REMICRUSH
Trial question
Is remifentanil noninferior to a rapid-onset neuromuscular blocker in patients at risk of aspiration during rapid sequence intubation in the operating room?
Study design
Multi-center
Open label
RCT
Population
Characteristics of study participants
50.0% female
50.0% male
N = 1150
1150 patients (573 female, 577 male).
Inclusion criteria: adult patients at risk of aspiration who underwent tracheal intubation in the operating room.
Key exclusion criteria: planned impossible intubation; contraindication to use of succinylcholine and rocuronium; cardiac arrest; preoperative hypoxemia; hemodynamic shock.
Interventions
N=575 remifentanil (an intravenous dose of 3-4 mcg/kg, immediately after injection of a hypnotic).
N=575 neuromuscular blockers (intravenous succinylcholine or rocuronium 1 mg/kg, immediately after injection of a hypnotic).
Primary outcome
Successful tracheal intubation on first attempt without major complications
66.1%
71.6%
71.6 %
53.7 %
35.8 %
17.9 %
0.0 %
Remifentanil
Neuromuscular
blockers
Difference exceeding
non-inferiority
margin ✗
Difference exceeding non-inferiority margin in successful tracheal intubation on first attempt without major complications (66.1% vs. 71.6%; AD -6.1%, 95% CI -11.6 to -0.5).
Secondary outcomes
No significant difference in time from induction to successful intubation (2.5 min vs. 2.5 min).
Significant increase in intubation difficulty scale score (3 points vs. 2.7 points; AD 0.4 points, 95% CI 0.2 to 0.6).
No significant difference in postoperative desaturation ≤ 92% (10.3% vs. 9.9%; AD 0.6%, 95% CI -2.7 to 3.9).
Safety outcomes
No significant difference in severe adverse events and hemodynamic instability.
Conclusion
In adult patients at risk of aspiration who underwent tracheal intubation in the operating room, remifentanil was not noninferior to neuromuscular blockers with respect to successful tracheal intubation on first attempt without major complications.
Reference
Nicolas Grillot, Gilles Lebuffe, Olivier Huet et al. Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration. JAMA. 2023 Jan 3;329(1):28-38.
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