Tracheal intubation in routine practice with and without muscular relaxation: an observational study.

BACKGROUND AND OBJECTIVE: The ease of endotracheal intubation has been recently shown to affect the incidence of laryngeal injury. There remains controversy as to whether or not a muscle relaxant is routinely required for tracheal intubation. This study examined conditions of intubation in our routine practice, which employs a relaxant-sparing approach. METHODS: All adult patients scheduled for surgery with general anaesthesia were prospectively included. A muscle relaxant was used to facilitate intubation when it was required for the surgical procedure and/or otherwise regarded as necessary by the anaesthesiologist. In the remaining patients, a relaxant-free intubation was performed. Intubating conditions were evaluated in all the patients as well as the post-intubation laryngeal symptoms. RESULTS: Between March and July 2003, 612 patients were consecutively included. A muscle relaxant was used in 32% of patients and no relaxant in the remaining patients (68%). Clinically acceptable intubating scores were observed in 98.4% overall with no significant difference between the two groups. Excellent conditions occurred more frequently in the relaxant group as compared to the relaxant-free group, 87% vs. 72%, P = 0.005. Laryngeal symptoms occurred in 184 (33%) patients with no difference between the two groups. CONCLUSIONS: Our relaxant-sparing approach did not increase the incidence of poor conditions of intubation nor laryngeal symptoms. However, excellent conditions occurred more frequently in the relaxant group. A more flexible approach to the issue of the need for neuromuscular blockade prior to intubation is proposed.

[Remifentanil-midazolam compared to sufentanil-midazolam for ICU long-term sedation]. / Rémifentanil-midazolam versus sufentanil-midazolam pour la sédation prolongée en réanimation.

OBJECTIVE: Remifentanil has a unique metabolic pathway that holds potential benefits for long-term sedation. We compared remifentanil-midazolam to sufentanil-midazolam in 41 critically ill adults requiring mechanical ventilation. STUDY DESIGN: Randomized double-blind trial. PATIENTS AND METHODS: Infusion rates were titrated every 4 hours to achieve the desired Ramsay score. Five fold increases in dose requirement was considered as the development of tolerance. Drugs requirement, development of tolerance and weaning time of ventilation were compared. RESULTS: The study was stopped after an interim analysis. The remifentanil and sufentanil groups were comparable regarding IGS II: 56+/-22 vs 64+/-26, mean+/-SD, ICU length of stay: 26 (8-45) vs 19 (11-34) days, and sedation duration: 6 (4-19) vs 6 (3-16)days, median [interquartile range, IQR]). There was a shorter weaning time in the remifentanil group as compared to sufentanil group: 22 h (12-53) vs 96 (47-142) h, median [IQR], p=0.04). The daily opioid infusion rate needed to be decreased over time only in sufentanil group, p < 0.001. Tolerance occurred in 6 (30%; CI(95), 10 to 40%) remifentanil and no sufentanil patients (P=0.02). CONCLUSION: Sufentanil infusion needed to be reduced over time and prolonged the weaning time when compared to remifentanil.