The rapid-onset opioid remifentanil failed to meet the criterion for noninferiority in comparison with rapid-onset neuromuscular blocking agents, researchers report. The drug was also “statistically inferior to neuromuscular blockers with regard to the rate of successful tracheal intubation without major complications, although the wide confidence interval limits conclusions about the difference,” the authors conclude.
Participants in the trial were 1,150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) when they underwent tracheal intubation in operating rooms at 15 French hospitals in 2019–21. Administered immediately after injection of a hypnotic agent, open-label neuromuscular blockers (succinylcholine or rocuronium) or remifentanil produced these outcomes: “In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, –6.1%; 95% CI, –11.6% to –0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, –5.7%; 2-sided 95% CI, –11.3% to –0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%).”