Authors
Paweł Radkowski, Izabella Jadwiga Brykczyńska, Łukasz Banasiak, Łukasz Grabarczyk
Published in
Medical science monitor : international medical journal of experimental and clinical research. Volume 32. Pages e951765. Jul 14, 2026. Epub Jul 14, 2026.
Abstract
Endotracheal intubation is a fundamental component of modern airway management in elective and emergency settings. Neuromuscular blocking agents (NMBAs) are commonly used to optimize intubating conditions by facilitating jaw relaxation, improving vocal cord visualization, and reducing airway trauma. However, their administration can be contraindicated or undesirable in specific situations, such as procedures requiring intraoperative neuromonitoring, short-duration surgeries, patients with neuromuscular disorders, or critically ill individuals at risk of prolonged blockade or adverse reactions. This review examines current evidence regarding the feasibility, effectiveness, and safety of intubation without neuromuscular blockade. Data from randomized trials and meta-analyses indicate that although NMBAs are associated with a higher incidence of optimal intubation conditions and improved first-attempt success rates, their omission does not significantly increase postoperative complications, such as sore throat or hoarseness. The principal concern with NMBA-free techniques remains hemodynamic instability, particularly hypotension and bradycardia, associated with the deeper levels of anesthesia required to suppress airway reflexes. Alternative strategies include short-acting opioids (remifentanil, alfentanil, fentanyl, and sufentanil), intravenous hypnotics (propofol, ketamine, and etomidate), inhalational agents (sevoflurane), and adjuncts (dexmedetomidine and magnesium sulfate). These agents attenuate sympathetic responses to laryngoscopy while preserving neuromonitoring compatibility. Their distinct pharmacodynamic profiles influence intubation conditions, apnea duration, and cardiovascular stability. Current evidence supports the feasibility of NMBA-free intubation in carefully selected patients when performed by experienced clinicians. Individualized risk assessment and careful drug titration are essential. Further large-scale studies are needed to establish standardized protocols and define patient populations most likely to benefit from this approach.
PMID:
42447073
Bibliographic data and abstract were imported from PubMed on 15 Jul 2026.
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