Tracheal intubation without muscle relaxants : A randomized study of remifentanil or alfentanil in combination with thiopental

T racheal intubation is usually facilitated by adm m ministration of a muscle relaxant to supplem m ment drugs given for the induction of anesm m thesia.Over the past few years, several factors have led researchers to consider omitting neuromuscular blockm m ing agents for tracheal intubation.The driving forces were the apparent ability of propofol to blunt responses to tracheal stimulation 1 and the availability of the rapm m idly acting opioids, alfentanil and remifentanil.In addim m tion, the inappropriate use of neuromuscular blocking agents was thought to be involved in problems such as awareness, residual paralysis and allergy.Therefore, many studies focused on the possibility of performing tracheal intubation without the use of neuromuscular blocking agents.The challenge was to find the correct choice and dose of induction agent and opioid drug BACKGROUND AND OBJECTIVE: The combination of alfentanil-propofol or remifentanil-propofol provides adequate conditions for tracheal intubation without neuromuscular blocking drugs in most patients, but hypo-tension can occur during induction of anesthesia with propofol.We compared clinically acceptable intubating conditions and cardiovascular responses to induction and endotracheal intubation in patients receiving either alfentanil 40 µg/kg or remifentanil 2, 3 or 4 µg/kg, followed by thiopental 5 mg/kg.PATIENTS AND METHODS: In a randomized trial, 80 patients were assigned in equal numbers to one of four groups: remifentanil 2, 3, or 4 µg/kg (groups R2, R3, R4, respectively) or alfentanil 40 µg/kg (group A40).In each group, the injection was given over 90 seconds followed by thiopental 5 mg/kg.Ninety seconds after the administration of thiopental, laryngoscopy and intubation were attempted.Intubating conditions were assessed as excellent, satisfactory, fair, or unsatisfactory.Arterial blood pressure and heart rate changes accompanying the four induction techniques were also recorded.RESULTS: Overall conditions at intubation were significantly better (P<.05), and the frequency of excellent con-ditions was significantly higher (P<.05) in the R4 or A40 group compared with the R2 or R3 group.Intubating conditions were not significantly different between group R4 and A40 (P>.05).The highest dose of remifentanil (4µg/kg) resulted in an 18.7% decrease in mean arterial pressure (MAP) after induction of anesthesia compared with a 16.4% decrease in MAP with alfentanil 40 µg/kg (difference not statistically significant).CONCLUSION: The administration of remifentanil 4 µg/kg or alfentanil 40 µg/kg before thiopental 5 mg/kg provided good to excellent conditions for endotracheal intubation with acceptable hemodynamic changes.