Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis

Abstract

SummaryThere is increasing interest in the use of short‐acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty‐one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5–4.0 μg.kg‐1) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94–1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate‐certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0–4.0 μg.kg‐1) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72–1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate‐certainty of evidence). There was no evidence of an effect between remifentanil (2.0–4.0 μg.kg‐1) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01–13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44–2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low‐certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Tracheal intubation without neuromuscular blocking drugs: isn't it an illusion?

“…comparing remifentanil with neuromuscular blocking (NMB) drugs for tracheal intubation in adults [1]. This identified 21 randomised controlled trials (RCTs), published between 1998 and 2023, that included 1945 adult patients.…”

“…Lundstrøm et al then published a meta-analysis of 34 RCTs (3565 patients aged ≥ 14 y) comparing tracheal intubation (using direct laryngoscopy) with and without NMB drugs [8]. Primary outcomes were the rates of difficult tracheal intubation, overall mortality and one or more events of upper airway discomfort or injury; these are quite different from those chosen by Santos et al [1]. With a moderate quality of evidence, the authors concluded that avoiding NMB drugs increased the incidence of difficult tracheal intubation and the risk of airway injury.…”

“…Several studies have described an increased risk of postoperative pneumonia (mainly after injections of non-depolarising NMB drugs) even with the use of neuromuscular block antagonists [16,17]. Neuromuscular blocking drugs are also the second most frequent class of drugs associated with severe anaphylactic reactions and the seventh most frequent cause of cardiac arrest, according to the 7th National Audit Project (NAP7) of the Royal College Table 1 Suggestions for the use of remifentanil for tracheal intubation without neuromuscular blocking drugs in an adult patient (adapted from the results of [1,2]).…”

“…After the recent publications of recommendations for the use of NMB drugs [14,15] and considering the their potential adverse effects [16][17][18][19] and good tolerance of NMB drug-free tracheal intubation [1], it would be useful to investigate the proportion of anaesthetists who always use NMB drugs during tracheal intubation in a real-life study.…”

“…NG received a French Ministry of Health grant in 2018 to finance the REMICRUSH study [2] that was included in the meta-analysis by Santos et al [1]. AR has received grants and consulting fees from Merck and bioMerieux.…”