Remifentanil for modified rapid sequence induction in children: a proof-of-concept study in a selected pediatric...

Rapid Sequence Induction (RSI) is widely used in pediatric anesthesia for children at risk of pulmonary aspiration. Modified RSI has been proposed to reduce the risk of hypoxemia during induction while maintaining airway protection. This proof-of-concept study aimed to describe peri-intubation outcomes associated with the use of intravenous bolus remifentanil during modified RSI in a selected pediatric population at risk of pulmonary aspiration.

This proof-of-concept study analyzed data from pediatric patients, with at least one risk factor for pulmonary aspiration, undergoing modified RSI with remifentanil 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 analyzed.

A total of 267 children were included (median age 8.0-years [IQR 5.0-12.0]). Successful first-attempt intubation without major complications was achieved in 92.9% (248/267; 95% CI 88.9-95.6). No major complications were reported. Nineteen patients (7.1%) required more than one intubation attempt. In multivariable analysis, age < 1-year (adjusted OR = 11.4, 95% CI 3.5-34.3; p < 0.001) and Cormack-Lehane grade ≥ 2 (adjusted OR = 10.2, 95% CI 1.8-57.2; p = 0.008) were associated with failed first-attempt intubation. Minor complications occurred in 15.7% of patients, mainly transient hypotension.

In this proof-of-concept study of a selected pediatric population, modified RSI with remifentanil was associated with a first-attempt intubation success rate of 92.9%, with no major complications observed. These descriptive findings should be considered hypothesis-generating and support further evaluation of remifentanil-based modified RSI in prospective randomized studies.