Remifentanil target-controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial

Abstract

Remifentanil TCI appears to provide better conditions for AFOI when compared with propofol TCI. The disadvantage of remifentanil in this setting may be a higher incidence of recall.

Conscious sedation for awake fibreoptic intubation: a review of the literature

“…Severe coughing in one patient did necessitate a second attempt. 10 The mean (range) propofol TCI in their study was 1.…”

“…9 A greater body of published work has focused on targetcontrolled infusion (TCI) of propofol for AFOI, either as the sole agent or in combination with remifentanil. [10][11][12][13] Targetcontrolled infusions of propofol for AFOI have been assessed in three RCTs providing level 1 evidence comparing it with remifentanil (Table 2) 10-12 and in one RCT comparing it with dexmedetomidine. 13 In the propofol arm of the randomized trial by Rai et al, the tracheas of 9/10 patients were successfully intubated at the first attempt after SAYGO topicalization.…”

“…9,10,[14][15][16] More recently, case reports have described the concurrent use of propofol TCI with remifentanil TCI for AFOI [14][15][16] Authors describing the combined use of TCI propofol and remifentanil for AFOI have reported mean effect-site concentrations during the procedure of 0.8-2.0 lgÁmL -1 and 1.5-3.2 ngÁmL -1 , respectively. Although there is no evidence supporting the superiority of TCI propofol over a fixed rate infusion in the setting of an AFOI, it is safe to say that a TCI has a more consistent pharmacodynamic effect and may allow for a more predictable level of sedation to be maintained.…”

“…[20][21][22][23][24] This makes it an attractive drug of choice for the intensely stimulating but usually brief airway manipulation during an AFOI. It is increasingly being used either as the primary agent or in conjunction with midazolam 10,11,25 and, more recently, propofol [14][15][16] to provide sedation during AFOI. Studies evaluating remifentanil as a primary agent have described its use at different set rates of infusion, by bolus dose followed by infusion, and, more recently as a TCI.…”

“…Tracheal intubation with a mean effect-site concentration of remifentanil of 3.2 (2.8-3.5) ngÁmL -1 was faster, rated easier by the operator, and better tolerated by patients than tracheal intubation with a mean effect-site concentration of propofol of 1.3 (1-1.6) lgÁmL -1 . 10 The authors attributed the improved conditions in the remifentanil group to the antitussive and analgesic properties of remifentanil, which resulted in reduced coughing and tracheal tube tolerance during intubation. Lallo et al randomized 60 patients to either TCI remifentanil or TCI propofol, both of which were titrated to the patients' comfort during the procedure and not to a sedation score.…”