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Intubation without muscle relaxant
- Valasubramaniam K Mahadevan (14 August 2007)
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Comparison of two induction regimens using or not using muscle relaxant
- Krishnan Melarkode (14 August 2007)
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Valasubramaniam K Mahadevan, Specialist Registrar Barts and the London School of Anaesthesia
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Editor-I would like to make few comments on the conclusion reached by Combes and colleagues in the recent paper comparing the impact of two induction regimens with or without muscle relaxant on postoperative upper airway discomfort. It is a well-designed study looking at clear end points namely hoarseness/sore throat after extubation. But what has been overlooked is the extubation response, which also has an impact on their endpoints as also smoking. So many techniques/drugs have been tried in order obtund the extubation response and thereby to reduce the incidence of sore throat. I agree one cannot expect the ideal intubating conditions without muscle relaxants and opioids are known to cause hypotension and bradycardia, but without opioids we will need something else to obtund the sympathetic response to laryngoscopy and intubation. The technique of intubating without muscle relaxant definitely has its role in current practice in cases of short duration and more so in paediatric population where deep inhalational anaesthesia is more commonly used. However, like anything else the technique of using opioids for intubation also has its limitations. It cannot be used in patients with a full stomach, as intubation may not be successful at the first attempt; also in patients undergoing neurosurgery or ophthalmic surgery where coughing is undesirable, and in patients in poor circulatory status, as it decreases significantly arterial pressure and heart rate. References: 1.Politis GD, Tobin JR, Morell RC, James RL, Cantwell MF. Tracheal intubation of healthy pediatric patients without muscle relaxant: a survey of technique utilization and perceptions of safety. Anesth Analg. 1999089(5): 1328. 2.Boulesteix G, Simon L, Lamit X, Aubineau JV, Claire P, Kindelberger P. Intratracheal intubation without muscle relaxant with the use of remifentanil- propofol. Ann Fr Anesth Reanim, 1999 Apr; 18(4): 393-7. Conflict of Interest:None declared |
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Krishnan Melarkode, Specialist Registrar in Anaesthesia Addenbrooke's Hospital NHS Trust, Cambridge, UK
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Editor - It was interesting to read the article by Combes X, Andriamifidy L, Dufresne E et al (1)on Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. I would like to comment on this study and would also like to clarify few questions from the authors. In the control arm (saline group), the authors mention that 20 patients out of 150 had unsatisfactory intubation conditions due to inadequate vocal cord paralysis. But the authors fail to report on the incidence of coughing or bucking during laryngoscopy and intubation in this group. Secondly, I fail to understand why the investigators chose to use a depolarising muscle relaxant (succinylcholine) as a rescue muscle relaxant in the control group. Succinylcholine is itself associated with side effects such us post-operative myalgia and parasympathomimetic effects (2). I would like to know why the authors did not choose another non- depolarising muscle relaxant like vecuronium or continued to use rocuronium as a rescue muscle relaxant in this group of patients as in any case although the intubating anaesthetist would have identified this group but the independent observer assessing post-operative laryngotracheal symptoms was blinded to events in the intra-operative period. Thirdly, I feel that there is always going to be an element of bias towards the muscle relaxant group at all stages of the sudy as the authors have compared use of a muscle relaxant versus saline which is effectively a placebo. Could the authors kindly clarify these issues? References: 1. Combes X, Andriamifidy L, Dufresne E et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth 2007; 99 (2): 276-81. 2. Drugs that act on the neuromuscular junction. In: Calvey TN, Williams NE eds. Principles and Practice of Pharmacology for Anaesthetists. 4th edition. Blackwell Science. 2001; 170-95. Conflict of Interest:None declared |
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