Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial

Thomas Mencke, Refa Maria Jacobs, Susann Machmueller, Martin Sauer, Christine Heidecke, Anja Kallert, Hans Wilhelm Pau, Gabriele Noeldge-Schomburg, Attila Ovari, Thomas Mencke, Refa Maria Jacobs, Susann Machmueller, Martin Sauer, Christine Heidecke, Anja Kallert, Hans Wilhelm Pau, Gabriele Noeldge-Schomburg, Attila Ovari

Abstract

Background: Tracheal intubation without muscle relaxants is usually performed with remifentanil and propofol or sevoflurane. Remifentanil 1.0 to 4.0 μg·kg(-1) and propofol 2.0-3.0 mg·kg(-1) or sevoflurane up to 8.0 Vol% provide acceptable, i.e. excellent or good intubating conditions. We hypothesized that sevoflurane 1.0 MAC would provide acceptable intubating conditions when combined with propofol and remifentanil.

Methods: Eighty-three patients to be intubated were randomised to two groups. The SEVO group received propofol 1.5 mg kg(-1), remifentanil 0.30 μg kg min(-1) and sevoflurane 1.0 MAC; the MR group received the same doses of propofol and remifentanil plus rocuronium 0.45 mg kg(-1). We evaluated intubation and extubation conditions, mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS). The vocal cords were examined for injury by videolaryngoscopy before and 24 hours after surgery.

Results: ACCEPTABLE INTUBATING CONDITIONS WERE SEEN MORE FREQUENTLY WITH ROCURONIUM THAN WITH SEVOFLURANE: 97% versus 82%; p = 0.03; the subscore for vocal cords was comparable: 100% versus 98%. MAP before intubation decreased significantly compared with the MAP at baseline to the same extent in both groups; ephedrine IV was given in 15 (SEVO) versus 16 (MR) patients; p = 0.93. BIS at tracheal intubation was 27 (13-65) in the SEVO group, 29 (14-62) in the MR group; p = 0.07. Vocal cord injuries (oedema, haematoma) were similar: 4 patients in each group.

Conclusions: Overall intubating conditions were better when rocuronium was used; the subscore for vocal cords was comparable. The incidence of side effects was the same in the two groups.

Trial registration: ClinicalTrials.Gov: NCT 01591031.

Trial registration: ClinicalTrials.gov NCT01591031.

Keywords: Intubating conditions; Laryngeal injury; Neuromuscular block; Propofol; Remifentanil; Sevoflurane.

Figures

Figure 1
Figure 1
Flow chart of patient distribution.
Figure 2
Figure 2
Patients (%) with excellent (black bars), good (grey bars) and poor intubation conditions (white bars). *p = 0.06 MR group versus SEVO group overall; p = 0.029 clinically acceptable (excellent and good) conditions. SEVO group = Induction of anaesthesia with sevoflurane. MR group = Induction of anaesthesia with rocuronium.
Figure 3
Figure 3
Patients (%) with excellent (black bars), good (grey bars) and poor intubation conditions (white bars) for subscore laryngoscopy. *p = 0.06 MR group versus SEVO group. SEVO group = Induction of anaesthesia with sevoflurane. MR group = Induction of anaesthesia with rocuronium.
Figure 4
Figure 4
Patients (%) with excellent (black bars), good (grey bars) and poor intubation conditions (white bars) for subscore vocal cords. MR group versus SEVO group: p = 0.59. SEVO group = Induction of anaesthesia with sevoflurane. MR group = Induction of anaesthesia with rocuronium.
Figure 5
Figure 5
Patients (%) with excellent (black bars), good (grey bars) and poor intubation conditions (white bars) for subscore reaction to tube insertion or cuff inflation. *p = 0.02 MR group versus SEVO group. SEVO group = Induction of anaesthesia with sevoflurane. MR group = Induction of anaesthesia with rocuronium.

References

    1. Bouvet L, Stoian A, Rimmelé T, Allaouchiche B, Chassard D, Boselli E. Optimal remifentanil dosage for providing excellent intubating conditions when co-administered with a single standard dose of propofol. Anaesthesia. 2009;64:719–726. doi: 10.1111/j.1365-2044.2009.05916.x.
    1. Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg. 1998;86:45–49.
    1. Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, Fuchs-Buder T. Laryngeal morbidity and quality of tracheal intubation. A randomized controlled trial. Anesthesiology. 2003;98:1049–1056. doi: 10.1097/00000542-200305000-00005.
    1. Erhan E, Ugur G, Alper I, Gunusen I, Ozyar B. Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Eur J Anaesthesiol. 2003;20:37–43. doi: 10.1097/00003643-200301000-00007.
    1. Baillard C, Adnet F, Borron SW, Racine SX, Ait Kaci F, Fournier JL, Larmignat P, Cupa M, Samama CM. Tracheal intubation in routine practice with and without muscular relaxation: an observational study. Eur J Anaesthesiol. 2005;22:672–677. doi: 10.1017/S0265021505001110.
    1. Erhan E, Ugur G, Gunusen I, Alper I, Ozyar B. Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade. Can J Anaesth. 2003;50:108–115. doi: 10.1007/BF03017840.
    1. Cagiran E, Eyigor C, Balcioglu T, Uyar M. Tracheal intubation in intellectually disabled patients: clinical usefulness of remifentanil and sevoflurane without a muscle relaxant. J Int Med Res. 2013;41:1632–1638. doi: 10.1177/0300060513497561.
    1. Goo EK, Oh AY, Cho SJ, Seo KS, Jeon YT. Optimal remifentanil dosage for intubation without muscle relaxants in elderly patients. Drugs Aging. 2012;29:905–909. doi: 10.1007/s40266-012-0019-y.
    1. Schneider G, Elidrissi C, Sebel PS. Bispectral index-guided administration of anaesthesia: comparison between remifentanil/propofol and remifentanil/isoflurane. Eur J Anaesthesiol. 2003;20:624–630. doi: 10.1097/00003643-200308000-00006.
    1. Fuchs-Buder T, Claudius C, Skovgaard LT, Eriksson LI, Mirakhur RK, Viby-Mogensen J. 8th International Neuromuscular Meeting: Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007;51:789–808. doi: 10.1111/j.1399-6576.2007.01352.x.
    1. Urbaniak GC, Plous S. Research Randomizer. 2012. URL: .
    1. Woo P, Colton R, Casper J, Brewer D. Diagnostic value of stroboscopic examination in hoarse patients. J Voice. 1991;5:231–238. doi: 10.1016/S0892-1997(05)80191-2.
    1. McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia. 1999;54:444–453. doi: 10.1046/j.1365-2044.1999.00780.x.
    1. Eikaas H, Raeder J. Total intravenous anaesthesia techniques for ambulatory surgery. Curr Opin Anaesthesiol. 2009;22:725–729. doi: 10.1097/ACO.0b013e3283310f6b.
    1. Fink H, Geldner G, Fuchs-Buder T, Hofmockel R, Ulm K, Wallek B, Blobner M. Muscle relaxants in Germany 2005: a comparison of application customs in hospitals and private practices. Anaesthesist. 2006;55:668–678. doi: 10.1007/s00101-006-1015-6.
    1. Mencke T, Noeldge-Schomburg G. Laryngeal morbidity after use of the laryngeal mask airway. Acta Anaesthesiol Scand. 2010;54:127–128. doi: 10.1111/j.1399-6576.2009.02159.x.
    1. Stefanutto TB, Feiner J, Krombach J, Brown R, Caldwell JE. Hemoglobin desaturation after propofol/remifentanil-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesth Analg. 2012;114:980–986. doi: 10.1213/ANE.0b013e31824e5bc4.
    1. Woods AW, Allam S. Tracheal intubation without the use of neuromuscular blocking agents. Br J Anaesth. 2005;94:150–158. doi: 10.1093/bja/aei006.
    1. Combes X, Andriamifidy L, Dufresne E, Suen P, Sauvat S, Scherrer E, Feiss P, Marty J, Duvaldestin P. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007;99:276–281. doi: 10.1093/bja/aem147.
    1. Patel SS, Goa KL. Sevoflurane: a review of its pharmacodynamic and pharmacokinetic properties and its clinical use in general anaesthesia. Drugs. 1996;51:658–700. doi: 10.2165/00003495-199651040-00009.
    1. Kimura T, Watanabe S, Asakura N, Inomata S, Okada M, Taguchi M. Determination of end-tidal sevoflurane concentration for tracheal intubation and minimum alveolar anesthetic concentration in adults. Anesth Analg. 1994;79:378–381.
    1. Iamaroon A, Pitimana-aree S, Prechawai C, Anusit J, Somcharoen K, Chaiyaroj O. Endotracheal intubation with thiopental/succinylcholine or sevoflurane-nitrous oxide anesthesia in adults: a comparative study. Anesth Analg. 2001;92:523–528. doi: 10.1213/00000539-200102000-00045.
    1. Sparr HJ, Giesinger S, Ulmer H, Hollenstein-Zacke M, Luger TJ. Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid-sequence induction using thiopentone and suxamethonium. Br J Anaesth. 1996;77:339–342. doi: 10.1093/bja/77.3.339.
    1. Cros AM, Lopez C, Kandel T, Sztark F. Determination of sevoflurane alveolar concentration for tracheal intubation with remifentanil, and no muscle relaxant. Anaesthesia. 2000;55:965–969. doi: 10.1046/j.1365-2044.2000.01538.x.
    1. Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Gätke MR, Wetterslev J. Danish Anaesthesia Database: Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103,812 consecutive adult patients recorded in the Danish Anaesthesia Database. Br J Anaesth. 2009;103:283–290. doi: 10.1093/bja/aep124.
    1. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011;66:163–167. doi: 10.1111/j.1365-2044.2010.06601.x.
    1. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110:891–897. doi: 10.1097/ALN.0b013e31819b5b87.
    1. Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F, Martin LD, Linton J, Epps JL, Fernandez-Bustamante A, Jameson LC, Tremper T, Tremper KK. Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee: incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119:1360–1369. doi: 10.1097/ALN.0000435832.39353.20.
    1. Bouvet L, Stoian A, Jacquot-Laperrière S, Allaouchiche B, Chassard D, Boselli E. Laryngeal injuries and intubating conditions with or without muscular relaxation: an equivalence study. Can J Anesth. 2008;55:674–684. doi: 10.1007/BF03017743.
    1. Benjamin B. In: Otolaryngology & Head & Neck Surgery. Cummings CW, Frederickson JM, editor. St. Louis: Mosby; 2001. Laryngeal trauma from intubation: endoscopic evaluation and classification; pp. 2013–2035.
    1. Peppard SB, Dickens JH. Laryngeal injury following short-term intubation. Ann Otol Rhinol Laryngol. 1983;92:327–330.
    1. Kambic V, Radsel Z. Intubation lesions of the larynx. Br J Anaesth. 1978;50:587–590. doi: 10.1093/bja/50.6.587.
    1. Mencke T, Echternach M, Plinkert PK, Johann U, Afan N, Rensing H, Noeldge-Schomburg G, Knoll H, Larsen R. Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg. 2006;102:306–312. doi: 10.1213/01.ANE.0000181290.37527.CE.
    1. González Obregón MP, Rivera Díaz RC, Ordóñez Molina JE, Rivera Diaz JS, Velasquez Ossa LF, Pineda Ibarra C, Serna Gutierrez J, Franco Botero V. Tracheal intubation quality under remifentanil-propofol with sevoflurane compared with remifentanil-propofol with rocuronium: a randomized double-blind clinical trial. Rev Esp Anestesiol Reanim. 2010;57:351–356. doi: 10.1016/S0034-9356(10)70247-4.
    1. Mendels EJ, Brunings JW, Hamaekers AE, Stokroos RJ, Kremer B, Baijens LW. Adverse laryngeal effects following short-term general anesthesia. Arch Otolaryngol Head Neck Surg. 2012;138:257–264. doi: 10.1001/archoto.2011.1427.
    1. Hamdan AL, Sibai A, Rameh C, Kanazeh G. Short-term effects of endotracheal intubation on voice. J Voice. 2007;21:762–768. doi: 10.1016/j.jvoice.2006.06.003.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner