Quality of intubation using remifentanil in obese patients (OBEREM): A randomised, double-blind pilot trial

Airway management can be challenging in obese patients. The intubation sequence should facilitate rapid achievement of optimal intubation conditions. In some patients, neuromuscular blocking agents (NMBAs) must be avoided. Therefore, an alternative intubation sequence is required. The objectives of this study were to evaluate the intubation conditions achieved with an NMBA-free intubation sequence using propofol and remifentanil, and to assess whether a higher dose of remifentanil improved these conditions.

We conducted a prospective, single-centre, randomised, double-blind pilot trial involving obese patients undergoing bariatric surgery. Patients were allocated to two groups to receive either remifentanil 3 µg kg^-1 or 3 µg kg^-1 + 30%, both in association with propofol. The primary outcome was the percentage of patients with excellent intubation conditions. Secondary outcomes included intubation difficulty, respiratory and haemodynamic effects, and traumatic complications.

Intubation conditions were excellent in 32.8% of patients and acceptable (excellent or good) in 86.2%. Increasing the remifentanil dose did not significantly modify intubating conditions (P-value = 0.548). Intubation was rated as easy in 89.7% of patients. No serious complications occurred, although haemodynamic instability was frequent (arterial hypotension 93.1%; bradycardia 48.3%).

An NMBA-free induction sequence with remifentanil may be feasible in obese patients, providing acceptable, easy, and atraumatic intubating conditions. Increasing the remifentanil dose does not appear to significantly improve these conditions. This sequence may represent an alternative when NMBAs must be avoided. However, before routine clinical use, further studies are now warranted to optimise it, particularly regarding haemodynamic safety.

ClinicalTrials.gov (NCT05026125).