The purpose of this research is to compare four commonly used anesthesia medication strategies for placing a breathing tube in patients undergoing spine surgery that requires motor evoked potential (MEP) monitoring.
American Society of Anesthesiologists (ASA) physical status I-III
Scheduled for elective spine surgery (cervical, thoracic, or lumbar) requiring intraoperative MEP monitoring
Able to provide written informed consent
Known or suspected difficult airway (Mallampati class IV, history of difficult intubation, limited mouth opening < 3 cm, limited neck extension)
Body mass index (BMI) > 40 kg/m2
Known allergy or hypersensitivity to remifentanil, succinylcholine, rocuronium, sugammadex, or propofol
Personal or family history of malignant hyperthermia
Parallel
Low-Dose Remifentanil
DrugRemifentanil 2 mcg/kg intravenous bolus
High-Dose Remifentanil
DrugRemifentanil 4 mcg/kg intravenous bolus
Succinylcholine
DrugSuccinylcholine 1 mg/kg intravenous bolus
Rocuronium
DrugRocuronium 0.6 mg/kg intravenous bolus
Sugammadex
DrugSugammadex reversal after intubation
Percentage of Participants With Clinically Acceptable Intubating Conditions
Clinically acceptable intubating conditions are defined as intubating conditions rated as excellent or good using a standardized intubating conditions assessment. The assessment includes ease of laryngoscopy, vocal cord position and movement, and participant reaction to intubation. Overall intubating conditions are categorized as excellent, good, or poor. Excellent and good conditions will be counted as clinically acceptable, and poor conditions will be counted as not clinically acceptable. The outcome will be reported as the percentage of participants in each arm with clinically acceptable intubating conditions.
Percentage of Participants With Excellent Intubating Conditions
Excellent intubating conditions are defined as all assessed intubating condition domains rated as excellent. Domains include ease of laryngoscopy, vocal cord position and movement, and participant reaction to intubation. The outcome will be reported as the percentage of participants in each arm with excellent intubating conditions.
Percentage of Participants With Successful First-Attempt Endotracheal Intubation
Successful first-attempt endotracheal intubation is defined as successful placement of the endotracheal tube on the first laryngoscopy attempt, confirmed by capnography over four respiratory cycles. The outcome will be reported as the percentage of participants in each arm with successful first-attempt intubation.
Cormack-Lehane Grade of Glottic Visualization grade
Glottic visualization will be assessed using the Cormack-Lehane grading system. Grades range from 1 to 4, with lower grades indicating better visualization of the glottis and higher grades indicating poorer visualization. The outcome will be reported by grade for each arm.
Intubation Difficulty Scale Score
Intubation difficulty will be assessed using the Intubation Difficulty Scale. Scores range from 0 to infinity, with 0 indicating an easy intubation and scores greater than 5 indicating difficult intubation. The outcome will be reported as the Intubation Difficulty Scale score for each arm.
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