Skip to main content

Tracheal intubation after induction of anesthesia in children with propofol — remifentanil or propofol-rocuronium

Abstract

Purpose: To compare the intubating conditions after remifentanil-propofol with those after propofol-rocuronium combination with the aim of determining the optimal dose of remifentanil.

Methods: In a randomized, double-blind study 80 healthy children aged three to nine years were assigned to one of four groups (n=20): 2 or 4 µg·kg−1 remifentanil (Re2 or Re4); 2 µg·kg−1 remifentanil and 0.2 mg·kg−1 rocuronium (Re2-Ro0.2); 0.4 mg·kg−1 rocuronium (Ro0.4). After atropine, remifentanil was injected over 30 sec followed by 3.5 mg·kg−1 propofol and rocuronium. After 60 sec, laryngoscopy and intubation were attempted. Intubating conditions were assessed as excellent, good or poor based on ease of ventilation, jaw relaxation, position of the vocal cords, and coughing to intubation.

Results: In all children intubation was successful. Overall intubating conditions were better (P<0.01), and the frequency of excellent conditions, 85%, was higher (P<0.01) in the Re4 group than in the Ro0.4 group. No child manifested signs of muscular rigidity. In the remifentanil groups, arterial pressure decreased 11–13% and heart rate 6–9% after anesthetic induction, and remained at that level throughout the study.

Conclusion: The best intubating conditions were produced by the combination of 4 µg·kg−1 remifentanil and 3.5 mg·kg−1 propofol. It provided excellent or good intubating conditions in all children without causing undue cardiovascular depression.

Résumé

Objectif: Comparer les conditions d’intubation après l’usage d’une combinaison de rémifentanil-propofol avec celles d’une combinaison de propofol-rocuronium dans le but de déterminer la dose optimale de rémifentanil.

Méthode: Lors d’une étude randomisée et à double insu, 80 enfants en bonne santé, de trois à neuf ans, ont été répartis en quatre groupes (n=20) et ont reçu: 2 ou 4 µg·kg−1 de rémifentanil (Ré2 ou Ré4); 2 µg·kg−1 de rémifentanil et 0,2 mg·kg−1 de rocuronium (Ré2-Ro0,2); 0,4 mg·kg−1 de rocuronium. Après l’administration d’atropine, le rémifentanil a été injecté pendant 30 s et a été suivi de 3,5 mg·kg−1 de propofol et de rocuronium. La laryngoscopie et l’intubation ont été tentées après 60 s. Les conditions d’intubation ont été évaluées comme excellentes, bonnes ou pavures selon la facilité de la ventilation, la relaxation de la mâchoire, la position des cordes vocales et la toux pendant l’intubation.

Résultats: L’intubation a été réussie chez tous les enfants. Les conditions générales d’intubation ont été meilleures (P<0,01), et la fréquence d’excellentes conditions, 85 %, plus élevée (P<0,01) dans le groupe Ré4 que dans le groupe Ro0,4. Aucun enfant n’a manifesté de signe de rigidité musculaire. Dans les groupes rémifentanil, la tension artérielle a baissé de 11–13% et la fréquence cardiaque de 6–9% après l’induction de l’anesthésie et sont demeurées à ce niveau tout au long de l’étude.

Conclusion: Les meilleures conditions d’intubation ont été réalisées avec la combinaison de 4 µg·kg−1 de rémifentanil et de 3,5 mg·kg−1 de propofol. L’intubation a été bonne ou excellente chez tous les enfants sans causer de dépression cardiovasculaire indue.

References

  1. Fisher DM. Neuromuscular blocking agents in paediatric anaesthesia. Br J Anaesth 1999; 83: 58–64.

    PubMed  CAS  Google Scholar 

  2. Saarnivaara L, Klemola U-M. Injection pain, intubating conditions and cardiovascular changes following induction of anaesthesia with propofol alone or in combination with alfentanil. Acta Anaesthesiol Scand 1991; 35: 19–23.

    PubMed  CAS  Google Scholar 

  3. Scheller MS, Zornow MH, Saidman LJ. Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil. Anesth Analg 1992; 75: 788–93.

    PubMed  Article  CAS  Google Scholar 

  4. Alexander R, Booth J, Olufolabi AJ, El-Moalem HE, Glass PS. Comparison of remifentanil with alfentanil or suxamethonium following propofol anaesthesia for tracheal intubation. Anaesthesia 1999; 54: 1032–6.

    PubMed  Article  CAS  Google Scholar 

  5. Hiller A, Klemola UM, Saarnivaara L. Tracheal intubation after induction of anaesthesia with propofol, alfentanil and lidocaine without neuromuscular blocking drugs in children. Acta Anaesthesiol Scand 1993; 37: 725–9.

    PubMed  CAS  Article  Google Scholar 

  6. McConaghy P, Bunting HE. Assessment of intubating conditions in children after induction with propofol and varying doses of alfentanil. Br J Anaesth 1994; 73: 596–9.

    PubMed  Article  CAS  Google Scholar 

  7. Rosow CE. An overview of remifentanil. Anesth Analg 1999; 89: S1–3.

    PubMed  Article  CAS  Google Scholar 

  8. Kapila A, Glass PSA, Jacobs JR, et al. Measured context-sensitive half-times of remifentanil and alfentanil. Anesthesiology 1995; 83: 968–75.

    PubMed  Article  CAS  Google Scholar 

  9. Egan TD, Minto CF, Herman DJ, Barr J, Muir KT, Shafer SL. Remifentanilversus alfentanil. Comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers. Anesthesiology 1996; 84: 821–33.

    PubMed  Article  CAS  Google Scholar 

  10. Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg 1998; 86: 45–9.

    PubMed  Article  CAS  Google Scholar 

  11. Alexander R, Olufolabi AJ, Booth J, El-Moalem HE, Glass PS. Dosing study of remifentanil and propofol for tracheal intubation without the use of muscle relaxants. Anaesthesia 1999; 54: 1037–40.

    PubMed  Article  CAS  Google Scholar 

  12. Robinson DN, O’Brien K, Kumar R, Morton NS. Tracheal intubation without neuromuscular blockade in children: a comparison of propofol combined either with alfentanil or remifentanil. Paediatr Anaesth 1998; 8: 467–71.

    PubMed  Article  CAS  Google Scholar 

  13. Barclay K, Eggers K, Asai T. Low-dose rocuronium improves conditions for tracheal intubation after induction of anaesthesia with propofol and alfentanil. Br J Anaesth 1997; 78: 92–4.

    PubMed  CAS  Google Scholar 

  14. Meistelman C, Plaud B, Donati F. Rocuronium (ORG 9426) neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis in humans. Can J Anaesth 1992; 39: 665–9.

    PubMed  CAS  Google Scholar 

  15. Wright PMC, Caldwell JE, Miller RD. Onset and duration of rocuronium and succinylcholine at the adductor pollicis and laryngeal adductur muscles in anesthetized humans. Anesthesiology 1994; 81: 1110–5.

    PubMed  Article  CAS  Google Scholar 

  16. Pollard BJ, Chetty MS, Wilson A, Healy TEJ. Intubation conditions and time-course of action of low-dose rocuronium bromide in day-case dental surgery. Eur J Anaesthesiol 1995; 12(Suppl 11): 81–3.

    Google Scholar 

  17. Woolf RL, Crawford MW, Choo SM. Dose-response of rocuronium bromide in children anesthetized with propofol. Anesthesiology 1997; 87: 1368–72.

    PubMed  Article  CAS  Google Scholar 

  18. Woelfel SK, Brandom BW, Cook DR, Sarner JB. Effects of bolus administration of ORG-9426 in children during nitrous oxide-halothane anesthesia. Anesthesiology 1992; 76: 939–42.

    PubMed  Article  CAS  Google Scholar 

  19. Hug CC Jr. Propofol requirements versus stimulus intensity (Editorial). Anesthesiology 1997; 87: 201–2.

    PubMed  Article  Google Scholar 

  20. Aun CST, Short SM, Leung DHY, Oh TE. Induction dose-response of propofol in unpremedicated children. Br J Anaesth 1992; 68: 64–7.

    PubMed  Article  CAS  Google Scholar 

  21. Murat I, Billard V, Vernois J, et al. Pharmacokinetics of propofol after a single dose in children aged 1–3 years with minor burns. Comparison of three data analysis approaches. Anesthesiology 1996; 84: 526–32.

    PubMed  Article  CAS  Google Scholar 

  22. Glass PSA, Hardman D, Kamiyama Y, et al. Preliminary pharmacokinetics and pharmacodynamics of an ultra-short-acting opioid: remifentanil (G187084B). Anesth Analg 1993; 77: 1031–40.

    PubMed  Article  CAS  Google Scholar 

  23. Glass PSA, Iselin-Chaves IA, Goodman D, Delong E, Hermann DJ. Determination of the potency of remifentanil compared with alfentanil using ventilatory depression as the measure of opioid effect. Anesthesiology 1999; 90: 1556–63.

    PubMed  Article  CAS  Google Scholar 

  24. Thompson JP, Rowbotham DJ. Remifentanil — an opioid for the 21st century (Edotiroal). Br J Anaesth 1996: 76: 341–3.

    PubMed  CAS  Google Scholar 

  25. Lang E, Kapila A, Shlugman D, Hoke JF, Sebel PS, Glass PSA. Reduction of isoflurane minimal alveolar concentration by remifentanil. Anesthesiology 1996; 85: 721–8.

    PubMed  Article  CAS  Google Scholar 

  26. Sanford TJ Jr,Weinger MB, Smith NT, et al. Pretreatment with sedative-hypnotics, but not with nondepolarizing muscle relaxants, attenuates alfentanil-induced muscle rigidity. J Clin Anesth 1994: 6: 473–80.

    PubMed  Article  Google Scholar 

  27. Sebel PS, Hoke JF, Westmoreland C, Hug CC Jr,Muir KT, Szlam F. Histamine concentrations and hemodynamic responses after remifentanil. Anesth Analg 1995: 80: 990–3.

    PubMed  Article  CAS  Google Scholar 

  28. Thompson JP, Hall AP, Russell J, Cagney B, Rowbotham DJ. Effect of remifentanil on the haemodynamic response to orotrahceal intubation. Br J Anaesth 1998; 80: 467–9.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ulla-Maija Klemola.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Klemola, UM., Hiller, A. Tracheal intubation after induction of anesthesia in children with propofol — remifentanil or propofol-rocuronium. Can J Anaesth 47, 854 (2000). https://doi.org/10.1007/BF03019664

Download citation

  • Accepted:

  • DOI: https://doi.org/10.1007/BF03019664

Keywords

  • Mean Arterial Pressure
  • Tracheal Intubation
  • Vocal Cord
  • Remifentanil
  • Rocuronium