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Grillot N, Lebuffe G, Huet O, Lasocki S, Pichon X, Oudot M, Bruneau N, David JS, Bouzat P, Jobert A, Tching-Sin M, Feuillet F, Cinotti R, Asehnoune K, Roquilly A. Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial. JAMA 2023; 329:28-38. [PMID: 36594947 PMCID: PMC9856823 DOI: 10.1001/jama.2022.23550] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent. OBJECTIVE To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021. INTERVENTIONS Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic. MAIN OUTCOMES AND MEASURES The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%. RESULTS Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%). CONCLUSIONS AND RELEVANCE Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03960801.
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Affiliation(s)
- Nicolas Grillot
- Nantes Université, CHU Nantes, Service d’Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes, France
| | - Gilles Lebuffe
- Université Lille, CHU Lille, ULR 7354–GRITA Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Pôle Anesthésie Réanimation, Lille, France
| | - Olivier Huet
- Département d’Anesthésie Réanimation et Médecine Péri-opératoire, CHRU Brest, Université de Bretagne occidentale, Brest, France
| | - Sigismond Lasocki
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Angers, Angers, France
| | - Xavier Pichon
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Toulouse, University Toulouse III–Paul–Sabatier, Toulouse, France
| | - Mathieu Oudot
- Department of Anesthesiology, Centre Hospitalier Departemental, La Roche sur Yon, France
| | - Nathalie Bruneau
- Université Lille, CHU Lille, Hopital Salengro, Pôle Anesthésie Réanimation, Lille, France
| | - Jean-Stéphane David
- Service d’Anesthésie Réanimation, Groupe Hospitalier Sud, Hospices Civils de Lyon, Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Grenoble, France
| | - Alexandra Jobert
- Nantes Université, CHU Nantes, DRCI, Departement Promotion, Nantes, France
- Nantes Université, Univerisité Tours, CHU Nantes, CHU Tours, INSERM, Methods in Patient-Centered Outcomes and Health Research, SPHERE, Nantes, France
| | - Martine Tching-Sin
- Nantes Université, CHU Nantes, Service de Pharmacie, Hôtel Dieu, Nantes, France
| | - Fanny Feuillet
- Nantes Université, Univerisité Tours, CHU Nantes, CHU Tours, INSERM, Methods in Patient-Centered Outcomes and Health Research, SPHERE, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacie, Hôtel Dieu, Nantes, France
- Nantes Université, CHU Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, Nantes, France
| | - Raphael Cinotti
- Nantes Université, CHU Nantes, Service d’Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes, France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, Service d’Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Service d’Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes, France
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Grillot N, Garot M, Lasocki S, Huet O, Bouzat P, Le Moal C, Oudot M, Chatel-Josse N, El Amine Y, Danguy des Déserts M, Bruneau N, Cinotti R, David JS, Langeron O, Minville V, Tching-Sin M, Faurel-Paul E, Lerebourg C, Flattres-Duchaussoy D, Jobert A, Asehnoune K, Feuillet F, Roquilly A. Assessment of remifentanil for rapid sequence induction and intubation in patients at risk of pulmonary aspiration of gastric contents compared to rapid-onset paralytic agents: study protocol for a non-inferiority simple blind randomized controlled trial (the REMICRUSH study). Trials 2021; 22:237. [PMID: 33785069 PMCID: PMC8009075 DOI: 10.1186/s13063-021-05192-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background Rapid-onset paralytic agents are recommended to achieve muscle relaxation and facilitate tracheal intubation during rapid sequence induction in patients at risk of pulmonary aspiration of gastric contents. However, opioids are frequently used in this setting. The study’s objective is to demonstrate the non-inferiority of remifentanil compared to rapid-onset paralytic agents, in association with an hypnotic drug, for tracheal intubation in patients undergoing procedure under general anesthesia and at risk of pulmonary aspiration of gastric contents. Methods The REMICRUSH (Remifentanil for Rapid Sequence Induction of Anaesthesia) study is a multicenter, single-blinded, non-inferiority randomized controlled trial comparing remifentanil (3 to 4 μg/kg) with rapid-onset paralytic agents (succinylcholine or rocuronium 1 mg/kg) for rapid sequence induction in 1150 adult surgical patients requiring tracheal intubation during general anesthesia. Enrolment started in October 2019 in 15 French anesthesia units. The expected date of the final follow-up is October 2021. The primary outcome is the proportion of successful tracheal intubation without major complications. A non-inferiority margin of 7% was chosen. Analyses of the intent-to-treat and per-protocol populations are planned. Discussion The REMICRUSH trial protocol has been approved by the ethics committee of The Comité de Protection des Personnes Sud-Ouest et Outre-Mer II and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals. The REMICRUSH trial is the first randomized controlled trial powered to investigate whether remifentanil with hypnotics is non-inferior to rapid-onset paralytic agents with hypnotic in rapid sequence induction of anesthesia for full stomach patients considering successful tracheal intubation without major complication. Trial registration ClinicalTrials.gov NCT03960801. Registered on May 23, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05192-x.
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Affiliation(s)
- Nicolas Grillot
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093, France.
| | - Matthias Garot
- CHU de Lille, Pole Anesthésie Réanimation, Hôpital Claude Huriez, Lille, France
| | - Sigismond Lasocki
- Université d'Angers, CHU d'Angers, Département Anesthésie Réanimation, Angers, F-49933, France
| | - Olivier Huet
- Anaesthesia, and Intensive Care Unit, Brest Regional University Hospital, Brest, France
| | - Pierre Bouzat
- Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, F-38043, Grenoble, France
| | - Charlène Le Moal
- Anaesthesia and Intensive Care Unit, Le Mans Public Hospital, Le Mans, France
| | - Mathieu Oudot
- Anaesthesia Unit, Vendée District Hospital Center, La Roche-sur-Yon, France
| | | | - Younes El Amine
- Anaesthesia Unit, Valenciennes Public Hospital, Valenciennes, France
| | | | - Nathalie Bruneau
- Anaesthesia and Intensive Care Unit, Lille Regional University Hospital, Lille, France
| | - Raphael Cinotti
- CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Guillaume et René Laennec, Université de Nantes, Saint-Herblain, 44800, France
| | - Jean-Stéphane David
- Hospices Civils de Lyon, Lyon Sud Regional University Hospital, Anaesthesia and Intensive Care Unit, Lyon, France
| | - Olivier Langeron
- Anaesthesia and Intensive Care Unit, Henri-Mondor University Hospital (AP-HP), Créteil, France
| | - Vincent Minville
- Anaesthesia and Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | | | - Elodie Faurel-Paul
- Department of Clinical Research, Nantes University Hospital, Nantes, France
| | - Céline Lerebourg
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093, France
| | - Delphine Flattres-Duchaussoy
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093, France
| | - Alexandra Jobert
- Department of Clinical Research, Nantes University Hospital, Nantes, France
| | - Karim Asehnoune
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093, France
| | - Fanny Feuillet
- Nantes University Hospital, Methodology and Biostatistics Platform, Department of Clinical Research, Nantes, France.,Nantes University, INSERM, SPHERE U1246, Nantes, France
| | - Antoine Roquilly
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093, France
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Rousvoal S, Oudot M, Fontaine J, Kloareg B, Goër SL. Witnessing the evolution of transcription in mitochondria: the mitochondrial genome of the primitive brown alga Pylaiella littoralis (L.) Kjellm. Encodes a T7-like RNA polymerase. J Mol Biol 1998; 277:1047-57. [PMID: 9571021 DOI: 10.1006/jmbi.1998.1679] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A region of the mitochondrial genome of the primitive brown alga Pylaiella littoralis containing a plasmid-like insert which contains a transcribed T7-phage-type RNA polymerase gene is described. This is a first report of a phage-type RNA polymerase gene integrated in a mitochondrial genome. As the mitochondrial genome of this alga also contains sigma-70 proteobacterial promoter regions, i.e. traces of the ancestral alpha2betabeta'sigma-70 proteobacterial RNA polymerase, this genome witnesses two types of RNA polymerases. As such the mitochondrial genome of P. littoralis represents a unique stage in the evolution of transcription in mitochondria, which contrasts with that of the primitive protist Reclinomonas americana, which still retains the ancestral alpha2betabeta'sigma-70 proteobacterial RNA polymerase genes, and with animals, land plants and fungi, which use phage-type polymerases.
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Affiliation(s)
- S Rousvoal
- Station Biologique de Roscoff, CNRS (UPR 9042), UPMC B.P. 74, Roscoff, Cedex, 29682, France
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