehSolimanian
DepartmentofAnesthesiology,BabolUniversityofMedicalSciences,Babol,Mazandaran,Iran
Addressforcorrespondence:Dr.HakimehAlerezaAmiri,DepartmentofAnesthesiology,AyatollahRouhaniHospital,BabolUniversityofMedical
Sciences,Babol,Mazandaran,Iran.Email:halereza@yahoo.com

Copyright:SaudiJournalofAnaesthesia

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNonCommercialShareAlike3.0License,whichallows
otherstoremix,tweak,andbuildupontheworknoncommercially,aslongastheauthoriscreditedandthenewcreationsarelicensedundertheidentical
terms.

Abstract Goto:

Introduction:
Endotrachealintubationisessentialduringgeneralanesthesiaandmusclerelaxantdrugsprovideidealconditions
forthispurpose.Theobjectiveofthisstudywastoevaluatetheintubatingconditionofremifentanilcombinedwith
propofolwithoutmusclerelaxant.

MaterialsandMethods:
Inthisprospectiverandomizedstudy,60childrenaged312years,AmericanSocietyofAnesthesiologistsphysical
statusIandIIwereincluded.Allthechildrenwerepremedicatedwith0.05mg/kgmidazolamand1.5mg/kg
lidocaine5minbeforetheinductionofanesthesiawith3mg/kgpropofol.Then,theywereallocatedrandomlyto
receiveeither2g/kgremifentanil(groupR)or1.5mg/kgsuccinylcholine(groupS).Trachealintubationwas
attempted90saftertheadministrationofpropofol.ThequalityofintubationwasassessedbyusingCopenhagen
scorebasedonjawrelaxation,easeoflaryngoscopy,positionofvocalcord,coughingandlimbmovement.Heart
rateandbloodpressurewererecordedbeforeandafterinduction,and1,3,5minafterintubation.

Results:
Therewasnosignificantdifferenceinintubatingconditionbetweenthetwogroups(P=0.11).Intubationcondition
wasexcellentin26of30(86.7%)patientsinthegroupRcomparedwith30(100%)patientsinthegroupS.We
observedsignificantdifferenceinheartrateandsystolicbloodpressureovertimebetweentwogroups(P=0.02,P
=0.03respectively).Afterintubation,wehadhigherheartrateandsystolicbloodpressurewithasignificant
differenceingroupScomparedwithgroupR(P=0.006,P=0.018).Noneofthechildrenhadachestrigidity,
laryngospasm,andhypoxia.

Conclusions:
Inpremedicatedchildren,propofolremifentanilcombinationprovidesadequateconditionsfortrachealintubation
thatiscomparablewithsuccinylcholine.Hemodynamicresponsetolaryngoscopyandtrachealintubationwas
controlledbetteringroupR.

Keywords:Endotrachealintubationcondition,propofol,remifentanil,succinylcholine

INTRODUCTION Goto:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610085/ 1/5
1/8/2017 Endotrachealintubationwithoutmusclerelaxantsinchildrenusingremifentanilandpropofol:Comparativestudy

Neuromuscularrelaxantsprovideoptimalconditionsforlaryngoscopyandtrachealintubationafterinductionof
generalanesthesia.Duetorapidonsetandshortdurationofsuccinylcholine,itisanappropriatemusclerelaxant
thatiscurrentlyavailable.However,duetotheriskofsomecomplications,suchasrhabdomyolysisand
hyperkalemiaaswellastheriskformasseterspasmandmalignanthyperthermia,itissuggestedthat
succinylcholineshouldnotbeusedroutinelyinchildren.[1]Forshortsurgicalprocedures,thattrachealintubationis
necessarytoprotecttheairway,residualweaknessduetotheuseofmusclerelaxantcouldinterferewithtimely
recovery.Recentstudieshaveshownthattrachealintubationcanbedonesuccessfullyinapatientwithnormal
anatomyoftheairwaywithhypnoticsandshortactingopioidssuchasalfentanilorremifentanilwithouttheneed
formusclerelaxants.[2,3]Highdosesofalfentanil(2550g/kgintravenous[IV]weakenhemodynamicresponse
tolaryngoscopyandintubation,butleadtodelayinspontaneousbreathingandrecoveryinashorttimesurgical
procedures.Remifentanilhassimilaronseteffectasalfentanil(12min).Remifentanilisnotdosedependent
becausehydrolysisbybloodesteraseandhasashorthalflifeandrapidrecovery.[4]Inthestudyperformedby
Bouvetetal.,itwasrevealedthattheeffectivedoseofremifentanil,ED50andED90,forintubationwas1.8g/kg,
4.0g/kgrespectively.However,thehigherdosewasassociatedwithamaximumdecreaseinheartrateandmean
arterialpressure.[5]Studiesalsoshowedthatpropofolcomparedwiththiopentaloretomidateprovidesbetter
conditionfortrachealintubation.[6]Wehypothesizedthat,thecombinationof3mg/kgpropofoland2g/kg
remifentanilmayprovidegoodconditionforlaryngoscopyandtrachealintubation.Hence,thisstudywas
scheduledbasedonacomparisonwithsuccinylcholineasstandardmusclerelaxantthatachievesoptimalconditions
forintubation.Hemodynamicresponsetolaryngoscopyandintubationwereassessedassecondaryobjectivesof
thisstudy.

MATERIALSANDMETHODS Goto:

Inaclinicaltrial,aftertheapprovalbyourInstitution'sEthicsCommitteeandobtainingwritteninformedconsentof
theparentspatient,60childrenaged312yearsaccordingtoAmericanSocietyofAnesthesiologistsphysicalstatus
IandIIwhowerecandidatesforelectivesurgeryrequiringoraltrachealintubationwereenrolled.Childrenwitha
historyofcolds,cardiopulmonarydisease,neuromusculardiseasesandotherunderlyingsystemicdiseaseswere
excluded.Patient'sairwaywasevaluatedbasedonMallampatitest.[7]Childrenwithdifficultintubationwere
excluded.Afterenteringtheoperatingroom,monitoringofbloodpressure,electrocardiogramandpulseoximetry
werestarted.Afterthestartofinfusionfluids(10ml/kg/h),0.05mg/kgmidazolam,1.5mg/kglidocainewere
administeredtobothgroupsofpatients.5minafterpremedication,inductionofanesthesiawasappliedwith3
mg/kgPropofolinbothgroups.ThepatientswererandomlyallocatedintotwogroupsgroupRreceived2g/kg
remifentanilandgroupSreceived1.5mg/kgsuccinylcholine.90safteradministrationofpropofol,laryngoscopy
withMillerbladeandintubationwasperformedusingapropercuffedtrachealtube.Thepatient'slungwas
ventilatedbeforeintubationviafacemaskwithnitrousoxide50%inoxygen50%.Thequalityofintubationwere
assessedbyusingCopenhagenscorebasedonjawrelaxation,easeoflaryngoscopy,positionofvocalcord,
coughingandlimbmovement[Table1].[8]Finally,intubatingconditionsweregradedasexcellent,allresponsesare
excellentgood,allresponsesareexcellentorgoodpoor,thepresenceofoneormorepoorresponse.Excellentand
goodintubationconditionsareconsideredasclinicallyacceptableintubationcondition.Bloodpressureandheart
rateweremeasuredandrecordedbeforetheinductionofanesthesiaasabaseline,afterinductionandat1,3and5
minafterintubation.

Table1
Intubatingscoringsystem

Statisticalanalysis
Thesamplesizewasdetermined30patientsaccordingtoBatraetal.,studywithalpha0.05andpowerof80%.[9]
TtestandChisquarewereusedforanalysisofthepatientscharacteristics.ChisquareandFisher'sexacttestwas
usedtocompareintubationconditions.Ttestandrepeatedmeasureswasusedforanalysisofhemodynamicdata.P
<0.05wasconsideredasstatisticallysignificant.Inthisresearch,dataanalysissoftwareSPSS18wasused.

RESULTS Goto:

Sixtychildrenwereenrolledintotal(30childrenineachgroup).Averageweight,ageandgenderweresimilar
betweentwogroups[Table2].Maskventilationwascarriedoutwitheaseinchildren.Noneofthechildrenhada

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610085/ 2/5
1/8/2017 Endotrachealintubationwithoutmusclerelaxantsinchildrenusingremifentanilandpropofol:Comparativestudy

chestrigidity,laryngospasmandhypoxia.Trachealintubationwasmadeinbothgroupsatthefirstattemptwithout
anyintervention.Theintubatingconditionswereexcellentin86.7%ingroupRascomparedto100%ofthe
patientsingroupS.However,notconsideringthereactiontoendotrachealintubation,thequalityofintubationin
groupRwas100%anditwasgreat.Jawwasrelaxed,andlaryngoscopywasdoneeasilyinallofthepatientsin
groupRandvocalcordwasopenduringlaryngoscopy.Only4patientshadcoughingandmildlimbmovement
afterintubation.Thereweresignificantdifferenceinsystolicbloodpressureandheartrateovertimebetweentwo
groups(P=0.03,P=0.02,respectively)[Figures1and2].IngroupR,valuesofheartrateandsystolicblood
pressureshowedasignificantdecreaseafteradministrationofinductiondrugscomparedtobaselinevalues(P=
0.012,P=0.000,respectively).Afterintubation,wehadhigherheartratewithsignificantdifferenceingroupS
comparedtogroupR(P=0.04).Therewasnointerventionbecauseofchangesinheartrateandbloodpressurein
bothgroups.

Table2
Patientcharacteristics,Valuesaremean(SD),number

Figure1
Meansystolicbloodpressurebaselinevalue,beforeintubation,after
intubation1min,3min,5min

Figure2
Heartratebaselinevalue,beforeintubation,afterintubation1min,3min,5
min

DISCUSSION Goto:

Theresultsofourstudyshowedthat,theadministrationof3mg/kgpropofolcombinedwith2g/kgremifentanil
providedgoodandexcellentintubationconditionscomparedwithsuccinylcholineinhealthy,premedicated
children.Tahaetal.,[10]showedthatpropofolispreferredoverotherIVanestheticagentsfortrachealintubations
withoutmusclerelaxantduetofurtherweakerlaryngealreflexesandbetterjawrelaxation.Analogoustoourstudy
Guptaetal.,[11]reportedthat,3mg/kgpropofolprovidesacceptableintubatingconditionsin80%patients.They
usedcombinationofpropofoland3g/kgfentanyl.InthestudybyBatraetal.,[9]2g/kgremifentaniland3
mg/kgpropofolprovidedacceptableintubatingconditionsin50%patients.Theyhadacceptableintubating
conditionsin90%patientafterincreasingthedoseofremifentanilto3g/kg.Itseemsthat,thedifferenceinresults
betweenstudiesisduetothedifferencesinpremedication.Inourstudy,weusedmidazolamandlidocaineas
premedication.Lidocainereducestheneedforanestheticdrugsduetoanalgesicfunction(antinociceptive)and
suppressingthecoughreflex.[12,13]Gulhasetal.,[14]concludedthatremifentanilwithoutmusclerelaxants
providessimilarintubatingconditionsassuccinylcholine.Furthermore,theyassertedthatremifentanilissuperiorto
succinylcholinewithregardtohemodynamicstabilityandrecoveryduration.Morganetal.,[15]showedthatthe
administrationof1.25g/kgremifentanilcombinedwith4mg/kgpropofolprovidesgoodtoexcellentintubating
conditionsin67%patients.Alexanderetal.,[16]concludedthat2g/kgremifentanilafteradministrationof2
mg/kgpropofolwillnotproduceintubatingconditionsasgoodasthoseobtainedwithalfentanil50g/kgor
succinylcholine1mg/kg.Thedifferencebetweentheresultsofourstudywiththeirsmaybebecauseofthe
differentagegroups(childrenvs.adults)andalowerdoseofpropofol(2mgkg).Inourstudy,inordertoavoid
bradycardiaandhypotensionwechoseadoseofremifentanilequalsto2g/kg.Thehemodynamicresponseto
laryngoscopyandtrachealintubationwasbluntedintheremifentanilgroupcomparedwithsuccinylcholinegroup.
Nopatientwastreatedforbradycardiaorhypotensioninourstudy.Hannaetal.,[17]concludedthat,the
combinationofpropofolremifentanilisabletocontrolthehemodynamicstressresponsetolaryngoscopyand
intubation.Inourstudy,thelungsofallpatientswereeasilyventilatedviamask.Nopatientexhibitedsignsof
opioidinducedmuscularrigiditysuchasstiffchest.Theabsenceofmuscularrigidityinourpatientsmightbedueto
usingrelativelylowdoseofremifentanilandpretreatmentwithmidazolam.Subanestheticdosesofmidazolam
prevent,attenuate,orsuccessfullytreattherigidity.[4]Weconcludedthatthecombinationofpropofoland
remifentanilcanbeusedeffectivelyinpremedicatedchildrenforendotrachealintubation,whentheuseofmuscle
relaxantsisnotindicated.

Footnotes Goto:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610085/ 3/5
1/8/2017 Endotrachealintubationwithoutmusclerelaxantsinchildrenusingremifentanilandpropofol:Comparativestudy

SourceofSupport:Nil

ConflictofInterest:Nonedeclared.

REFERENCES Goto:

1.CotCJ.Pediatricanesthesia.In:MillerR,editor.Miller'sAnesthesia.7thed.Philadelphia:Churchill
LivingstoneCo2010.pp.255997.

2.KlemolaUM,MennanderS,SaarnivaaraL.Trachealintubationwithouttheuseofmusclerelaxants:
Remifentaniloralfentanilincombinationwithpropofol.ActaAnaesthesiolScand.200044:4659.[PubMed]

3.JabbourKhourySI,DabbousAS,RizkLB,AbouJaladNM,BartelmaosTE,ElKhatibMF,etal.A
combinationofalfentanillidocainepropofolprovidesbetterintubatingconditionsthanfentanyllidocainepropofol
intheabsenceofmusclerelaxants.CanJAnesth.200350:11620.[PubMed]

4.FukudaK.Opioids.In:MillerR,editor.Miller'sAnesthesia.7thed.Philadelphia:ChurchillLivingstoneCo
2010.pp.769824.

5.BouvetL,StoianA,RimmeleT,AllaouchicheB,ChassardD,BoselliE.Optimalremifentanildosagefor
providingexcellentintubatingconditionswhencoadministeredwithasinglestandarddoseofpropofol.
Anesthesia.200964:71926.[PubMed]

6.ErhanE,UgurG,GunusenI,AlperI,OzyarB.Propofolnotthiopentaloretomidatewithremifentanil
providesadequateintubatingconditionsintheabsenceofneuromuscularblockade.CanJAnaesth.200350:108
15.[PubMed]

7.AdamusM,FritscherovaS,HrabalekL,GabrhelikT,ZapletalovaJ,JanoutV.Mallampatitestasapredictorof
laryngoscopicview.BiomedPapMedFacUnivPalackyOlomoucCzechRepub.2010154:33944.[PubMed]

8.VibyMogensenJ1,EngbaekJ,ErikssonLI,GramstadL,JensenE,JensenFS,etal.Goodclinicalresearch
practice(GCRP)inpharmacodynamicstudiesofneuromuscularblockingagents.ActaAnaesthesiolScand.
199640:5974.[PubMed]

9.BatraYK,AlQattanAR,AliSS,QureshiMI,KuriakoseD,MigahedA.Assessmentoftrachealintubating
conditionsinchildrenusingremifentanilandpropofolwithoutmusclerelaxant.PaediatrAnaesth.200414:4526.
[PubMed]

10.TahaS,SiddikSayyidS,AlameddineM,WakimC,DahabraC,MoussaA,etal.Propofolissuperiorto
thiopentalforintubationwithoutmusclerelaxants.CanJAnaesth.200552:24953.[PubMed]

11.GuptaA,KaurR,MalhotraR,KaleS.Comparativeevaluationofdifferentdosesofpropofolprecededby
fentanylonintubatingconditionsandpressorresponseduringtrachealintubationwithoutmusclerelaxants.Paediatr
Anaesth.200616:399405.[PubMed]

12.HansGA,LauwickSM,KabaA,BonhommeV,StruysMM,HansPC,etal.Intravenouslidocaineinfusion
reducesbispectralindexguidedrequirementsofpropofolonlyduringsurgicalstimulation.BrJAnaesth.
2010105:4719.[PubMed]

13.AltermattFR,BugedoDA,DelfinoAE,SolariS,GuerraI,MuozHR,etal.Evaluationoftheeffectof
intravenouslidocaineonpropofolrequirementsduringtotalintravenousAnesthesiaasmeasuredbybispectral
index.BrJAnaesth.2012108:97983.[PubMed]

14.GulhasN,TopalS,ErdoganKayhanG,YucelA,BegecZ,YologluS,etal.Remifentanilwithoutmuscle
relaxantsforintubationinmicrolaryngoscopy:Adoubleblindrandomisedclinicaltrial.EurRevMedPharmacol
Sci.201317:196773.[PubMed]

15.MorganJM,BarkerI,PeacockJE,EissaA.Acomparisonofintubatingconditionsinchildrenfollowing
inductionofAnesthesiawithpropofolandsuxamethoniumorpropofolandremifentanil.Anesthesia.200762:135
9.[PubMed]

16.AlexanderR,BoothJ,OlufolabiAJ,ElMoalemHE,GlassPS.Comparisonofremifentanilwithalfentanilor
suxamethoniumfollowingpropofolAnesthesiafortrachealintubation.Anesthesia.199954:10326.[PubMed]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610085/ 4/5
1/8/2017 Endotrachealintubationwithoutmusclerelaxantsinchildrenusingremifentanilandpropofol:Comparativestudy

17.HannaSF,AhmadF,PappasAL,MikatStevensM,JellishWS,KleinmanB,etal.Theeffectof
propofol/remifentanilrapidinductiontechniquewithoutmusclerelaxantsonintraocularpressure.JClinAnesth.
201022:43742.[PubMed]

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