Remifentanil inferior to neuromuscular blockers for successful tracheal intubation in adults at risk of aspiration

There remains uncertainty on whether a rapid-onset opioid is non-inferior to a rapid-onset neuromuscular blocker during rapid sequence intubation?

Grillot et al. and colleagues from Nantes Université and 2Université Lille, France, did a study with the main objective of determining, "Are rapid-onset opioids non-inferior to rapid-onset neuromuscular blockers for rapid sequence intubation?"

The study summary includes the following:

• The study was carried out in 15 hospitals in France. There were a total of 1150 randomized patients with a mean age of 51 years.
• Patients were randomized as:

Five hundred seventy-five patients received intravenous Remifentanil 3 to 4 μg/kg immediately after injection of a hypnotic.

Five hundred seventy-five patients received neuromuscular blockers, intravenous succinylcholine or rocuronium 1 mg/kg immediately after injection of a hypnotic.

• The researchers measured the primary outcome as successful tracheal intubation without major complications (in the first attempt).
• The successful intubation on the first attempt occurred in 374 out of 575 patients, constituting 66.1 % receiving Remifentanil.
• Among patients receiving Neuromuscular blockers, 408 out of 575 patients constituting 71.6 %, had successful intubation on the first attempt.
• Remifentanil was inferior to neuromuscular blockers. The adjusted between-group difference was –6.1%.
• Nineteen patients with Remifentanil and 3 with neuromuscular blockers had hemodynamic instability with an adjusted difference of 2.8%.

To conclude, as per the study's findings, Remifentanil was inferior to neuromuscular blockers in the rate of successful tracheal intubation without major complications.

Further reading:

Grillot N et al. Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial. JAMA. 2023;329(1):28–38. doi:10.1001/jama.2022.23550