Can remifentanil replace neuromuscular block for rapid sequence induction?

The ultra-short-acting opioid remifentanil could theoretically be a safer induction agent with less risk of aspiration than neuromuscular blockers like succinylcholine or rocuronium. Neuromuscular blockers relax lower esophageal sphincter tone, increasing the risk for reflux and aspiration.

But among 1150 patients considered high risk for aspiration at 15 French hospitals, those randomized to receive remifentanil had a higher rate of severe complications of intubation (aspiration, hypoxemia, hypotension, arrhythmia, cardiac arrest, or anaphylaxis), compared to those receiving neuromuscular blockade. This was a noninferiority trial; remifentanil fell below the prespecified threshold for inferiority, though with a wide confidence interval. Read in JAMA

Rapid sequence intubation: neuromuscular blockade vs remifentanil.