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Review paper

Conditions of endotracheal intubation with and without muscle relaxant in children

By
Nermina Rizvanović ,
Nermina Rizvanović
Contact Nermina Rizvanović

Department of Anesthesiology and Intensive Care, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

Senada Čaušević ,
Senada Čaušević

Department of Anesthesiology and Intensive Care, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

Adisa Šabanović
Adisa Šabanović

Department of Anesthesiology and Intensive Care, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

Abstract

Aim
To compare intubation conditions and hemodynamic response of two induction regimens, with or without muscle relaxant
using a combination of either fentanyl and propofol or propofol and suxamethonium.
Methods
A total of 80 children aged 4-12 years were enrolled in a prospective randomized double-blinded study. Children were randomly allocated in two equal groups. In group F induction was done with fentanyl and propofol, while propofol and suxamethonium were used in group S. Intubation conditions were assessed using Copenhagen Consensus Score (CCS), based on ease of laryngoscopy, position of vocal cords, degree of coughing, jaw relaxation and limb movements. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) were observed at preinduction, postinduction and postintubation at 1, 3 and 5 minute.
Results
Clinically acceptable CCS was found in 95% of patients in group F versus 100% in group S. Intubation conditions were
excellent in 85%, good in 10% and poor in 5% of patients in group F. In the group F, signifficantly lower SBP and MAP postinduction and postintubation at 1 and 3 minute, and lower DBP postinduction and postintubation at 1 minute (p<0.05) was found comparing to group S. In group S, significantly higher postinduction and postintubation HR at 1 minute was found comparing to group F (p<0.05).
Conclusion
Induction combination fentanyl-propofol provide acceptable intubation conditions comparable with suxamethonium
in children. This induction regimen ensures better hemodynamic stability associated with endotracheal intubation. It could be recommended for intubation when muscle relaxants are not indicated.

References

1.
Holzman R, Mancuso T, Polaner D. A Practical Approach to Pediatric Anesthesia. Wolters Kluwer; 2008.
2.
Burmester M, Mok Q. Randomized controlled trial comparing cisatracurium and vercuronium infusions in a paediatric intensive care unit. Intensive Care Med. 2005. p. 686–92.
3.
Ledowski T, ’dea O, Meyerkort B, Hegarty L, Von Ungern-Sternberg M, B. Postoperative residual neuromusular paralysis at an Australian tertiary children’s hospital. Anesthesiol Res Pract. 2015. p. 410248.
4.
Sneyd J, Sullivan O, E. Tracheal intubation without neuromuscular blocking anents: is there any point? Br J Anaesth. 2010. p. 535–7.
5.
Lerman J. Perioperative management of the paediatric patient with coexisting neuromuscular disease. Br J Anaesth. 2011. p. 79–89.
6.
Abdullayev R, Kucukebe O, Kaya R, Celik B, Kusderci H, Duran M, et al. Pseudocholinesterase enzyme deficiency in Adiyaman city area. Turk J Anaesthesiol Reanim. 2015. p. 381–6.
7.
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. p. 108–15.
8.
Rhona C, Mark C. Rapid sequence induction. Contin Educ Anaesth Crit Care Pain. 2005. p. 45–8.
9.
Meakin G. Role of muscle rekaxants in pediatric anesthesia. Curr Opin Anaesthesiol. 2007. p. 227–31.
10.
Dewhirst E, Tobias J, Martin D. Propofol and remifenttanil for rapid sequence intubation in a pediatric patient at risk for aspiration with elevated intracranial pressure. Pediatr Emerg Care. 2013. p. 1201.
11.
Rajan S, Gotluru P, Andews S, Paul J. Evaluation of endotracheal intubating conditions without the use of muscle relaxants following induction with propofol and sevorane in pediatric cleft lip and palate surgeries. J Anaesthesiol Clin Pharmacol. 2014. p. 360–5.
12.
Klemola U, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in combination with propofol. Acta Anaesthesiol Scand. 2000. p. 465–9.
13.
Fotopoulou G, Theocharis S, Vasileiou I, Kouskouni E, Xanthos T. Management of neuromuscular blocking agents: the use of remifentanil. Fundam Clin Pharmacol. 2012. p. 72–85.
14.
Channaiah V, Kurek N, Moses R, Chandra S. Attenuation of hemodynamic response to laryngoscopy and endotracheal intubation with pre induction IV fentanyl versus combination of IV fentanyl and sub lingual nitroglycerin spray. Med Arch. 2014. p. 339–44.
15.
Tarquinio K, Howell J, Montgomery V, Turner D, Hsing D, Parker M. Brown CA 3rd, Walls RM, Nadkarni VM, Nishisaki A. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015. p. 210–8.
16.
Raghavendra T, Yoganasasimha N, Radha M, Madhu R. A clinical study to compare the ease of intubation with propofol alone. IJMHS. 2013. p. 143–8.
17.
ASA physical sttus classification system. American Society of Anesthesiologist; 2014.
18.
Viby-Mogensen J, Engbaek J, Eriksson L. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents. Acta Anaesthesiol Scand. 1996. p. 59–74.
19.
Owczarek M, Bultowicz R, Kazmirczuk R, Sadaj-Owczarek K, Paciorek P, Jakubczyk M, et al. Is suxamethonium still useful for paediatric anaesthesia? Anesteziol Intens Ter. 2011. p. 181–5.
20.
Tran D, Newton E, Mount V, Lee J, Wells G, Perry J. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015.
21.
Narang S. Is it not time to stop use of suxamethonium chloride for rapid sequence intubation. SQU Med J. 2011. p. 524–6.
22.
Morton N. Tracheal intubation without neuromuscular blocking drugs in children. Paediatr Anaesth. 2009. p. 199–201.
23.
Keaveny J, Knell P. Intubation under induction doses of propofol. Anaesthesia. 1988. p. 80–1.
24.
Chidambaran V, Costandi A, Mello D’, A. Propofol: a review of its role in pediatric anesthesia and sedation. CNS Drugs. 2015. p. 543–63.
25.
Yazicioglu H, Muslu S, Yamak B, Erdemli O. Laryngeal mask airway insertion with remifentanil. Acta Anaesthesiol Belg. 2005. p. 171–6.
26.
Hassani V, Movassaghi G, Goodarzi V, Safari S. Comparison of fentanyl and fentanyl plus lidocaine on attenuation of hemodynamic responses to tracheal intubation in controlled hypertensive patients undergoing general anesthesia. Anesth Pain Med. 2013. p. 115–8.
27.
Aouad M, Vg YK, Mallat C, Esso J, Sidik-Sayyid S, Kaddoum R. The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials. Paediatr Anaesth. 2012. p. 616–26.
28.
Naziri F, Amiri H, Rabiee M, Banihashem N, Nejad F, Shirkhani Z, et al. Endotracheal intubation without muscle relaxants in children using remifentanil and propofol: Comparative study. Saudi J Anaesth. 2015. p. 409–12.
29.
Adamus M, Koutna J, Gabrhelik T, Zapletalova J. Tracheal intubation without muscle relaxant-the impact of different sufentanil doses on the quality of intubating conditions: a prospective study. Cas Lek Cesk. 2008. p. 96–101.
30.
Bharti N, Chari P, Kumar P. Effect sevoflurane versus propofol-based anesthesia on the hemodynamic response and recovery characteristics in patients undergoing microlaryngeal surgery. Saudi J Anaesth. 2012. p. 380–4.
31.
El Motlb E, Deeb E, A. Tracheal intubation for cesarean section without muscle relaxant: An alternative for rapid tracheal intubation with no adverse neonatal effect. Egypt J Anaesth. 2011. p. 13–7.
32.
Kaddoum R, Ahmed Z, Augustine D, Zestos A, M. Guidelines for elective pediatric fiberoptic intubation. J Vis Exp. 2011. p. 2364.
33.
Vlajković G, Sindelić R, Marinković D, Terzić M, Bumbasirević V. Endotracheal intubation without the use of muscle relaxants in patients with myasthenia gravis. Med Pregl. 2009. p. 412–6.
34.
Yushi U, Maiko S, Hideyuki H. Fentanyl attenuates the haemodynamic response to endotracheal intubation more than response to laryngoscopy. Anesth Analg. 2002. p. 233–7.
35.
Coruh B, Tonelli M, Park D. Fentanyl-induced chest wall rigidity. Chest. 2013. p. 1145–6.
36.
Gurulingappa A, Ma, Awati M, Adarsh S. Attenuation of cardiovascular responses to direct laryngoscopy and intubation-a comparative study between iv bolus fentanyl, lignocain and placebo. J Clin and Diagn Res. 2012. p. 1749–52.
37.
Gupta A, Kaur R, Malhotra R, Kale S. Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants. Paediatr Anaesth. 2006. p. 399–405.
38.
Gore M, Harnagale K. Evaluation of intubating conditions with varying doses of propofol without muscle relaxants. J Anaesthesiol Clin Pharmacol. 2011. p. 27–30.
39.
Caldvell C, Watterberg K. Effect of premedication regimen on infant pain and stress response to endotracheal intubation. J Perinatol. 2015. p. 415–8.
40.
Lesage S, Drolet P, Donati F, Racine S, Fortier L, Audy. Low -dose fentanyl-midazolam combination improves sevofluran induction in adults. Can J Anaesth. 2009. p. 733–9.
41.
Shaikh S, Bellagali V. Tracheal intubation without neuromuscular block in children. Indian J Anaesth. 2010. p. 29–34.
42.
Shah T. Tracheal intubation without neuromuscular block in. J Postgrad Med. 2004. p. 117–23.
43.
Lieutaud T, Billard V, Khalaf H, Debaene B. Muscle relaxation and increasing doses of propofol improve intubating conditions. Can J Anaesth. 2003. p. 121–6.
44.
Tsuda A, Yasumoto S, Akazawa T, Nakahara T. Tracheal intubation without muscle rekaxants using propofol and varying doses of fentanyl. Masui. 2001. p. 1129–32.
45.
Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert P, et al. Laryngeal morbidity and quality of tracheal intubation; a randomized controlled trial. Anaesthesiology. 2003. p. 1049–56.
46.
Trabold F, Casetta M, Duranteau J, Albaladejo P, Mazoit J, Samii K, et al. Propofol and remifentanil for intubation without muscle relaxant: the effect of the order of injection. Acta Anaesthesiol Scand. 2004. p. 35–9.
47.
Baillard C, Adnet F, Borron B, Racine S, S, Kaci A, et al. Samama CM. Tracheal intubation in routine practice with and without muscular relaxation: an observational study. Eur J Anesthesiol. 2005. p. 672–7.
48.
Bouvet L, Stoian A, Jacquot-Laperriere S, Allaouchiche B, Chassard D, Boselli E. Laryngeal injuries and intubating conditions with or without muscular relaxation: an equivalence study. Can J Anaesth. 2008. p. 674–84.
49.
Combes X, Andriamifidy L, Dufresne E, Suen P, Sauvat S, Scherrer E, et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper arway discomfort. Br J Anaesth. 2007. p. 276–81.
50.
Rezultati Klinički prihvatljiv CCS zabilježen je u 95% pacijenata u grupi F, a 100% u grupi S. Intubacijski uvjeti bili su odlični u 85%, dobri u 10% i loši u 5% pacijenata u grupi F. U grupi F zabilježen je statistički značajno niži SBP i MAP poslije indukcije i poslije intubacije u 1. i 3. minuti i niži DBP poslije indukcije i poslije intubacije u 1. minuti u odnosu na grupu S (p<0,05). U grupi S zabilježen je statistički značajno veći HR poslije indukcije i poslije intubacije u 1. minuti u odnosu na grupu F (p<0,05).

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