Aantaa

Abdallah

Aouad

Batra

Blair

Bode

Crawford

De Fatima De Assuncao Braga

Drenger

Duman

Gupta

Hansen

Helbo-Hansen

Hiller

Humphries

Inomata

Klemola

Lerman

Meakin

Mertes

Morgan

Nishina

O’Brien

Politis

Robinson

Senel

Simon

Splinter

Steyn

Swan

Taguchi

Thwaites

Wappler

Warner

Watcha

Weber

Woods

Yaguchi

English

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Tracheal intubation without neuromuscular blocking drugs in children

Morton, Neil S.

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nn     Morton, N. S. (2009) Tracheal intubation without neuromuscular blocking drugs in children. Paediatric Anaesthesia, 19(3). pp. 199-201.  Copyright © 2009 Blackwell Publishing Ltd.  A copy can be downloaded for personal non-commercial research or study, without prior permission or charge  Content must not be changed in any way or reproduced in any format or medium without the formal permission of the copyright holder(s)     http://eprints.gla.ac.uk/40941/      Deposited on:  18 February 2015              Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk Editorial Tracheal intubation without neuromuscular blocking drugs in children NEIL S. MORTON MBCHB, FRCA, FRCPCH, FFPMRCA Royal Hospital for Sick Children, Glasgow, Scotland Studies of tracheal intubation without neuromuscular blocking drugs in adults and children have focussed on intubating conditions, hemodynamic responses and changes in intraocular and intracranial pressure or cerebral blood flow velocity. These studies go back some 20 years and techniques have evolved as new drugs have been introduced (1). Thus, volatile or intravenous agents have been used alone or in combination, or with opioids, nitrous oxide, lignocaine or premedication. Study designs have varied widely from open dose-finding studies to double blind randomized controlled trials. Comparisons of single drugs with combinations of drugs or with muscle relaxants have been made and clinical practice surveys have shown that these techniques have become quite popular (2,3). The assessment of intubating conditions has largely been standardized (4) but the blinding of observers and inter-observer variability in the assessment of intubating conditions and in the timing of tracheal intubation has not been well controlled in some studies. Why have clinicians adopted these techniques when neuromuscular blocking agents have become _cleaner_, shorter acting, more easily reversible, or possess characteristics which make reversal unnecessary (5)? The initial motivation was to avoid suxamethonium particularly after induction with halothane or to avoid relatively long acting muscle relaxant agents for relatively short surgical procedures (6,7). There was also interest around this time in techniques for ameliorating the pressor response to tracheal intubation and consequently also the rises in intra-ocular and intracranial pressure (8–14). With the introduction of propofol and analogues of fentanyl with rapid onset and offset of effect, techniques were developed to secure adequate intubating conditions rapidly without neuromuscular blocking drugs whilst concurrently controlling the pressor response to intubation (4,15–28). Sevoflurane has largely replaced halothane for inhalational induction in the last 15 years and it was natural, that intubating conditions produced by this newer agent should be assessed (29–35) and compared with other agents and techniques (36–39). Adjuvants to sevoflurane which have been studied include nitrous oxide (40), lignocaine (41), clonidine (42–45) and remifentanil (46,47). In this issue of Pediatric Anesthesia (48), a study of sevoflurane induction with propofol supplementation for tracheal intubation attempts to formally analyse a technique which is quite widely employed but has not been widely reported. With increased use of the laryngeal mask airway in children, the number of children requiring tracheal intubation has reduced significantly but for many operations where a tracheal tube is required, muscle relaxation is not necessary and this literature now strongly supports relaxant-free techniques in children for elective surgery. It is clear that neuromuscular blocking agents are among the most common triggers of anaphylactoid reactions associated with anesthesia (49) and there is now a school of thought which suggests that their use must be justified when alternative methods are available to reduce the risk of such reactions. As always, the alternative techniques are not without risk, and cases of hypotension, bradycardia, sinus arrest, asystole and airway damage have been reported when relaxant-free methods have been used. The administration of vagolytic agents prior to attempting intubation has been recommended when such _vagotonic_ drug combinations are administered to children. Continued vigilance and critical incident reporting systems  will reveal the prevalence of such adverse events. It is also important to emphasize that nearly all studies have been in healthy, elective children with normal airway anatomy and the results cannot be extrapolated to emergency cases, ill children and those with airway abnormalities. The doses of drugs and combinations of drugs recommended from this body of literature may result in serious adverse effects in sick children. Where control of hemodynamics, intraocular pressure or intracranial pressure is critical, techniques involving muscle relaxants with opioid adjuvants will still be recommended (50– 53). However, relaxant-free techniques of tracheal intubation do work well in the majority of pediatric cases and should be in the repertoire of every pediatric anesthetist. The most useful techniques are propofol or remifentanil supplementation after a sevoflurane induction or either a propofol ⁄ alfentanil or a propofol ⁄ remifentanil induction sequence. References 1 Woods AW, Allam S. Tracheal intubation without the use of neuromuscular blocking agents. Br J Anaesth 2005; 94: 150– 158. 2 Politis GD, Tobin JR, Morell RC et al. Tracheal intubation of healthy pediatric patients without muscle relaxant: a survey of technique utilization and perceptions of safety. Anesth Analg 1999; 88: 737–741. 3 Simon L, Boucebci KJ, Orliaguet G et al. A survey of practice of tracheal intubation without muscle relaxant in paediatric patients. Paediatr Anaesth 2002; 12: 36–42. 4 Helbo-Hansen S, Ravlo O, Trap-Andersen S. The influence of alfentanil on the intubating conditions after priming with vecuronium. Acta Anaesthesiol Scand 1988; 32: 41–44. 5 Meakin GH. Role of muscle relaxants in pediatric anesthesia. Curr Opin Anaesthesiol 2007; 20: 227–231. 6 Watcha MF, Forestner JE, Connor MT et al. Minimum alveolar concentration of halothane for tracheal intubation in children. Anesthesiology 1988; 69: 412–416. 7 Hansen D, Heitz E, Toussaint S et al. Deep halothane anaesthesia compared with halothane-suxamethonium anaesthesia for tracheal intubation in young children. Eur J Anaesthesiol 1997; 14: 29–34. 8 Drenger B, Pe_er J. Attenuation of ocular and systemic responses to tracheal intubation by intravenous lignocaine. Br J Ophthalmol 1987; 71: 546–548. 9 Splinter WM. Intravenous lidocaine does not attenuate the haemodynamic response of children to laryngoscopy and tracheal intubation. Can J Anaesth 1990; 37(4 Pt 1): 440–443. 10 Warner LO, Bremer DL, Davidson PJ et al. Effects of lidocaine, succinylcholine, and tracheal intubation on intraocular pressure in children anesthetized with halothane-nitrous oxide. Anesth Analg 1989; 69: 687–690. 11 Bode H, Ummenhofer W, Frei F. Effects of laryngoscopy and tracheal intubation on cerebral and systemic haemodynamics in children under different protocols of anaesthesia. Eur J Pediatr 1993; 152: 905–908. 12 Watcha MF, White PF, Tychsen L et al. Comparative effects of laryngeal mask airway and endotracheal tube insertion on intraocular pressure in children. Anesth Analg 1992; 75: 355– 360. 13 Watcha MF, Chu FC, Stevens JL et al. Intraocular pressure and hemodynamic changes following tracheal intubation in children. J Clin Anesth 1991; 3: 310–313. 14 Watcha MF, Chu FC, Stevens JL et al. Effects of halothane on intraocular pressure in anesthetized children. Anesth Analg 1990; 71: 181–184. 15 Humphries C, McConachie I. Tracheal intubation without neuromuscular block in children. Br J Anaesth 1994; 73: 431– 432. 16 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: 725–729. 17 Steyn MP, Quinn AM, Gillespie JA et al. Tracheal intubation without neuromuscular block in children. Br J Anaesth 1994; 72: 403–406. 18 Senel AC, Akturk G, Yurtseven M. Comparison of intubation conditions under propofol in children – alfentanil vs atracurium. Middle East J Anesthesiol 1996; 13: 605–611. 19 Hansen D, Schaffartzik W, Dopjans D et al. Halothanepropofol anaesthesia for tracheal intubation in young children. Br J Anaesth 1997; 78: 366–369. 20 Robinson DN, O_Brien K, Kumar R et al. Tracheal intubation without neuromuscular blockade in children: a comparison of propofol combined either with alfentanil or remifentanil. Paediatr Anaesth 1998; 8: 467–471. 21 Klemola UM, Hiller A. Tracheal intubation after induction of anesthesia in children with propofol – remifentanil or propofol- rocuronium. Can J Anaesth 2000; 47: 854–859. 22 De Fatima De Assuncao Braga A, Da Silva Braga FS, Poterio GM et al. The effect of different doses of propofol on tracheal intubating conditions without muscle relaxant in children. Eur J Anaesthesiol 2001; 18: 384–388. 23 Abdallah C, Karsli C, Bissonnette B. Fentanyl is more effective than remifentanil at preventing increases in cerebral blood flow velocity during intubation in children. Can J Anaesth 2002; 49: 1070–1075. 24 Batra YK, Al Qattan AR, Ali SS et al. Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant. Pediatr Anesth 2004; 14: 452–456. 25 Blair JM, Hill DA, Wilson CM et al. Assessment of tracheal intubation in children after induction with propofol and different doses of remifentanil. Anaesthesia 2004; 59: 27–33. 26 Crawford MW, Hayes J, Tan JM. Dose-response of remifentanil for tracheal intubation in infants. Anesth Analg 2005; 100: 1599–1604. 27 Gupta A, Kaur R, Malhotra R et al. Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants. Pediatr Anesth 2006; 16: 399–405. 28 Morgan JM, Barker I, Peacock JE et al. A comparison of intubating conditions in children following induction of anaesthesia with propofol and suxamethonium or propofol and remifentanil. Anaesthesia 2007; 62: 135–139. 29 Inomata S, Nishikawa T. Determination of end-tidal sevoflurane concentration for tracheal intubation in children with the rapid method. Can J Anaesth 1996; 43: 806–811. 30 Taguchi M, Watanabe S, Asakura N et al. End-tidal sevoflurane concentrations for laryngeal mask airway insertion and for tracheal intubation in children. Anesthesiology 1994; 81: 628–631. 31 Inomata S, Watanabe S, Taguchi M et al. End-tidal sevoflurane concentration for tracheal intubation and minimum alveolar concentration in pediatric patients. Anesthesiology 1994; 80: 93– 96. 32 Aantaa R, Takala R, Muittari P. Sevoflurane EC50 and EC95 values for laryngeal mask insertion and tracheal intubation in children. Br J Anaesth 2001; 86: 213–216. 33 Duman A, Ogun CO, Okesli S. The effect on intraocular pressure of tracheal intubation or laryngeal mask insertion during sevoflurane anaesthesia in children without the use of muscle relaxants. Paediatr Anaesth 2001; 11: 421–424. 34 Politis GD, Frankland MJ, James RL et al. Factors associated with successful tracheal intubation of children with sevoflurane and no muscle relaxant. Anesth Analg 2002; 95: 615–620. 35 Wappler F, Frings DP, Scholz J et al. Inhalational induction of anaesthesia with 8% sevoflurane in children: conditions for endotracheal intubation and side-effects. Eur J Anaesthesiol 2003; 20: 548–554. 36 O_Brien K, Kumar R, Morton NS. Sevoflurane compared with halothane for tracheal intubation in children. Br J Anaesth 1998; 80: 452–455. 37 Inomata S, Yamashita S, Toyooka H et al. Anaesthetic induction time for tracheal intubation using sevoflurane or halothane in children. Anaesthesia 1998; 53: 440–445. 38 Thwaites AJ, Edmends S, Tomlinson AA et al. Double-blind comparison of sevofluran vs propofol and succinylcholine for tracheal intubation in children. Br J Anaesth 1999; 83: 410–414. 39 Blair JM, Hill DA, Bali IM et al. Tracheal intubating conditions after induction with sevoflurane 8% in children. A comparison with two intravenous techniques. Anaesthesia 2000; 55: 774–778. 40 Swan HD, Crawford MW, Pua HL et al. Additive contribution of nitrous oxide to sevoflurane minimum alveolar concentration for tracheal intubation in children. Anesthesiology 1999; 91: 667–671. 41 Aouad MT, Sayyid SS, Zalaket MI et al. Intravenous lidocaine as adjuvant to sevoflurane anesthesia for endotracheal intubation in children. Anesth Analg 2003; 96: 1325–1327. 42 Nishina K, Mikawa K, Shiga M et al. Oral clonidine premedication reduces minimum alveolar concentration of sevoflurane for tracheal intubation in children. Anesthesiology 1997; 87: 1324–1327. 43 Inomata S, Kihara S, Yaguchi Y et al. Reduction in standard MAC and MAC for intubation after clonidine premedication in children. Br J Anaesth 2000; 85: 700–704. 44 Inomata S, Kihara S-I, Miyabe M et al. The hypnotic and analgesic effects of oral clonidine during sevoflurane anesthesia in children: a dose-response study. Anesth Analg 2002; 94: 1479–1483. 45 Yaguchi Y, Inomata S, Kihara S-I et al. The reduction in minimum alveolar concentration for tracheal extubation after clonidine premedication in children. Anesth Analg 2002; 94: 863–866. 46 Weber F, Fussel U, Gruber M et al. The use of remifentanil for intubation in paediatric patients during sevoflurane anaesthesia guided by Bispectral Index (BIS) monitoring. Anaesthesia 2003; 58: 749–755. 47 Min SK, Kwak YL, Park SY et al. The optimal dose of remifentanil for intubation during sevoflurane induction without neuromuscular blockade in children. Anaesthesia 2007; 62: 446–450. 48 Lerman J, Matthews BT, Houck J et al. Propofol for tracheal intubation in children anesthetized with sevoflurane: a dose response study. Pediatr Anesth 2009; 19: 218–224. 49 Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions occurring during anaesthesia in France in 1999–2000. Anesthesiology 2003; 99: 536–545. 50 Xue FS, Xu YC, Liu Y et al. Different small-dose remifentanil blunting the cardiovascular response to laryngoscopy and intubation in children: a randomized double-blind comparison. Eur J Anaesthesiol 2008; 25: 106–112. 51 Xue FS, Xu YC, Liu Y et al. Different small-dose sufentanil blunting cardiovascular responses to laryngoscopy and intubation in children: a randomized, double-blind comparison. Br J Anaesth 2008; 100: 717–723. 52 Xue FS, Liu KP, Liu Y et al. Assessment of small-dose fentanyl and sufentanil blunting the cardiovascular responses to laryngoscopy and intubation in children. Pediatr Anesth 2007; 17: 568–574. 53 Xue FS, Liao X, Liu KP et al. The circulatory responses to tracheal intubation in children: a comparison of the oral and nasal routes. Anaesthesia 2007; 62: 220–226. EDITORIAL 201 _ 2009   

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Tracheal intubation without neuromuscular blocking drugs in children

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