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Published on: January 17, 2011
Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and
Luc E Vanlinthout1,2, Bénédicte Geniets2, Jacques J Driessen3
1Department of Anesthesiology and Algology, University Hospital Gasthuisberg, Leuven, Belgium.
Insights
Neuromuscular-blocking agents significantly improve tracheal intubation success and quality in pediatric patients. Their use is linked to better hemodynamic stability and fewer failed intubation attempts during anesthesia.
Area of Science:
- Anesthesiology
- Pediatric Critical Care
- Pharmacology
Background:
- Tracheal intubation in pediatric patients can be challenging.
- The efficacy of neuromuscular-blocking agents (NMBAs) for this procedure is debated due to varied study designs.
- A meta-analysis was needed to synthesize existing evidence on NMBA use for pediatric intubation.
Purpose of the Study:
- To determine the effectiveness of neuromuscular-blocking agents in facilitating tracheal intubation in pediatric patients.
- To assess the impact of NMBAs on intubation conditions and hemodynamic parameters.
- To generalize findings across different populations, settings, and treatments.
Main Methods:
- Systematic search for randomized controlled trials (RCTs) involving pediatric patients (0-12 years, ASA class I-II).
- Meta-analysis of 22 RCTs (1651 participants) comparing NMBA use versus no NMBA for tracheal intubation.
- Outcomes analyzed included intubation conditions and hemodynamic values using random-effects models.
Main Results:
- NMBAs significantly increased the likelihood of excellent (RR=1.41) and acceptable (RR=1.13) intubating conditions.
- Unacceptable intubation conditions (RR=0.35) and failed first attempts (RR=0.25) were less frequent with NMBA use.
- NMBA use was associated with improved systolic/mean arterial pressure, heart rate, and reduced arrhythmias.
Conclusions:
- Neuromuscular-blocking agents enhance the quality and success rate of tracheal intubation in pediatric patients.
- NMBA administration during light-to-moderate anesthesia improves hemodynamic stability during induction.
- Evidence supports the routine use of NMBAs for facilitating pediatric tracheal intubation.
Background:
The benefit of using neuromuscular-blocking agents to facilitate tracheal intubation in pediatric patients remains unclear due to variations in design, treatments, and results among trials. By combining the available evidence, we aimed to establish whether scientific findings are consistent and can be generalized across various populations, settings, and treatments.
Methods:
A systematic search for randomized controlled trials, related to the use of neuromuscular-blocking agents for tracheal intubation in American Society of Anesthesiologists class I-II participants (0-12 years), was performed. We considered all randomized controlled trials that studied whether intubation conditions and hemodynamics obtained by using neuromuscular-blocking agents were equivalent to those that were achieved without neuromuscular-blocking agents. We combined the outcomes in Review Manager 5.3 (RevMan, The Cochrane Collaboration) by pairwise random-effects meta-analysis using a risk ratio (RR) for intubation conditions and mean difference for hemodynamic values (mean [95% Confidence Intervals]). Heterogeneity among trials was explored using sensitivity analyses.
Results:
We identified 22 eligible randomized controlled trials with 1651 participants. Overall, the use of a neuromuscular-blocking agent was associated with a clinically important increase in the likelihood of both excellent (RR = 1.41 [1.19-1.68], I2 = 76%) and acceptable (RR = 1.13 [1.07-1.19], I2 = 68%) intubating conditions. There is strong evidence that both unacceptable intubation conditions (RR = 0.35 [0.22-0.46], I2 = 23%) and failed first intubation attempts (RR = 0.25 [0.14-0.42], I2 = 0%) were less likely to occur when a neuromuscular-blocking agent was used compared with when it was not. Higher systolic or mean arterial pressures (mean difference = 13.3 [9.1-17.5] mm Hg, I2 = 69%) and heart rates (mean difference = 15.9 [11.0-20.8] beats/min, I2 = 75%) as well as a lower incidence of arrhythmias were observed when tracheal intubation was facilitated by neuromuscular-blocking agents.
Conclusion:
The use of a neuromuscular-blocking agent during light-to-moderate depth of anesthesia can improve the quality as well as the success rate of tracheal intubation and is associated with better hemodynamic stability during induction of anesthesia.
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