The primary aim of this review was to assess the effect of pharmacological agents administered to attenuate the haemodynamic response to tracheal intubation in paediatric patients up to 16 years of age undergoing elective surgery. Secondary aims were to identify adverse effects related to these agents, and the agents' roles in decreasing arrhythmias. A systematic search was conducted for articles listed in PubMed, CINAHL or the Cochrane database between January 1980 and June 2014. We included randomised controlled trials where the stated aim of the study included observing the effects of pharmacological agents on the haemodynamic response to tracheal intubation. The outcome measures were changes in mean, systolic and diastolic blood pressure and heart rate, adverse effects of drugs and arrhythmias. Sixteen publications with a total of 1408 children (ages two to 15 years) were identified. These studies varied in methodology and quality. Opioids were the commonest agents used and appeared to obtund the response in a dose-related manner. Fentanyl 2 μg/kg, remifentanil 1 μg/kg, sufentanil 0.1 and 0.2 μg/kg and alfentanil 25 μg/kg blunted the haemodynamic response. Remifentanil 3 μg/kg and sufentanil 0.3 μg/kg were the most effective in obliterating the response but led to hypotension in unstimulated patients. Opioid-related side-effects and arrhythmias were observed in few patients. We recommend that when required, the safe and effective doses identified in this review be used to obtund the haemodynamic response to intubation in paediatric patients, with close observation for the uncommon but recognised side-effects.
ShribmanA.J., SmithG., AcholaK.J.Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth1987; 59: 295–299.
2.
XueF.S., LiaoX., LiuK.P., LiuY., XuY.C., YangQ.Y.The circulatory responses to tracheal intubation in children: a comparison of the oral and nasal routes. Anaesthesia2007; 62: 220–226.
3.
PiccirilloG., CacciafestaM., ViolaE., SantagadaE., NoccoM., LionettiM.Influence of aging on cardiac baroreflex sensitivity determined non-invasively by power spectral analysis. Clin Sci (Lond)2001; 100: 267–274.
4.
CotéC.J., LermanJ., WardR.M.Pharmacokinetics and pharmacology of drugs used in children. In: CotéC.J., LermanJ., TodresD.I., ed. A Practice of Anesthesia for Infants and Children, 4th ed. Philadelphia: Saunders Elsevier2009. pp. 89–146.
5.
KliegmanR.M., StantonB.F., SchorN.F., St GemeJ.W.III, BehrmanR.E.Nelson Textbook of Paediatrics: 19th Ed.Philadelphia, PA: Elsevier Saunders2011, pp. 1613–1616.
6.
GuptaA., KaurR., MalhotraR., KaleS.Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants. Paediatr Anaesth2006; 16: 399–405.
7.
HigginsJ.P.T., AltmanD.G., SterneJ.A.C.Assessing risk of bias in included studies. In: HigginsJ.P.T., GreenD. (eds). Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011], The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org. Accessed January 2015.
8.
SplinterW.M.Intravenous lidocaine does not attenuate the haemodynamic response of children to laryngoscopy and tracheal intubation. Can J Anaesth1990; 37: 440–443.
9.
LindgrenL., RautiainenP., KlemolaD.M., SaarnivaaraL.Haemodynamic responses and prolongation of QT interval of ECG after suxamethonium-facilitated intubation during anaesthetic induction in children: a dose-related attenuation by alfentanil. Acta Anaesthesiol Scand1991; 35: 355–358.
10.
MikawaK., NishinaK., MaekawaN., TakaoY., AsanoM., ObaraH.Attenuation of the catecholamine response to trachea intubation with oral clonidine in children. Can J Anaesth1995; 42: 869–874.
11.
RobinsonD.N., O'BrienK., KumarR., MortonN.S.Trachea intubation without neuromuscular blockade in children: a comparison of propofol combined either with alfentanil or remifentanil. Paediatr Anaesth1998; 8: 467–471.
12.
AouadM.T., SayyidS.S., ZalaketM.I., BarakaA.S.Intravenous lidocaine as adjuvant to sevoflurane anaesthesia for endotracheal intubation in children. Anesth Analg2003; 96: 1325–1327.
13.
BatraY.K., Al QattanA.R., AliS.S., QureshiMl, KuriakoseD., MigahedA.Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant. Paediatr Anaesth2004; 14: 452–456.
14.
BlairJ., HillD., WilsonC.M., FeeJ.P.Assessment of tracheal intubation in children after induction with propofol and different doses of remifentanil. Anaesthesia2004; 59: 27–33.
15.
XueF.S., LiuK.P., LiuY., XuY.C., LiaoX., ZhangG.H.Assessment of small-dose fentanyl and sufentanil blunting the cardiovascular responses to laryngoscopy and intubation in children. Paediatr Anaesth2007; 17: 568–574.
16.
XueF.S., XuY.C., LiuY., YangQ.Y., LiaoX., LiuH.P.Different small-dose sufentanil blunting cardiovascular responses to laryngoscopy and intubation in children: a randomized, double-blind comparison. Br J Anaesth2008; 100: 717–723.
17.
XueF.S., XuY.C., LiuY., YangQ.Y., LiaoX., LiuH.P.Different small-dose remifentanil blunting the cardiovascular response to laryngoscopy and intubation in children: a randomized double-blind comparison. Eur J Anaesthesiol2008; 25: 106–112.
18.
ParkK., ParkS., KimJ., KimJ., ChaeY.Effect of remifentanil on tracheal intubation conditions and haemodynamics in children anaesthetised with sevoflurane and nitrous oxide. Anaesth Intensive Care2009; 37: 577–583.
19.
YangQ.Y., XueF.S., LiaoX., LiuH.P., LuoM.P., XuY.C.Comparison of bolus remifentanil versus bolus fentanyl for blunting cardiovascular intubation responses in children: a randomized, double-blind study. Chin Med J2009; 122: 44–50.
20.
LiaoX., YangQ.Y., XueF.S., LuoM.P., XuY.C., LiuY.Bolus dose remifentanil and sufentanil blunting cardiovascular intubation responses in children: a randomized, double-blind comparison. Eur J Anaesthesiol2009; 26: 73–80.
21.
YoonS-H, KimK-H, SeoS-H. Dose of remifentanil for minimizing the cardiovascular changes to tracheal intubation in paediatric patients. Korean J Anesthesiol2010; 59: 167–172.
22.
MireskandariS.M., AbulahrarN., DarabiM.E., RahimiI., Haji-MohamadiF., MovafeghM.Comparison of the effect of fentanyl, sufentanil, alfentanil, and remifentanil, on cardiovascular response to tracheal intubation in children. Iran J Pediatr2011; 21: 173–180.
23.
WangS.S., ZhangM.Z., SunY., WuC., XuW.Y., BaiJ.The sedative effects and the attenuation of cardiovascular and arousal responses during anaesthesia induction and intubation in paediatric patients: a randomized comparison between two different doses of preoperative intranasal dexmedetomidine. Paediatr Anaesth2014; 24: 275–281.
24.
GerardiM.J., SacchettiA.D., CantorR.M., SantamariaJ.P., GauscheM., LucidW., FoltinG.L.Rapid-sequence intubation of the pediatric patient. Ann Emerg Med1996; 28: 55–74.
25.
FriesenR.H., HondaA.T., ThiemeR.E.Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg1987; 66: 874–878.
26.
ShinoharaK., AonoH., UnruhG.K., KindscherJ.D., GotoH.Suppressive effects of remifentanil on hemodynamics in baro-denervated rabbits. Can J Anesth2000; 47: 361–366.
27.
NoseirR.K., FickeD.J., KunduA., ArainS.R., EbertT.J.Sympathetic and vascular consequences from remifentanil in humans. Anesth Analg2003; 96: 1645–1650.
28.
MorganJ.M., BarkerI., PeacockJ.E., EissaA.A comparison of intubating conditions in children following induction of anaesthesia with propofol and suxamethonium or propofol and remifentanil. Anaesthesia2007; 62: 135–139.
29.
SingletonM.A., RosenJ.I., FisherD.M.Plasma concentrations of fentanyl in infants, children and adults. Can J Anesth1987; 34: 152–155.
30.
GuayJ., GuadreaultP., TangA., GouletB., VarinF.Pharmacokinetics of sufentanil in normal children. Can J Anesth1992; 39: 14–20.
31.
MunozH.R., CortinezL.I., IbacacheM.E., AltermattF.R.Remifentanil requirements during propofol administration to block the somatic response to skin incision in children and adults. Anesth Analg2007; 104: 77–80.
32.
MunozH.R., CortinezL.I., AltermattF.R., DagninoJ.A.Remifentanil requirements during sevoflurane administration to block somatic and cardiovascular responses to skin incision in children and adults. Anesthesiology2002; 97: 1142–1145.
