The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials


  • Section Editor: Jerrold Lerman

  • Work attributed to Department of Anesthesiology, American University of Beirut-Medical Center.

Roland Kaddoum, Department of Anesthesiology, American University of Beirut Medical Center, P. O. Box 11 0236, Beirut, Lebanon


Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1–9 years. Sevoflurane with remifentanil (1 or 2 μg·kg−1), lidocaine (2 mg·kg−1), or propofol (2 mg·kg−1) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg−1) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 μg·kg−1). No serious adverse events were reported with these combinations.