Remifentanil as an alternative in modified rapid sequence induction: A Proof-of-concept study in a selected paediatric population

IntroductionRapid sequence induction (RSI) is widely used in paediatric anaesthesia. Concerns over complications associated with classical RSI have prompted the exploration of alternatives. This study was conducted to determine the feasibility and safety of using bolus remifentanil in combination with a hypnotic agent for paediatric RSI. MethodsThis proof-of-concept study analysed data from paediatric patients, with at least one risk factor for pulmonary aspiration, undergoing RSI with remifentanil at the Montpellier University Hospital between December 2021 and August 2023. Exclusion criteria included the planned use of a neuromuscular blocking agent for RSI, preoperative hypoxemia, hemodynamic shock or difficult intubation risk factors. Remifentanil was administered by direct intravenous injection with optional prophylactic administration of atropine. Data on intubation success rates, major and minor complications and rescue treatment were collected and analysed. ResultsThe study included 267 children with a mean age of 7.8 +/- 4.4 years. The success rate for the first intubation attempt was 92.9% (95% CI, 88.9-95.6). No major complication or pulmonary aspiration was reported. Minor complications, primarily hypotension, occurred in 15.7% of patients. The prophylactic use of atropine was correlated with a reduction in minor complications. DiscussionThis study supports the use of remifentanil for RSI in a selected paediatric population. Remifentanil offers good intubation conditions with a high success rate at the first attempt and a high safety profile with no major complication reported. Prophylactic atropine administration seems beneficial in reducing minor complications. These findings advocate for integrating remifentanil as an alternative in protocols for modified RSI. Further randomised studies are required to validate such outcomes and refine clinical approaches.