Skip to main content
SpringerLink
Log in

Comparison of intubating conditions after induction with propofol and remifentanil or sufentanil

Randomized controlled REMIDENT trial for surgical tooth extraction

Vergleich der Intubationsbedingungen nach Induktion mit Propofol und Remifentanil oder Sufentanil

Randomisierte kontrollierte REMIDENT-Studie bei chirurgischer Zahnextraktion

  • Originalien
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Abstract

Purpose

The aim of this study was to compare tracheal intubation conditions after induction of anesthesia with a bolus of propofol-sufentanil or propofol-remifentanil and a rapid induction technique.

Material and methods

A total of 70 patients (American Society of Anesthesiologists (ASA) classification I‑II) undergoing outpatient surgery under general anesthesia with intubation for tooth extraction were randomly assigned to two groups in this double-blind study. Patients received either a bolus of remifentanil (3 μg/kg) or sufentanil (0.3 μg/kg) together with 2.5 mg/kg propofol for intubation. The primary outcome was the percentage of excellent intubation conditions and the secondary outcomes were the percentage of patients with a decrease of over 20% in mean arterial pressure (MAP) or heart rate (HR), time to achieve spontaneous respiration, time between the end of surgery and extubation and time to achieve an Aldrete score of 10. VAS pain score was >3 or having laryngeal pain 15 min after arriving in the postanesthesia care unit (PACU) were also analyzed.

Results

Intubating conditions (perfect + good conditions) were significantly better with remifentanil than with sufentanil (88.5% vs. 68.6%; p = 0.01). When using remifentanil, the hemodynamic conditions were good. Using remifentanil did not significantly increase the pain score or the laryngeal pain in the recovery room. This was confirmed by no significant differences between the groups for morphine consumption. Remifentanil significantly decreased the time to achieve an Aldrete score of 10.

Conclusion

When intubation without muscle relaxants is required, intubating conditions are much better when a remifentanil bolus is used compared to a sufentanil bolus. The remifentanil/propofol rapid induction technique is a valuable technique to quickly intubate and achieve good conditions.

Zusammenfassung

Zweck

Ziel dieser Studie war es, die Bedingungen der Trachealintubation nach Narkoseeinleitung mit einem Bolus Propofol-Sufentanil oder Propofol-Remifentanil und einer schnellen Induktionstechnik zu vergleichen.

Material und Methoden

In dieser Doppelblindstudie wurden insgesamt 70 Patienten (American Society of Anesthesiologists(ASA)-Klassifikation I–II), bei denen ambulant unter Vollnarkose mit Intubation eine Operation zur Zahnextraktion durchgeführt wurde, in 2 Gruppen randomisiert. Die Patienten erhielten entweder einen Bolus Remifentanil (3 μg/kg) oder Sufentanil (0,3 μg/kg), zusammen mit 2,5 mg/kg Propofol zur Intubation. Das primäre Ergebnis war der Prozentsatz ausgezeichneter Intubationsbedingungen, und die sekundären Ergebnisse waren der prozentuale Anteil der Patienten mit einer Senkung des mittleren arteriellen Drucks (MAP) oder der Herzfrequenz (HR) um mehr als 20 %, die Zeit bis zum Erreichen der Spontanatmung, die Zeit zwischen dem Ende der Operation und der Extubation sowie die Zeit bis zum Erreichen eines Aldrete-Scores von 10. Der prozentuale Anteil der Patienten mit einem Schmerzscore >3 oder mit Kehlkopfschmerzen 15 min nach Ankunft auf der „postanesthesia care unit“ (PACU) wurde ebenfalls analysiert.

Ergebnisse

Die Intubationsbedingungen waren mit Remifentanil signifikant besser als mit Sufentanil (51,4 % vs. 20 %; p = 0,0064). Bei der Verwendung von Remifentanil waren die hämodynamischen Bedingungen gut. Die Verwendung von Remifentanil führte zu keiner signifikanten Erhöhung des Schmerzscores oder der Kehlkopfschmerzen im Aufwachraum. Dies wurde dadurch bestätigt, dass es keine signifikanten Unterschiede in den Gruppen für die Morphineinnahme gab. Remifentanil verkürzte die Zeit bis zum Erreichen eines Aldrete-Scores von 10 signifikant.

Schlussfolgerung

Wenn eine Intubation ohne Muskelrelaxanzien erforderlich ist, sind die Intubationsbedingungen bei Verwendung eines Remifentanil-Bolus wesentlich besser als bei Verwendung eines Sufentanil-Bolus. Die Methode der schnellen Induktion durch Remifentanil/Propofol ist eine wertvolle Technik, mit der eine schnelle Intubation möglich ist und gute Bedingungen erreicht werden können.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

HR:

Heart rate

IDS:

Intubation difficulty scale

IV:

Intravenous

MAP:

Mean arterial pressure

PACU:

Post anesthesia care unit

SpO2 :

Oxygen saturation

VAS:

Visual analog scale

References

  1. Baillard C, Adnet F, Borron SW et al (2005) Tracheal intubation in routine practice with and without muscular relaxation: an observational study. Eur J Anaesthesiol 22:672–677

    Article  CAS  Google Scholar 

  2. Heerdt PM, Sunaga H, Savarese JJ (2015) Novel neuromuscular blocking drugs and antagonists. Curr Opin Anaesthesiol 28:403–410

    Article  CAS  Google Scholar 

  3. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM (2016) Nondepolarizing neuromuscular blocking agents, reversal, and risk of postoperative pneumonia. Anesthesiology 125:647–655

    Article  CAS  Google Scholar 

  4. Grosse-Sundrup M, Henneman JP, Sandberg WS et al (2012) Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 345:e6329

    Article  Google Scholar 

  5. Kirmeier E, Eriksson LI, Lewald H et al (2019) Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med 7(2):129–140. https://doi.org/10.1016/S2213-2600(18)30294-7

    Article  PubMed  Google Scholar 

  6. Combes X, Andriamifidy L, Dufresne E et al (2007) Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth 99:276–281

    Article  CAS  Google Scholar 

  7. Laxenaire MC, Auroy Y, Clergue F, Péquignot F, Jougla E, Lienhart A (1998) Organization and techniques of anesthesia. Ann Fr Anesth Reanim 17:1317–1323

    Article  CAS  Google Scholar 

  8. Alexander R, Olufolabi AJ, Booth J, El-Moalem HE, Glass PS (1999) Dosing study of remifentanil and propofol for tracheal intubation without the use of muscle relaxants. Anaesthesia 54:1037–1040

    Article  CAS  Google Scholar 

  9. Adamus M, Koutná J, Gabrhelík T, Zapletalová J (2008) Tracheal intubation without muscle relaxant—the impact of different sufentanil doses on the quality of intubating conditions: a prospective study. Cas Lek Cesk 147:96–101

    CAS  PubMed  Google Scholar 

  10. Minto CF, Schnider TW, Shafer SL (1997) Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology 86:24–33

    Article  CAS  Google Scholar 

  11. Alexander R, Booth J, Olufolabi AJ, El-Moalem HE, Glass PS (1999) Comparison of remifentanil with alfentanil or suxamethonium following propofol anaesthesia for tracheal intubation. Anaesthesia 54:1032–1036

    Article  CAS  Google Scholar 

  12. Demirkaya M, Kelsaka E, Sarihasan B, Bek Y, Üstün E (2012) The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without neuromuscular blockade. J Clin Anesth 24:392–397

    Article  CAS  Google Scholar 

  13. Bouvet L, Stoian A, Rimmelé T, Allaouchiche B, Chassard D, Boselli E (2009) Optimal remifentanil dosage for providing excellent intubating conditions when co-administered with a single standard dose of propofol. Anaesthesia 64:719–726

    Article  CAS  Google Scholar 

  14. Trabold F, Casetta M, Duranteau J et al (2004) Propofol and remifentanil for intubation without muscle relaxant: the effect of the order of injection. Acta Anaesthesiol Scand 48:35–39

    Article  CAS  Google Scholar 

  15. Hanna SF, Ahmad F, Pappas ALS et al (2010) The effect of propofol/remifentanil rapid-induction technique without muscle relaxants on intraocular pressure. J Clin Anesth 22:437–442

    Article  CAS  Google Scholar 

  16. Gulhas N, Topal S, Erdogan Kayhan G et al (2013) Remifentanil without muscle relaxants for intubation in microlaryngoscopy: a double blind randomised clinical trial. Eur Rev Med Pharmacol Sci 17:1967–1973

    CAS  PubMed  Google Scholar 

  17. Naziri F, Amiri HA, Rabiee M et al (2015) Endotracheal intubation without muscle relaxants in children using remifentanil and propofol: comparative study. Saudi J Anaesth 9:409–412

    Article  Google Scholar 

  18. Erhan E, Ugur G, Alper I, Gunusen I, Ozyar B (2003) Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Eur J Anaesthesiol 20:37–43

    Article  CAS  Google Scholar 

  19. Stevens JB, Wheatley L (1998) Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg 86:45–49

    CAS  PubMed  Google Scholar 

  20. Fuchs-Buder T, Claudius C, Skovgaard LT et al (2007) Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand p:789–808

    Article  Google Scholar 

  21. Adnet F, Borron SW, Racine SX et al (1997) The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 87:1290–1297

    Article  CAS  Google Scholar 

  22. Hanci V (2012) Tracheal intubation without use of muscle relaxants: comparison of remifentanil and alfentanil. Anesth Pain Med 1:210–211

    Article  Google Scholar 

  23. Scheller MS, Zornow MH, Saidman LJ (1992) Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil. Anesth Analg 75:788–793

    Article  CAS  Google Scholar 

  24. Jabbour-Khoury SI, Dabbous AS, Rizk LB et al (2003) A combination of alfentanil-lidocaine-propofol provides better intubating conditions than fentanyl-lidocaine-propofol in the absence of muscle relaxants. Can J Anaesth 50:116–120

    Article  Google Scholar 

  25. Klemola UM, Mennander S, Saarnivaara L (2000) Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in combination with propofol. Acta Anaesthesiol Scand 44:465–469

    Article  CAS  Google Scholar 

  26. Goo E‑K, Oh A‑Y, Cho S‑J, Seo K‑S, Jeon Y‑T (2012) Optimal remifentanil dosage for intubation without muscle relaxants in elderly patients. Drugs Aging 29:905–909

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors thank Leonie Smith for the English editing of this article.

Funding

Support was provided solely from institutional and department sources. CHU Toulouse supported this work.

Author contributions

Conceived and designed the experiments: CR, VM. Performed the experiments: CR, LB, FF, AD. Wrote the paper: JMC, AD, LB, CR, VM.

Author information

Authors and Affiliations

  1. Department of Anaesthesiology and Intensive Care, Toulouse University Hospital, Avenue Jean Poulhès, 31432, Toulouse, France

    A. Dolsan, L. Bruneteau, C. Roche, F. Ferré, F. Labaste, J.‑M. Conil &  V. Minville

  2. Laboratory of Medical and Clinical Pharmacology, Pharmacoepidemiology, Inserm U1027, Toulouse University, Faculty of Medicine, Toulouse, France

    A. Sommet

  3. INSERM, U1048, Université Paul Sabatier, Institute of Metabolic and Cardiovascular Diseases, I2MC, 31432, Toulouse, France

    V. Minville

Authors
  1. A. Dolsan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L. Bruneteau
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Roche
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. F. Ferré
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. F. Labaste
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. A. Sommet
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. J.‑M. Conil
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. V. Minville
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to V. Minville.

Ethics declarations

Conflict of interest

A. Dolsan, L. Bruneteau, C. Roche, F. Ferré, F. Labaste, A. Sommet, J.-M. Conil and V. Minville declare that they have no competing interests..

Ethical standards

All procedures performed in studies involving human participants or on human tissue were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the research ethics board (protocol number 09.001.03, favorable opinion of the CPP Sud-Ouest et Outre-Mer 1) and written informed consent was obtained from each patient. This trial was registered at ClinicalTrials.gov (NCT01910285 dated July 29, 2013)

Additional information

The authors A. Dolsan and L. Bruneteau contributed equally to the manuscript.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dolsan, A., Bruneteau, L., Roche, C. et al. Comparison of intubating conditions after induction with propofol and remifentanil or sufentanil. Anaesthesist 69, 262–269 (2020). https://doi.org/10.1007/s00101-020-00739-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-020-00739-0

Keywords

Schlüsselwörter

Search

Navigation