If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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E-letters: Electronic letters published:
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Remifentanil vs Propofol for awake fibreoptic intubation
- Mario Shekar (29 February 2008)
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Increasing acceptance of Remifentanil for Sedation in Awake Fibreoptic Intubation
- Glyn D Harrison, Dr F Spears and Dr M Osiyemi (12 February 2008)
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Remifentanil vs propofol for awake fibreoptic Intubation
- Sally J Hargreaves, Nihat Bhuiyan (22 January 2008)
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Mario Shekar, Anaesthetic Spr Sheffield Teaching Hospitals
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Editor I found the paper by Rai and colleagues comparing propofol and remifentanil very interesting.I have recently changed from using propofol with boluses of fentanyl to remifentanil after attending an airway course conducted by Sheffield Hospitals Airway Group.Remifentanil has made awake fibre optic intubation a far better experience for me and my patients.I have found the patients to be far more comfortable and cooperative.As many of these patients come for repeated operations it is important to get it right the first time.It is interesting to note that the authors didn't need to anaesthetise the airway appart from the vocal cords. Conflict of Interest:None declared |
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Glyn D Harrison , Dr F Spears and Dr M Osiyemi
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Editor We read with interest the paper by Rai and colleagues comparing remifentanil with propofol for sedation in awake fibreoptic intubation (AFOI). 1 We have been using remifentanil for sedation during AFOI for nearly three years and the paper confirms our strongly held belief the intubating conditions afforded by remifentanil are superior to other methods of sedation. In a recent review of 35 of our own cases all using remifentanil for sedation (plus 1-2 mg of midazolam) and spray-as-you-go local anaesthetic technique we had no significant complications. Passing the fibrescope into the trachea was described as easy in 68% of cases and passing the tube easy in 80%. We also found that recall of the event occurs frequently but 26 out of 28 patients were satisfied with the procedure. We teach our trainees a standard technique for fibreoptic intubation using remifentanil and run a fibreoptic workshop which all trainees are expected to attend before using the fibrescopes on patients. They then progress through using the fibrescopes on anaesthetised patients before performing awake fibreoptic intubations. The standard technique includes remifentanil at a dose of 0.3mcg/kg/min with no initial bolus, and topical local anaesthetic to the nose and airway. A small amount of midazolam can be administered which reduces recall of the procedure. Verbal contact is maintained throughout the procedure and monitoring includes the use of a carbon dioxide monitoring device that is placed intranasally We are currently conducting a national survey to evaluate the extent to which remifentanil has been adopted for sedation in awake fibreoptic intubation. 1 Rai MR, Parry TM, Dombrovskis A, Warner OJ. Remifentanil target- controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blind randomized controlled trial Br J Anaesth 2008; 100:123-130 Dr Glyn Harrison Consultant Anaesthetist Luton and Dunstable Hospital Luton Dr F Spears Consultant Anaesthetist Luton and Dunstable Hospital Luton Dr M Osiyemi SpR Anaesthetics Luton and Dunstable Hospital Luton Conflict of Interest:None declared |
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Sally J Hargreaves , Nihat Bhuiyan
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Editor - We read with interest the Randomised Controlled Trial by Rai and colleagues1 on remifentanil target-controlled infusion (TCI) vs propofol TCI for conscious sedation for awake fibreoptic intubation (AFOI). We are not surprised by the conclusions that remifentanil TCI appears to provide better conditions for AFOI when compared to propofol TCI. Our institution (University Hospital Aintree in Liverpool), is a tertiary referral centre for ENT and maxillofacial surgery and we perform around 400 AFOI a year for bona fide difficult airways. We have used remifentanil as the sole sedation agent for AFOI for the last four years, and we use it for both elective and emergency work. We would not consider using propofol in any circumstances because of remifentanil’s far superior analgesic and anti-tussive properties. Of the twenty or so Consultants, Staff Grades and Associate Specialists who regularly use remifentanil in this setting there is some variation in the use of midazolam and topical anaesthesia of the airway. We have found that cocaine applied nasally is sufficient as the sole topical agent. However some practitioners also use lidocaine spray to the oropharynx and/or 4% lidocaine to the vocal cords. We always have two experienced anaesthetists, one to administer sedation and one to perform the intubation. A survey we are conducting confirms our impression that patients are satisfied with the technique and have minimal discomfort and recall. Its use has significantly improved confidence through all grades of anaesthetists and senior trainees can expect to undertake approximately 20 AFOI using remifentanil in an average six month attachment. S. Hargreaves N. Bhuiyan Liverpool, UK *E-mail: sally_hargreaves@yahoo.com 1 Rai MR, Parry TM, Dombrovskis A, Warner OJ. Remifentanil target- controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial. Br J Anaesth 2008; 100: 125-30 Conflict of Interest:None declared |
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