Propofol relieves post-extubation laryngospasm in obstetric anesthesia

Comparison of the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm among patients awakening from general anaesthesia: A prospective randomised clinical trial

BACKGROUND

Coughing and laryngospasm are undesirable consequences occurring when patients awaken from general anaesthesia. The objective of the study aimed to compare the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm.

METHODS

In all, 120 patients scheduled surgery under general anaesthesia were randomly assigned into three groups. Patients in the control group (C-group) received intravenous 0.9% NaCl, while patients in the propofol group (P-group) received intravenous 0.25mg/kg propofol and patients in the propofol combined with ketamine group (PK-group) received intravenous 0.25mg/kg of propofol plus 0.15mg/kg of ketamine. Drugs were administered before extubation. Incidence and severity of coughing and laryngospasm were recorded by a blinded anaesthesiologist.

RESULTS

Subjects of the PK-group (25%) experienced significantly reduced incidence of postoperative cough than that in the P-group (55%) and C-group (72.5%) (all P < 0.05). The severity of cough in the PK-group was significantly less than that in the P-group and C-group (P = 0.039 and P < 0.001, respectively). No significant difference was found in the incidence and severity of laryngospasm between comparison groups.

CONCLUSION

Intravenous combination of propofol and low-dose ketamine significantly reduced the incidence and severity among patients awakening from general anaesthesia.

Management of Refractory Laryngospasm

Laryngospasm has been well described in patients emerging from general anesthesia (GA) and is routinely managed with intermittent positive-pressure mask ventilation, a temporary increase in the depth of anesthesia, or small, titrated amounts of succinylcholine. Patients with severe laryngospasm require reintubation to maintain adequate oxygenation and ventilation. However, reintubation may be only a temporary solution because laryngospasm may recur during re-emergence and re-extubation; thus, anesthesiologists need a comprehensive plan that addresses potential causes of laryngospasm and incorporates continuous positive airway pressure (CPAP) for patients with difficulty emerging from GA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a noninvasive ventilation and oxygenation technique used to provide apneic oxygenation, which also generates CPAP. THRIVE uses a high-flow nasal cannula and is more easily tolerated than CPAP with a tight-fitting mask. To our knowledge, we present the first case of refractory laryngospasm during emergence from GA that was successfully managed with THRIVE.

Low dose propofol vs. lidocaine for relief of resistant post-extubation laryngospasm in the obstetric patient

Background

Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5 mg.kg⁻¹) vs. lidocaine (1.5 mg.kg⁻¹) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures.

Method

This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed.

Results

In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. Among these, 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. Among these, 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm.

Conclusion

Small dose of propofol (0.5 mg.kg⁻¹) is marginally more effective than lidocaine (1.5 mg.kg⁻¹) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.

[Low dose propofol vs. lidocaine for relief of resistant post-extubation laryngospasm in the obstetric patient]

BACKGROUND

Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5mg.kg^-1) vs. lidocaine (1.5mg.kg^-1) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures.

METHOD

This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed.

RESULTS

In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm.

CONCLUSION

Small dose of propofol (0.5mg.kg^-1) is marginally more effective than lidocaine (1.5mg.kg^-1) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.

The effects of propofol, ketamine and combination of them in prevention of coughing and laryngospasm in patients awakening from general anesthesia: A randomized, placebo-controlled, double blind clinical trial

BACKGROUND

Coughing and laryngospasm are undesirable outcomes occurring during emergence from general anesthesia. We compared the effect of small doses of propofol, ketamine and a combination of them on the occurrence and severity of coughing and laryngospasm in patients awakening from general anesthesia.

MATERIALS AND METHODS

160 patients who were scheduled to undergo operations under general anesthesia were randomly assigned to one of the following groups, 40 in each group: propofol group (0.25 mg/kg intravenous (IV) propofol), ketamine group (0.25 mg/kg IV ketamine), combination group (0.25 mg/kg IV propofol, and 0.25 mg/kg IV ketamine) and control (0.1 ml/kg IV saline). Drugs were administered before extubation at previously defined time. Presence and severity of coughing and laryngospasm were recorded within twominutes after extubation.

RESULTS

The presence of coughing in the combination group (27.5%) was less than that in other groups; also it was less frequent in the propofol group (57.5%) than the control (82.5%) (all P < 0.05). But the incidence did not differ between the propofol and the ketamine (70%) group; nor did it differ between the ketamine and control groups (P = 0.356 and P = 0.121, respectively). The cases with severe coughing (grade 3) in the combination group (none) were significantly less than in the propofol (four) and the control groups (seven) (P = 0.040 and P = 0.006 respectively). There was no significant difference between the groups in frequency of laryngospasm.

CONCLUSION

Administration of propofol or combination of propofol and ketamine decreases the incidence of post extubation coughing. This combination can also decrease severe cases.

Perinatal neuroprotection by muscle relaxants against hypoxic-ischemic lesions: Is it a possible hypothesis?

The incidence of neurological disabilities ascribable to hypoxia-ischemia in the perinatal period (HIPP) is rising. Glutamate plays a key role in the development of cerebral damage related to HIPP: it triggers the excitotoxic cascade by overactivating N-methyl-D-aspartate receptors (NMDA), implicated as important mediators of both learning and neuronal development. Laudanosine is the metabolite of the neuromuscular blocking drugs, atracurium and cisatracurium, administered as part of obstetric general anesthesia. In elective cesarean section, laudanosine may be found in the fetus with a mean umbilical vein concentration of 26 (range 6-60) ng ml(-1). At nM concentrations, laudanosine can activate alpha4beta2 nACh subtype receptors. Activation of alpha4beta2 nAChRs provided neuroprotection against NMDA excitotoxic cascade in a neonatal model. Taken together, experimental and clinical data widely indicate a potential neuroprotective role for laudanosine against perinatal brain lesions of hypoxic-ischemic origin. The clinical relevance is that administration of the neuromuscular blocking drugs atracurium and cisatracurium, administered as part of general anesthesia for cesarean section, could be potentially therapeutic in obstetric anesthesia. Therefore, we find laudanosine to be an attractive proposal for further studies in the prevention of neurological disabilities ascribable to perinatal injury related to hypoxia and ischemia.

Laryngospasm: review of different prevention and treatment modalities

Laryngospasm is a common complication in pediatric anesthesia. In the majority of cases, laryngospasm is self-limiting. However, sometimes laryngospasm persists and if not appropriately treated, it may result in serious complications that may be life-threatening. The present review discusses laryngospasm with the emphasis on the different prevention and treatment modalities.