1/8/2017 Trachealintubationwithoutneuromuscularblockinchildren

IndianJAnaesth.2010JanFeb54(1):2934. PMCID:PMC2876911
doi:10.4103/00195049.60493

Trachealintubationwithoutneuromuscularblockinchildren
SafiyaIShaikhandVijayalaxmiPBellagali
DepartmentofAnesthesiology,KarnatakaInstituteofMedicalSciences,Hubli,Karnataka580022,India
Addressforcorrespondence:Dr.SafiyaIShaikh,DepartmentofAnesthesiology,KarnatakaInstituteofMedicalSciences,Hubli580022,Karnataka,
India.Email:ssafiya11@yahoo.com

CopyrightIndianJournalofAnaesthesia

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

EndotrachealintubationhasbeenperformedduringtheadministrationofPropofolanaesthesiawithout
neuromuscularblockade.Inthestudy,wehaveassessedtrachealintubatingconditionsandhaemodynamic
responsesinchildrenaged4to12yearsbyusingcombinationofeitherFentanylandPropofolorPropofolanda
neuromuscularblocker,suxamethonium.Intubatingconditionswereassessedona14scalebasedoneaseof
laryngoscopy,positionofvocalcords,degreeofcoughingandjawrelaxation.Trachealintubationwassuccessfulin
95%ofpatientsreceivingFentanylPropofoland100%ofpatientsreceivingPropofolsuxamethonium.Fentanyl
PropofolprovidedbetterhaemodynamicstabilitythanPropofolsuxamethonium.WeconcludethatPropofol
Fentanylcombinationcouldbeausefulalternativetechniquefortrachealintubationwhenneuromuscularblocking
drugsarecontraindicatedorneedtobeavoided.

Keywords:Endotrachealintubation,Fentanyl,Propofol,suxamethonium

INTRODUCTION Goto:

Endotrachealintubationisfrequentlyfacilitatedbyadministrationofadepolarizingmusclerelaxantsuchas
suxamethoniumduringinductionofanaesthesiawithshortactinghypnoticdrugs.However,suxamethonium
administrationmaybeassociatedwithsideeffectssuchaspostoperativemyalgia,prolongedparalysis,increasein
intraocularpressureandhyperkalaemia.[1]

Routineuseofsuxamethoniumfortrachealintubationinchildrenisbeingcriticizedfollowingsomereportsof
cardiacarrestanddeathinyoungchildren.[2]Eventheuseofnondepolarizingrelaxantsmaybeassociatedwith
undesirableeffectssuchasprolongedneuromuscularblockade,theneedtoreverseneuromuscularblockadeorthe
inabilitytoreversetheparalysisquicklyifairwaymanagementviamaskortrachealintubationisnotpossible.For
thesereasons,amethodofprovidinggoodintubatingconditionsrapidlywithoutusingmusclerelaxantshasbeen
soughtbyanumberofinvestigators[2]

Propofolhasbeenreportedtopossesssomecharacteristicsthatprovideadequateconditionsforintubationin
combinationwithFentanyl[3,4]oralfentanil[58]orremifentanil.[9,10]

Thepurposeofthepresentstudywastoassessintubatingconditionsandhaemodynamicresponsesinchildrenafter
inductionofanaesthesiausingFentanylPropofolandtocomparetheresultswiththoseobtainedwithaPropofol
suxamethoniuminductionsequence.

METHODS Goto:

Afterinstitutionalethicalclearance,80childrenaged4to12years,belongingtoAmericanSocietyof
Anaesthesiologists(ASA)gradeIandII,wereincludedinthisstudy.Thechildrenpostedtoundergovarious

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electivesurgicalprocedures,forwhichendotrachealanaesthesiawasplanned,wereselectedforstudy.Children
withsuspecteddifficultintubation,havinghistoryofallergytoanyofthestudydrugs,undergoingophthalmicand
neurosurgicaloperationswereexcludedfromthestudy.

Informedandwrittenparentalconsentwasobtained.Patientswereallottedtooneofthefollowinggroupsbasedon
computerbasedrandomization:GroupFtoreceiveInj.Fentanyl4g/kg+Inj.Propofol3mg/kgand

GroupStoreceiveInj.Propofol3mg/kg+Inj.suxamethonium1mg/kg.

AllthepatientswerepremedicatedwithInj.Midazolam0.05mg/kgandatropine0.01mg/kgI.V.,10minutesprior
toinduction.

GroupF(studygroup)Inj.Fentanyl4g/kgwasgivenI.V.over30seconds.Fiveminuteslater,thechildren
receivedPropofol3mg/kgoveraperiodof30seconds(Lignocaine0.2mg/kgwasaddedtoPropofolsolutionto
abolishpainoninjection).Laryngoscopyandintubationwereattempted60secondsafterinductionofanaesthesia
inboththegroups.Additionalbolusof1mg/kgofPropofolwasgiveniflaryngoscopywasnotpossibledueto
musclespasm,coughingorexcessivemovements.Inthosepatientswhereintubationwasimpossibleaftertwo
attemptsduetoanycause,suxamethonium1mg/kgwasinjectedandintubationcompleted.

InGroupS(controlgroup),anaesthesiawasinducedbyInj.Propofol3mg/kgfollowedbyInj.suxamethonium1
mg/kgendotrachealintubationwasperformed60secondslater.

Laryngoscopyandintubationweredoneinallthepatientsbyaseniorconsultantanaesthesiologist.Thequalityof
intubationwasgradedbytheconsultantusingthescoringsystemdevisedbyHelboHansenRauloandTrap
Anderson[11][Table1].

Table1
Scoringcriteriaforintubatingconditions

Duringlaryngoscopyandintubation,theintubatinganaesthesiologistassessedeachpatientforfourvariables[
Table1]:

Easeoflaryngoscopy
Positionofvocalcords
Degreeofcoughing
Jawrelaxation

Theobservedconditionswithrespecttoeachoftheabovewereallocatedscoresof1to4.Ascoreof34was
consideredexcellent58,good912,poorand1316,bad.Excellentandgoodscoreswereconsideredas
clinicallyacceptable,andfairandpoorscoreswereconsideredasclinicallyunacceptable.

Measurementsofheartrate,systolicarterialpressureandarterialO2saturationwerenotedatdifferenttimeintervals
(preinduction,postinduction,postintubationat0,1,3and5minutes).Measurementsat1minuteafterinjectionof
atropineweretakenasbaselinevalues.

Balancedanaesthesiawasmaintainedsubsequentlyasnecessaryforeachcase.

Statisticalanalysis
Theresultswereexpressedasmeanwithstandarderrorofmeanasindexofdispersion.Bloodpressure,pulserate
andarterialO2saturationwerecomparedwithbaselinevaluesusingpairedttest.Comparisonofvariablesobtained
withPropofolFentanylwasdonewiththoseobtainedwithPropofolsuxamethoniumusingFisherexacttest.
P<0.05wasregardedasstatisticallysignificant,P<0.001wastakenashighlysignificantandP>0.05wasregarded
asnotsignificant.Forsamplesizecalculation,weconsideredexcellentandgoodconditionsasacceptablewhereas
fairandpoorasnonacceptable.Samplesizewasdecidedinconsultationwiththestatistician:Thirtywasthe
smallestnumberineachgroup,whereanyresultscouldbestatisticallysignificant(withpowerof80%).Hence
samplesizeof40patientswasselectedforboththegroups.TheFisherexacttestwasusedtocomparethe
intubationscores.

RESULTS Goto:
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Allthepatientparametersandtheresultsfromthetwogroups(groupFandgroupS)wereenteredinthepre
designedstudyproformasheet,intubatingconditionswerescoredandhaemodynamicparameterswerenoted.

Therewasnosignificantdifferenceindemographicdataforboththegroups[Table2].

Table2
Patientdata(meanSD)

Thescoresobservedineachgroupbasedonthecriteriausedtoassesseaseofintubation[Table1]areshownin
Table3.Excellentintubatingconditions(intubationscore,34)wereachievedin14(35%)outof40patientsin
groupFand36(90%)outof40patientsingroupS.Goodintubatingconditions(intubationscore,58)were
achievedin24(60%)patientsingroupFand4(10%)patientsingroupS.Inpatientswithascoreof1to2,
laryngoscopywaseasy,thevocalcordswereopen,coughwasneitherobservedorwastoominimaltoimpedethe
passageofthetrachealtube[Tables3and4].

Table3
Comparisonofscoringcriteria

Table4
Scoringconditionsfortrachealintubation

Fairintubatingconditions(intubationscore,912)wereobservedin1(2.5%)outof40patientsingroupFas
comparedto0ingroupS[Table4].Thispatientwashavingascoreof12withdifficultlaryngoscopy,stiffjaw,
vocalcordclosingandmoderatecoughinresponsetointubation.Poorintubatingconditions(intubationscore,13
16)wereobservedin1(2.5%)patientingroupFandinnopatientingroupS.Thispatienthadstiffjaw,difficult
laryngoscopy,closingvocalcordsandseverecoughinresponsetointubation(intubationscore,13).Forboththese
patients,belongingtogroupF,additionalbolusdoseof1mg/kgPropofolwasadministered,andasecondattempt
ofintubationwasmade.Sincethiscouldnotfacilitateintubation,suxamethonium1mg/kgwasadministeredand
intubationwascompleted.

Overallintubatingconditions
Acceptableintubatingconditions(i.e.,excellentandgood)wereobservedin38(95%)outof40patientsingroupF,
whereasall(100%)patientsingroupShadexcellentintubatingconditions(notstatisticallysignificant).

Unacceptableintubatingconditionswereobservedin2(5%)outof40patientsingroupFandnoneingroupS
thiswasnotstatisticallysignificant[Table5].Inallunacceptableintubatingconditions(fairandpoor)werepresent
in2(5%)outof40patientsingroupFandnopatientingroupSthiswasnotstatisticallysignificant.

Table5
Intubatingconditionsinthetwogroups

Haemodynamicchangesduringintubation
Themeanbasalheartratewas109.211.7/miningroupFand114.111.4/miningroupS,bothofwhichwerenot
statisticallysignificant(P>0.05)[Figure1].TherewassignificantdecreaseinheartrateingroupFafterintubation
at0,1,3and5minutes(P<0.001),whereasgroupSshowedsignificantincreaseinheartrateafterintubationat0,
1,3and5minutes(P<0.001)[Figures1and2].

Figure1
Comparisonofheartrate

Figure2
Comparisonofsystolicbloodpressure

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Thepreinductionsystolicbloodpressurewas112.56.39mmHgingroupFand115.79.03mmHgingroupS,
respectively,bothofwhichwerenotstatisticallysignificant.Thesystolicbloodpressuredecreasedsignificantly
afterintubationat0,1,3and5minutesingroupF(P<0.001),whereasgroupSshowedsignificantincreasein
systolicbloodpressureat0,1,3and5minutes(P<0.001)[Figure2].

TherewasnosignificantchangeinarterialoxygensaturationingroupFcomparedtogroupsSduringthestudy
period.

DISCUSSION Goto:

Trachealintubationwithouttheuseofneuromuscularblockingdrugsisatechniquewhichhasbeenwidelystudied
andpracticedfollowingtheworkofMCKeating,BaliandDundee.Thestudyshowedthatconditionsfor
laryngoscopyweresuperiorafterinductionofanaesthesiawithPropofolratherthanthiopentone.[12]Propofol
decreaseslaryngotrachealreactivityandmuscletoneandthusallowseaseinintubation,[13]buttheintubating
conditionsarenotoptimal.[5,14]Increasingthedepthofanaesthesiabyadministeringsupplementaryincrementsof
inductionagentoropioidsorlignocaineimprovesintubatingconditions.[7,15]AdministrationofFentanyl
suppressesthehaemodynamicresponsetoendotrachealintubation.[16]TheobservationthatPropofolcauses
greatersuppressionoflaryngealreflexeshasrenewedinterestintheuseofrelaxantfreetechniquesoftracheal
intubation.IntubatingconditionsattainedusingPropofolalone,however,arefarfromidealandhavebeen
consideredadequateinonly38%to60%ofpatients.[14,17,18]Additionofopioidsimprovedintubation
conditions.[3,12,1824]Batraetal.[24]concludedthatremifentanil(3g/kg)administeredbeforePropofol3
mg/kgprovidesacceptabletrachealintubatingconditionsinchildrenandcompletelyinhibitstheincreaseinheart
rateassociatedwithintubation.

BasedontherespectivefindingsofGuptaandothers,[19]Andeletal.,[25]andKoetal.,[26]aPropofolFentanyl
techniquewasusedforthecurrentstudy.Guptaandothersintheirstudyonevaluationofdifferentdosesof
Propofolwithprioradministration(3minutesbefore)of3g/kgofFentanylinchildrenintheagegroupof3to10
yearsfoundadoseofPropofolof3.5mg/kgtobeeffectiveinproducingacceptableintubatingconditions.Dosesof
3to3.5mg/kgofPropofolproducedgoodattenuationofhaemodynamicresponsestointubation.Andelandothers
determinedtherequiredPropofoldoseincombinationwithFentanylallowingreliablysuccessfultracheal
intubationwithoutneuromuscularblockingagentsinallpatients.Accordingtotheirfinding,amedianPropofol
doseof2.7mg/kgisneeded.RegardingtheuseofFentanylinthiscontext,Ko,etal[26]reportedthatintermsof
bluntingthehaemodynamicresponsetolaryngoscopyandtrachealintubation,itwasmoreeffectivetoadminister
thebolusdoseofFentanyl5minutesbeforeintubation.

Basedontheabovestudies,inourstudy4g/kgFentanylwasgiven5minutesbeforeintubation,andinduction
doseofPropofol3mg/kgwasused.Anadditionaladvantageistheabilitytomaintainspontaneousbreathingin
caseofintubationfailureasaresultofairwaypathology.Lignocaineinthedoseof0.2mg/kgbodyweightwas
mixedwithPropofoltoavoidpainoninjection.Lignocainehasbeenusedinmanystudiesinthepastasadjuvant.It
attenuatestheintraocularpressureresponsetorapidtrachealintubationinchildren.Ithasbeenshowntoattenuate
thepressureresponsetolaryngoscopyandtrachealintubation,buttimingsofadministrationofdosesareimportant.

Thepresentstudywascarriedoutinchildrentoassesstrachealintubatingconditionsandhaemodynamicchanges
afterinductionofanaesthesiabyusingFentanylPropofolwithouttheuseofneuromuscularblockingdrugs.This
wascomparedwiththestandardtechniqueofusingPropofolsuxamethonium.Outof80patients,40received
FentanylPropofoland40receivedPropofolsuxamethonium.

Ourresultsshowedthattrachealintubationwassuccessfulin95%ofchildrenreceivingFentanylPropofoland
100%ofpatientsreceivingPropofolsuxamethonium.Only2outof40patientshadunacceptableintubating
conditionsintheFentanylPropofolgroup,requiringadministrationofsuxamethoniumforintubation.Theoverall
scoresforeaseoflaryngoscopy,thepositionofvocalcords,relaxedjawsandabsenceofcoughingwerehowever
betterinthePropofolsuxamethoniumgroup.Olmos,Stribelandcolleagues[3]weresuccessfulinintubatingmore
than95%ofadultpatientsgivenFentanylandPropofol.TheystatedthatcombinationofFentanyl,thiopentoneand
succinylcholineresultsinnobetterintubatingconditionsthanFentanylplusPropofol.Gupta,[19]Tahira[12]andde
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Fatima[20]alsoconcludedthatPropofolFentanylprovidedadequatetrachealintubatingconditionswithout
significanthaemodynamicchanges.Onthecontrary,UmaSrivastavaetal.,[3]MenckeThomasetal.[27]and
Samaretal.[28]haveachievedlowersuccessratedespiteaugmentationofPropofolwithFentanyl.Tsudaetal.[17]
alsofoundthatlowdoseFentanylinthepresenceofPropofolprovidedpoorintubatingconditions.

Regardingthehaemodynamiceffectsofthedifferentcombinationsforanaestheticinductionandintubation,Market
al.[18]conductedthestudyininfantsandshowedthatPropofolRemifentanilprovidesclinicallyacceptable
intubatingconditionsandstablehaemodynamics.Ourresultsshowedthatafterintubation,heartratedecreased
significantlyinpatientswhoreceivedFentanylandPropofol,whereasheartratewasincreasedinpatientsgiven
Propofolsuxamethonium.Thishasbeenobservedbyseveralotherinvestigators.[4,5,9]Ourresultsshowedthat
systolicbloodpressurewasdecreasedinPropofolFentanylgroupafterintubation,whereasitincreasedinthe
suxamethoniumgroup.Thefallinsystolicbloodpressurefromthepreinductionvaluewashighlysignificantinthe
PropofolFentanylgroup.ThefallinsystolicbloodpressureiscomparabletothatinstudiesbyUmaSrivastavaet
al.,[2]TahiraShah[12]andBillardetal.[29]Randallandothers[30]concludedthatlowdoseFentanylreduces
someaspectsofstressresponsetorapidsequenceinductionofanaesthesia.DahlgrenandMesseter[31]havealso
shownthatlowdoseFentanylbeforeintubationeffectivelybluntsthehaemodynamicresponsetointubation.Gupta
andothers[19]foundthatadoseof3mg/kgofPropofolwithaFentanyldoseof3g/kgwasthebestcombination
toreduceintubationresponses,withoutgreaterfallsinmeanarterialpressureandheartrate.Theadministrationof
Propofolinadoseof22.5mg/kgcanlowermeanbloodpressureby25%to40%.Thisdropissecondarytoboth
thevasodilatorandthemyocardialdepressanteffectsofPropofol.Inviewofthedropinmeanarterialpressure,this
techniqueoftrachealintubationwithoutmusclerelaxantsmaynotbeappropriateforelderlypatientsandinpatients
withcardiovascularorcerebrovasculardisease.[27]

Musclerigidityfollowingopiateadministrationhasbeenstudiedinhumanvolunteers,andpreviousreportsshow
thatrigidityoccursin80%ofpatientswhen175g/kgofalfentanilisadministeredandin50%ofpatientswhen
15g/kgofFentanylwasused[30]Musclerigiditywasnotobservedduringourstudy.Theabsenceofmuscle
rigidityinourstudycanbeattributedtothemuchlowerdosageofnarcoticusedandalsotoourslowinjectionrate
ofnarcotics,sincethereisevidencethattheincidenceandseverityofopiateinducedrigidityarenotonlydependent
onthedosagebutalsoontherateofadministration.[1]

Ourstudyhadthelimitationoflackofdoubleblindingthesamestudywithadoubleblindingisinprogress.If
confirmedinfurthertrials,thefindingsmayleadtomodificationofthescoringsystempresentlyused.

CONCLUSION Goto:

Thepresentstudywasundertakentohighlightthebenefitsofavoidingsuxamethonium,usingonlytheopioid
Propofoltechniqueforroutineintubationinpaediatricagegroups.Weconcludethatinpremedicatedhealthy
children,trachealintubationmaybeaccomplishedusingacombinationofFentanyl(4g/kg)andPropofol(3
mg/kg).Thesimultaneousadministrationofmusclerelaxantmaynotbenecessarytoensureacceptablejaw
mobility,easylaryngoscopyandvocalcordexposure.Thismethodrepresentsausefulalternativetechniquefor
trachealintubationwhenneuromuscularblockingdrugsarecontraindicatedorshouldbeavoided.

Footnotes Goto:

SourceofSupport:Nil

ConflictofInterest:Nonedeclared

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