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Tracheal Intubation without muscle relaxant in children
1. Adjuvant drugs on the quality of
tracheal
intubation without muscle relaxants
in children
Dr. Ashraf Arafat Abdelhalim, MD
Professor of anesthesia
Department of Anesthesia, Faculty of Medicine Alexandria University, Egypt
1
2. Intubation without prior administration of
muscle relaxants is a common practice in
children.
Reasons for omitting muscle relaxants
surgical procedures in which paralysis is
undesirable,
possible allergy to muscle relaxants,
the presence of neuromuscular disorders,
brief procedures, 2
3. Sevoflurane induction
Sevoflurane alone
4 studies evaluated sevoflurane alone for
intubation
acceptable intubatingconditions was 49% .
Sevoflurane with N2O
3 studies evaluated the combination of
sevoflurane with N2O (50–60%)
Acceptable intubating conditions was
81.5% 3
4. Sevoflurane with remifentanil 3
In one study ,remifentanil (1 microÆkg)) yielded
an incidence of 85% excellent intubating
conditions.
In another study ,remifentanil (1 or 2 microÆkg)
added to sevoflurane-50%N2O yielded an
incidence of excellent intubating conditions of
75% and 81.2%, respectively.
Sevoflurane with alfentanil
Evaluated in only one study
4
5. Sevoflurane with lidocaine
One study using sevoflurane with lidocaine (2
mg/kg) reported an incidence of 84% excellent
intubating conditions
Sevoflurane with propofol 2
Smaller doses achieved <60% excellent
intubatingand 3 mg/kg) an incidence of
excellent intubating conditions of 90%
5
6. Sevoflurane exposure time and endtidal
concentration
Excellent intubating conditions >80% using
sevoflurane 8% sevoflurane was used with ET
sevoflurane concentrationat intubation ranging from
3.7% to 5.7%, andsevoflurane exposure time ranging
from 197 s to 504 s
Ventilation was assisted during exposure time in the
above-mentioned studies, except for one study ,in
which children were spontaneouslybreathing
6
7. Propofol induction
Propofol with alfentanil
Three studies evaluated the combination of
mg/kg) with alfentanil (10 mcg/kg)
Propofol with remifentanil
6 studies investigated the addition of remifentanil (1–4
mcg/kg) to propofol (3–4 mg/kg)
excellent intubating conditions were reported 29% -
with the 1 mcg/kg remifentanil with propofol(3 mg/kg)
to 85% with the (4 mcg/kg) remifentanil with propofol
(3.5 mg/kg) 7
8. Propofol with fentanyl
Two studies investigated three doses of
propofol (2.5, 3, and 3.5 mg/kg) with fentanyl
3 mcg/kg)
Excellent intubating conditions were
reported in one study (24) and did not
exceed 60%
8
9. The 2 and 3 mg/kg) of propofol with sevoflurane
achieved the same results, and there appeared to be
no advantage to increasing the dose more than 2
mg/kg).
Propofol causes greater suppression of laryngeal
reflexes than do other IV anesthetics.
Cough, which are the most frequentlyreported
reasons for less than ideal intubating conditions,
occurred more frequently during propofol anesthesia,
whereas laryngospasm is more frequent with
sevoflurane
9
10. The beneficial effect of lidocaine on intubating
conditions is mainly related to cough suppression
The appropriate dose appears to be 2 mg/kg). Doses
<2 mg/kg) appear to only partially suppress
cough .
Exposure time to sevoflurane and patient age are
factors that may influence the quality of intubation.
Longer exposure time of a high inspired sevoflurane
concentration results in a higher concentration of the
agent in the brain and subsequently a deeper level of
anesthesia.
10
11. in the presence of intranasal remifentanil, the
incidence of acceptable intubating conditions
increases when sevoflurane exposure time increases
from 180 s to240 s
the time needed to achieve 80% incidence of
adequate intubating conditions with 8% sevoflurane in
60% N2O was 137 s for ages 1–4 years and 187 s (for
ages 4–8 years.
In most of the studies which included children aged 1–
10 years, sevoflurane exposure time was at least 180
s.
Excellent intubating conditions more than 80% were
achieved only when the adequate adjuvant was 11
12. The 95% effective value of ET sevoflurane is about
3.5% for smooth intubating conditions after an
exposure time of at least 8 min
The lowest ET value among the studies in this
review at which intubation was attempted was 2.7%
after 8% sevoflurane for 3 min with children breathing
spontaneously
12
13. the persistence of spontaneous ventilation
at the time of laryngoscopy was associated with
poor intubating conditions.
In nearly all the regimens recommended
for intubation without muscle relaxants, assisted
ventilation was used. The continuous delivery of
sevoflurane through assisted ventilation provides a
greater depth of anesthesia at the time of
intubation.
13
14. All drug combinations recommended for intubation
without muscle relaxants were administered
to children aged 1–9 years.
More studies are needed in infants.
Also, most of these recommended combinations were
preceded by midazolam or ketamine, suggesting that
premedication contributes to the quality of intubation.
14
15. oral midazolam (0.5 mgÆkg)1) given 30–60 min
before anesthesia decreases by one-third the propofol
requirements for the insertion of a laryngeal mask
airway in children. However, no studies evaluated the
effect of premedication on the quality of intubation.
15
