Propofol and remifentanil for rapid sequence intubation in a pediatric patient at risk for aspiration with elevated intracranial pressure.

Aspiration is a significant cause of anesthetic morbidity, occurring most commonly during the induction of anesthesia. For patients with a high likelihood of aspiration, rapid sequence intubation (RSI) techniques may minimize this risk by reducing the time between the loss of protective airway reflexes and the placement of a cuffed endotracheal tube. Although RSI frequently involves the administration of a neuromuscular-blocking agent (NMBA) such as succinylcholine or rocuronium, there are times when the administration of an NMBA is contraindicated or undesirable. We present an 11-year-old boy who presented with vomiting, papilledema, and a history concerning for an undiagnosed neuromuscular disorder. Deep sedation or anesthesia was required during an emergent lumbar puncture to evaluate his symptoms. Rapid sequence intubation was successfully performed with propofol and remifentanil without the use of an NMBA. We highlight the anesthetic considerations in such a clinical scenario and review the literature regarding the combination of remifentanil and propofol for RSI.