Optimal Concentration of Remifentanil for NIM Tube Intubation With Low-dose NMBA
Status:
Recruiting
Trial end date:
2024-03-20
Target enrollment:
Participant gender:
Summary
During thyroid surgery, Intraoperative Neuromonitoring (IONM) plays a crucial role in
preventing serious complications such as bilateral vocal cord paralysis. It achieves this by
detecting damage to the recurrent laryngeal nerve (RLN) and predicting the RLN's functional
status. The utilization of Nerve Integrity Monitoring tubes (NIM tubes) is on the rise for
effective IONM. As IONM relies on observing electromyographic (EMG) responses to direct
electrical nerve stimulation, the routine use of neuromuscular blocking agents (NMBAs) in
general anesthesia can impact the interpretation of IONM results and potentially reduce
sensitivity to nerve responses to stimulation. However, the use of NMBAs is essential for
ensuring smooth endotracheal intubation in patients undergoing general anesthesia. Numerous
studies suggest that NMBA usage provides superior intubation conditions and reduces vocal
cord complications compared to scenarios without NMBA.
Various regimens for neuromuscular blockade methods are employed during IONM in thyroid
surgery, ranging from not using NMBAs at all to using a full dose of NMBA for intubation.
This is followed by the administration of sugammadex, an NMBA reversal agent, before nerve
monitoring. One of the methods known for providing satisfactory intubation conditions while
ensuring the quality of EMG signals during IONM in thyroid surgery is using rocuronium at an
ED95 dose of 0.3 mg/kg. This approach is considered suitable for most IONM scenarios.
However, when adequate muscle relaxation is not achieved, not all patients can undergo
intubation, necessitating a strategy for appropriate intubation conditions.
Historically, it has been reported that achieving satisfactory intubation conditions without
the use of NMBA during general anesthesia requires higher amounts of propofol and opioids.
Therefore, the assumption is made that using remifentanil, an opioid used in total
intravenous anesthesia (TIVA), at an appropriate concentration can provide acceptable
intubation conditions with minimal NMBA use for patients undergoing IONM.
This study aims to determine the optimal concentration of remifentanil needed to achieve
excellent intubation conditions in patients undergoing thyroid surgery with IONM using
rocuronium 0.3 mg/kg as the NMBA during TIVA