Cardiovascular and plasma catecholamine responses at tracheal extubation

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial

BACKGROUND

Post-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general anesthesia occurs more frequently in nasal surgery than in other surgical procedures. This study aimed to assess the occurrence of emergence agitation in patients undergoing nasal surgery who were extubated under deep anesthesia or when fully awake.

METHODS

A total of 202 patients (18-60 years, American Society of Anesthesiologists classification: I-II) undergoing nasal surgery under general anesthesia were randomized 1:1 into two groups: a deep extubation group (group D) and an awake extubation group (group A). The primary outcome was the incidence of emergence agitation. The secondary outcomes included number of emergence agitations, sedation score, vital signs, and incidence of adverse events.

RESULTS

The incidence of emergence agitation was lower in group D than in group A (34.7% vs. 72.8%; p < 0.001). Compared to group A, patients in group D had lower Richmond Agitation-Sedation Scale scores, higher Ramsay sedation scores, fewer agitation episodes, and lower mean arterial pressure when extubated and 30 min after surgery, whereas these indicators did not differ 90 min after surgery. There was no difference in the incidence of adverse events between the two groups.

CONCLUSIONS

Extubation under deep anesthesia can significantly reduce emergence agitation after nasal surgery under general anesthesia without increasing the incidence of adverse events.

TRIAL REGISTRATION

Registered in Clinicaltrials.gov (NCT04844333) on 14/04/2021.

Comparison of Response First Technique with Reversal First Technique for Quality of Extubation in Patients Undergoing Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

Early and smooth extubation following anesthesia is an important concern in patients undergoing transsphenoidal pituitary surgery to permit early neurological evaluation and prevent complications. The aim was to compare the RESPONSE FIRST and REVERSAL FIRST techniques for quality of extubation (QOE) in patients undergoing endoscopic transsphenoidal pituitary surgery.

METHODS

Fifty-six patients aged 18-60 years, with American Society of Anesthesiologists Physical Statuses I-II, and undergoing transsphenoidal surgery for pituitary tumors were randomized into either the RESPONSE FIRST group, in which neuromuscular reversal was given following the patient's response to oral commands, or the REVERSAL FIRST group, in which reversal of neuromuscular blockade (NMB) was given at the return of spontaneous respiration. QOE was the primary outcome. Hemodynamic response, jugular venous oxygen saturation (SjVO2), time to extubation, and awareness during emergence were assessed as secondary outcomes.

RESULTS

The QOE in the RESPONSE FIRST group was significantly better than the REVERSAL FIRST group (mean (interquartile range (IQR)), 18 (17-19) vs 14 (12-14.75), P < 0.001). Heart rate (HR) and mean arterial pressure (MAP) were better in the RESPONSE FIRST group when compared to the REVERSAL FIRST group at the time of extubation, at 5 minutes, and 15 minutes following extubation (P < 0.05). SjVO2values were higher in the REVERSAL FIRST group as compared to the RESPONSE FIRST group during extubation and at 5 minutes after extubation (P < 0.01). There was no significant difference in the time to extubation between the groups (P = 0.73).

CONCLUSION

The RESPONSE FIRST technique is associated with better QOE and preservation of systemic and cerebral hemodynamics during extubation in patients undergoing transsphenoidal pituitary surgery when compared to the REVERSAL FIRST technique.

Compound lidocaine/prilocaine cream combined with tetracaine prevents cough caused by extubation after general anaesthesia: a randomised controlled trial

BACKGROUND

Coughing caused by tracheal extubation is common following general anaesthesia. Heavy aerosol production by coughing during recovery from general anaesthesia in patients with respiratory infections (especially COVID-19) may be one of the highest risk factors for infection in healthcare workers. The application of local anaesthetics to the endotracheal tube is an effective method to reduce coughing. The most commonly used anaesthetics are compound lidocaine/prilocaine cream and tetracaine spray. However, coughing still occurs when the two anaesthetics are used alone. We speculated that the application of compound lidocaine/prilocaine combined with tetracaine spray would better prevent coughing caused by tracheal extubation.

METHODS

Patients scheduled for laparoscopic cholecystectomy or cholecystectomy combined with common bile duct exploration under general anaesthesia were randomly assigned to Group C (saline spray), Group L (2 g compound lidocaine/prilocaine cream contains 5 mg of lidocaine and 5 mg prilocaine)), Group T (tetracaine) and Group F (compound lidocaine/prilocaine cream combined with tetracaine). The incidence of coughing, the endotracheal tube tolerance assessment, the incidence of agitation, the active extubation rate, the incidence of postoperative pharyngeal pain and the incidence of postoperative cough were recorded and analysed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and the plasma concentrations of epinephrine and norepinephrine were measured immediately before extubation and 1 min after extubation.

RESULTS

A total of 211 patients were randomly assigned to Group C (53 cases), Group L (52 cases), Group T (52 cases) and Group F (54 cases). The primary result is assessment of the incidence of cough. The patients emerged from general anaesthesia, 96% of Group C had cough, which was significantly reduced in Group L (61.5%, P < 0.001), Group T (75%, P < 0.05) and Group F (22.2%, P < 0.001). Group F had a significantly reduced incidence of cough compared to Group L and Group T (P < 0.05 or P < 0.01, respectively). The secondary results were assessed. The endotracheal tube tolerance score in Group C ((1, 3) 4, P < 0.001) was higher than Group L ((0, 1) 2), Group T ((0, 1.25) 3) and Group F ((0, 0) 1). Group F had a significantly lower score than Group L and Group T (P < 0.05, P < 0.01, respectively). The incidence of agitation and the active extubation rate were also higher in Group C (96.2% and 71.7%, respectively, P < 0.001) than Group L (48.1% and 15.4%, respectively), Group T (61.5% and 26.9%, respectively) and Group F (17.3% and 7.7%, respectively). Blood pressure, HR and plasma concentrations of epinephrine and norepinephrine were significantly higher in Group C than in all other groups at the time of extubation and 1 min after extubation (P < 0.001). Group F exhibited significantly reduced blood pressure, heart rate and plasma concentrations of epinephrine and norepinephrine compared to Group L and Group T (P < 0.05, P < 0.01 or P < 0.001, respectively). The incidence of postoperative pharyngeal pain and the incidence of postoperative cough were not significantly different among the groups.

CONCLUSIONS

Compound lidocaine/prilocaine cream combined with tetracaine may be a more effective approach for preventing coughing and stabilising circulation during extubation following general anaesthesia. This may play an important role in preventing medical staff from contracting respiratory infectious diseases.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2200058429 (registration date: 09-04-2022) "retrospectively registered".

Comparison of neostigmine and sugammadex for hemodynamic parameters in neurointerventional anesthesia

Introduction

Hemodynamic stability is important during neurointerventional procedures. However, ICP or blood pressure may increase due to endotracheal extubation. The aim of this study was to compare the hemodynamic effects of sugammadex and neostigmine with atropine in neurointerventional procedures during emergence from anesthesia.

Methods

Patients undergoing neurointerventional procedures were allocated to the sugammadex group (Group S) and the neostigmine group (Group N). Group S was administered IV 2 mg/kg sugammadex when a train-of-four (TOF) count of 2 was present, and Group N was administered neostigmine 50 mcg/kg with atropine 0.2 mg/kg at a TOF count of 2. We recorded heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure (MAP), and peripheral arterial oxygen saturation during administration of the reverse agent and at 2, 5, 10, 15, 30, 120 min, and 24 h thereafter. The primary outcome was blood pressure and heart rate change after the reversal agent was given. The secondary outcomes were systolic blood pressure variability standard deviation (a measure of the amount of variation or dispersion of a set of values), systolic blood pressure variability-successive variation (square root of the average squared difference between successive blood pressure measurements), nicardipine use, time-to-TOF ratio ≥0.9 after the administration of reversal agent, and time from the administration of the reversal agent to tracheal extubation.

Results

A total of 31 patients were randomized to sugammadex, and 30 patients were randomized to neostigmine. Except for anesthesia time, there were no significant differences in any of the clinical characteristics between the two groups. The results demonstrated that the increase in MAP from period A to B was significantly greater in Group N than in Group S (regression coefficient = -10, 95% confidence interval = -17.3 to -2.7, P = 0.007). The MAP level was significantly increased from period A to B in the neostigmine group (95.1 vs. 102.4 mm Hg, P = 0.015), but it was not altered in Group S. In contrast, the change in HR from periods A to B was not significantly different between groups.

Conclusion

We suggest that sugammadex is a better option than neostigmine in interventional neuroradiological procedures due to the shorter extubation time and more stable hemodynamic change during emergence.

Intensive Care Management of the Cardiogenic Shock Patient

Optimal management of patients with cardiogenic shock requires a detailed and systematic assessment of all organ systems, balancing the risks and benefits of any investigation and intervention, while avoiding the complications of critical illness. Overall prognosis depends upon a number of factors, including that of the underlying cardiac disease and its potential reversibility, the severity of shock, the involvement of other organ systems, the age of the patient and comorbidities. As with all intensive care patients, the mainstay of management is supportive, up to and including implementation and management of a number of devices, including acute mechanical circulatory support. The assessment and management of these most critically ill patients therefore demands in-depth knowledge and skill relating to cardiac intensive care, extending well beyond standard intensive care or cardiology practice.

Tracheal Extubation Under Deep Anesthesia Using Transnasal Humidified Rapid Insufflation Ventilatory Exchange vs. Awake Extubation: An Open-Labeled Randomized Controlled Trial

Background

Tracheal extubation can be associated with several complications, including desaturation, agitation, hypertension, and tachycardia. We hypothesize that the use of transnasal humidified rapid insufflation ventilator exchange (THRIVE) immediately after extubation under deep anesthesia reduces the incidence of these adverse events.

Methods

One hundred patients who underwent elective abdominal surgery under general anesthesia were randomly assigned to undergo tracheal extubation under deep anesthesia employing THRIVE (THRIVE group) or awake extubation (CONTROL group). The primary outcome was the incidence of experiencing desaturation (SpO₂ < 90%) at any time during emergence from anesthesia. Secondary outcomes included variations in heart rate and blood pressure, comfort level, bucking, and agitation.

Results

The THRIVE group showed a lower incidence of desaturation than the CONTROL group (12 vs. 54%, OR = 0.22 [95% CI, 0.10-0.49], P < 0.001). Less patients in the THRIVE group experienced a 20% (or more) increase in mean arterial pressure (4 vs. 26%, OR = 0.15 [95% CI, 0.04-0.65], P = 0.002). THRIVE patients did not suffer from agitation or bucking, while in the CONTROL group agitation and bucking occurred in 22 and 58% of the patients, respectively. Additionally, the THRIVE group showed a lower incidence of uncomfortable experience than the CONTROL group (8 vs. 36%, OR = 0.22 [95% CI, 0.08-0.61], P = 0.001).

Conclusion

Tracheal extubation under deep anesthesia using THRIVE decreases the incidence of desaturation and adverse haemodynamic events and increases patient satisfaction. Extubation under deep anesthesia using THRIVE might be an alternative strategy in selected patient populations.

Reliable and Rapid Smooth Extubation After "Ketamine-Propfol Mixture" for Induction of General Anesthesia in Laparoscopic Drilling of Polycystic Ovary: A Randomized, Double-blind, Comparative Study

Background

Ketofol's effect on hemodynamics and the airway response during inducing general anesthesia has been studied previously. However, ketofol's effect on the smoothness of extubation has not been studied yet.

Objectives

We aimed to assess ketofol’s effect on the smoothness of extubation and compare it with propofol for inducing general anesthesia.

Methods

This double-blind, randomized, and controlled study was conducted on 106 class I and II female patients with the “American Society of Anesthesiologists Physical Status (ASAPS),” aged 18 - 40 years, scheduled for laparoscopic drilling for polycystic ovary disease under general anesthesia. The patients were assigned to two groups of 53 patients each: Group KP = ketofol and Group P = propofol.

Results

There was an excellent sedation score during suction and extubation in the ketofol group. The airway response and smoothness of extubation were better in the ketofol group than in the propofol group.

Conclusions

Ketofol as an induction anesthetic agent more effectively attenuated the airway response during extubation than only propofol.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques

Background:

The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management.

Aims and Objectives:

The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery.

Materials and Methods:

Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test.

Results:

A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K.

Conclusion:

Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Attenuation of Hemodynamic Response to Tracheal Extubation: A Comparative Study between Esmolol and Labetalol

Background and Aims

Cardiovascular stress response to extubation can result in elevated heart rate (HR) and mean arterial blood pressures which can be detrimental in high-risk patients.

Settings and Design

The objective of this study is to compare the esmolol and labetalol efficacy in attenuating hemodynamic response to tracheal extubation.

Materials and Methods

Sixty patients scheduled for elective surgical procedures were selected randomly and divided into two groups of thirty each. Group I - esmolol 1.5 mg/kg and Group II - labetalol 0.25 mg/kg were administered 2 min before extubation after following a standard perioperative anesthetic management. Hemodynamic parameters recorded include HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) at baseline, reversal, study drug, 1 min after study drug, extubation, and at 1, 2, 3, 4, 5, and 15 min postextubation.

Statistical Analysis

Student's t-test and analysis of variance have been used to find the significance of study parameters between groups of patients. P <0.05 was considered statistically significant.

Results

Both esmolol and labetalol obtunded extubation response throughout the extubation and postextubation period. At extubation and immediately postextubation at 1^st and 2^nd min, there was statistical significance (P < 0.05) in SBP, DBP, and MAP which showed esmolol was better than labetalol. Whereas labetalol was more efficient in controlling HR at 5^th and 15^th min postextubation having statistical significance.

Conclusions

Both esmolol and labetalol attenuated hemodynamic response. Esmolol was more efficient than labetalol at extubation and immediately postextubation. If patient has tachycardia at extubation, labetalol is preferred. If patient has raised blood pressure, then esmolol is a good option in blunting the response.

Comparison of the effects of oxycodone versus fentanyl on airway reflex to tracheal extubation and postoperative pain during anesthesia recovery after laparoscopic cholecystectomy: A double-blind, randomized clinical consort study

BACKGROUND

Fentanyl has been suggested to be effective for controlling airway and hemodynamic responses to tracheal extubation. This study was performed to compare the effects of oxycodone and fentanyl on airway and hemodynamic responses and postoperative pain during the recovery period in patients undergoing laparoscopic cholecystectomy.

METHODS

Ninety patients aged 18 to 65 years were randomly allocated to 1 of 3 groups: fentanyl, oxycodone, and control. Coughing responses (incidence and severity), hemodynamic responses during the recovery period, and acute postoperative pain were assessed.

RESULTS

The incidence of cough was decreased in the fentanyl and oxycodone groups compared with that in the control group at the points of awareness and extubation, and no significant difference was observed between the 2 treatment groups. Severe cough response was decreased in the fentanyl and oxycodone groups compared with that in the control group at the point of extubation, and no significant change was observed in cough severity between the 2 treatment groups. Postoperative pain scores were lower in the fentanyl and oxycodone groups than those in the control group at 5 and 30 minutes postoperatively, and no significant difference was observed between the 2 treatment groups. Hemodynamic responses did not differ among the 3 groups during the recovery period.

CONCLUSION

Oxycodone treatment before tracheal extubation reduced cough response and was as effective as fentanyl treatment for improving extubation quality. Furthermore, single boluses of fentanyl and oxycodone showed equal effectiveness in attenuating acute postoperative pain in patients undergoing laparoscopic cholecystectomy.

Continuous postoperative infusion of remifentanil inhibits the stress responses to tracheal extubation of patients under general anesthesia

PURPOSE

The study aimed to assess the combined effects of parecoxib with three different doses of remifentanil and its effect on the stress and cough responses following tracheal extubation under general anesthesia.

METHODS

A total of 120 patients with American Society of Anesthesiologists (ASA) scores of I or II, undergoing selective thyroidectomy with total intravenous anesthesia (propofol-remifentanil) and tracheal intubation, were randomly allocated to be treated with an intravenous injection of parecoxib and a continuous infusion of remifentanil at 0.1 μg/kg/min (R1), 0.2 μg/kg/min (R2), 0.3 μg/kg/min (R3), or an isotonic saline injection (the control group). Hemodynamic vital signs, emergence time, extubation time, sedation-agitation scale (SAS) score, pain visual analog scale (VAS) score, occurrence of coughing, and side effects were recorded before surgery and during the peri-extubation period. The vital signs included blood pressure (BP), heart rate (HR), respiratory rate (R), and peripheral arterial oxygen saturation (SPO₂).

RESULTS

BP, HR, the occurrence rate of coughing, and extubation awareness decreased with the dose of remifentanil, and the differences among the groups were significant (P < 0.05). Emergence and extubation time increased with the dose of remifentanil, and the differences among the groups were significant (P < 0.05). The occurrence rates of respiratory depression and bradycardia in group R3 were significantly higher than those in other groups (P < 0.05). SAS and VAS were lowest in group R3, and the differences among the groups were significant (P < 0.05). BP, HR, SAS, and VAS increased with time in the remifentanil groups.

CONCLUSION

The combined use of parecoxib and a moderate dose of remifentanil can effectively suppress the stress and coughing responses during the peri-extubation period. The appropriate quantity of remifentanil was found to be 0.2 μg/kg/min, as this dosage caused no side effects.

Effects of Lignocaine Administered Intravenously or Intratracheally on Airway and Hemodynamic Responses during Emergence and Extubation in Patients Undergoing Elective Craniotomies in Supine Position

INTRODUCTION

Sympathoadrenergic responses during emergence and extubation can lead to an increase in heart rate (HR) and blood pressure whereas increased airway responses may lead to coughing and laryngospasm. The aim of our study was to compare the effects of lignocaine administered intravenously (IV) or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies.

METHODOLOGY

Sixty patients with physical status American Society of Anaesthesiologists Classes I and II aged 18-70 years, scheduled to undergo elective craniotomies were included. The patients were randomly divided into three groups of twenty patients; Group 1 receiving IV lignocaine and intratracheal placebo (IV group), Group 2 receiving intratracheal lignocaine and IV placebo (I/T group), and Group 3 receiving IV and intratracheal placebo (placebo group). The tolerance to the endotracheal tube was monitored, and number of episodes of cough was recorded during emergence and at the time of extubation. Hemodynamic parameters such as HR and blood pressure (systolic, diastolic, mean arterial pressure) were also recorded.

RESULTS

There was a decrease of HR in both IV and intratracheal groups in comparison with placebo group (P < 0.005). Rise in blood pressure (systolic blood pressure, diastolic blood pressure and mean arterial pressure) was comparable in both Groups 1 and 2 but was lower in comparison with placebo group (P < 0.005). Cough suppression was comparable in all the three groups. Grade III cough (15%) was documented only in placebo group.

CONCLUSION

Both IV and intratracheal lignocaine are effective in attenuation of hemodynamic response if given within 20 min from skull pin removal to extubation. There was comparable cough suppression through intratracheal route and IV routes than the placebo group.

All India Difficult Airway Association 2016 guidelines for the management of anticipated difficult extubation

Extubation has an important role in optimal patient recovery in the perioperative period. The All India Difficult Airway Association (AIDAA) reiterates that extubation is as important as intubation and requires proper planning. AIDAA has formulated an algorithm based on the current evidence, member survey and expert opinion to incorporate all patients of difficult extubation for a successful extubation. The algorithm is not designed for a routine extubation in a normal airway without any associated comorbidity. Extubation remains an elective procedure, and hence, patient assessment including concerns related to airway needs to be done and an extubation strategy must be planned before extubation. Extubation planning would broadly be dependent on preventing reflex responses (haemodynamic and cardiovascular), presence of difficult airway at initial airway management, delayed recovery after the surgical intervention or airway difficulty due to pre-existing diseases. At times, maintaining a patent airway may become difficult either due to direct handling during initial airway management or due to surgical intervention. This also mandates a careful planning before extubation to avoid extubation failure. Certain long-standing diseases such as goitre or presence of obesity and obstructive sleep apnoea may have increased chances of airway collapse. These patients require planned extubation strategies for extubation. This would avoid airway collapse leading to airway obstruction and its sequelae. AIDAA suggests that the extubation plan would be based on assessment of the airway. Patients requiring suppression of haemodynamic responses would require awake extubation with pharmacological attenuation or extubation under deep anaesthesia using supraglottic devices as bridge. Patients with difficult airway (before surgery or after surgical intervention) or delayed recovery or difficulty due to pre-existing diseases would require step-wise approach. Oxygen supplementation should continue throughout the extubation procedure. A systematic approach as briefed in the algorithm needs to be complemented with good clinical judgement for an uneventful extubation.

Rapid and reliable smooth extubation - Comparison of fentanyl with dexmedetomidine: A randomized, double-blind clinical trial

BACKGROUND

Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation.

AIM

To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube.

SETTING AND DESIGN

This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2.

METHODOLOGY

All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 μg/kg or dexmedetomidine 0.75 μg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed.

STATISTICAL ANALYSIS USED

Chi-square test for nonparametric data and t-test for parametric data.

RESULTS

Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group.

CONCLUSION

Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

A comparative study of hemodynamic changes between prone and supine emergence from anesthesia in lumbar disc surgery

BACKGROUND

Supine emergence from anesthesia in patients undergoing lumbar surgery in prone position leads to tachycardia, hypertension, coughing, laryngospasm and loss of monitoring as the patients are rolled back to supine position at the end of surgery. The prone extubation might facilitate a smoother emergence because the patients are not disturbed during emergence and secretions are drained away from patient's airway.

MATERIALS AND METHODS

The patients were randomly allocated to one of the two groups of 30 each at conclusion of surgery. First group was extubated in prone position and second in supine position at conclusion of surgery. Supine group patients were rolled back and prone group patients were left undisturbed. Extubation was done after complete reversal of neuromuscular block. Heart rates (HR), mean arterial pressure (MAP) were noted at various points of time. Coughing, laryngospasm, vomiting, monitor disconnection if any were also noted.

RESULTS

During emergence from anesthesia heart rate was significantly more in group S than group P at all intervals (P < 0.001). Mean arterial pressure was significantly higher in the supine group at 2, 3, and 4 min compared to prone group (P = 0.003). Compared to supine patients, prone patients had fewer incidences of coughing (P = 0. 0004), laryngospasm, vomiting and monitor disconnection.

CONCLUSION

In healthy normotensive patients, emergence from anesthesia in the prone position is associated with minimal hemodynamic change, and fewer incidences of coughing, laryngospasm, and monitor disconnections.

Attenuation of circulatory and airway responses to endotracheal extubation in craniotomies for intracerebral space occupying lesions: Dexmedetomidine versus lignocaine

OBJECTIVES

The objective of the study is to compare the effect of dexmedetomidine versus lignocaine in attenuation of circulatory and airway responses during endotracheal extubation in craniotomies for intracerebral space occupying lesions (ICSOL).

MATERIALS AND METHODS

A total of 50 patients of American Society of Anesthesiologists Grade I and II of either sex, aged 18-50 years undergoing craniotomies for non-vascular ICSOL under general anesthesia were divided into two groups according to drug received. Group D (n = 25) received dexmedetomidine (0.5 mcg/kg) whereas group L (n = 25) received lignocaine (1.5 mg/kg). Both the drugs were given 5 min before the extubation over a period of 60 s. Values for heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), were recorded just before (A0) and 1, 3, 5 (A1, A3, A5) min after the study drug administration, at extubation (E) and 1, 3, 5, 10, 15 min after extubation (E1, E3, E5, E10 and E15). Respiratory rate, oxygen saturation and airway responses like coughing, breath-holding, laryngospasm/bronchospasm were recorded only at extubation (E) and 1, 3, 5, 10, 15 min after extubation (E1, E3, E5, E10, E15). Quality of extubation was recorded with four point scale. After extubation all these patients were also observed for sedation by Ramsey sedation score.

RESULTS

Both groups showed a statistically significant increase (D < L) in HR, SBP and DBP during (E) and immediately after extubation (E1) (P < 0.05). Dexmedetomidine (72%) produced a higher degree of sedation (Grade 3) as compare with lignocaine (0%) and with no incidence of coughing or breath holding (P < 0.05).

CONCLUSION

Single dose of dexmedetomidine (0.5 mcg/kg) given 5 min before extubation produced significant attenuation of circulatory and airway responses produced during extubation as compared to Lignocaine (1.5 mg/kg) in ICSOL.

Optimal dose of dexmedetomidine for attenuating cardiovascular response during emergence in patients undergoing total laparoscopic hysterectomy

OBJECTIVE

To investigate the optimal dose of dexmedetomidine for attenuating the haemodynamic response during emergence from anaesthesia.

METHODS

Patients undergoing laparoscopic total hysterectomy were randomly allocated to receive 0.9% normal saline (control group) or dexmedetomidine (0.5 µg/kg, 0.75 µg/kg or 1.0 µg/kg 30 min) before extubation. Heart rate, systolic and diastolic arterial pressure and extubation time were measured before drug administration, immediately after the end of drug administration, 10 min after the end of drug administration, immediately after extubation and 5 min after extubation.

RESULTS

A total of 120 patients were included in the study (30 per group). Systolic and diastolic arterial pressure and heart rate after drug administration were significantly lower in all three dexmedetomidine groups compared with controls. Extubation times in the 0.75 and 1.0 µg/kg dexmedetomidine groups were significantly longer than in the control group.

CONCLUSION

Intravenous infusion of 0.5 µg/kg dexmedetomidine 30 min before the end of surgery attenuated the haemodynamic responses during emergence without prolonging the extubation time. Dexmedetomidine doses higher than 0.5 µg/kg did not exert additional positive effects on cardiovascular responses, but did significantly prolong the extubation time.

Comparison of the effects of dexmedetomidine versus fentanyl on airway reflexes and hemodynamic responses to tracheal extubation during rhinoplasty: A double-blind, randomized, controlled study

BACKGROUND

Stimulation of various sites, from the nasal mucosa to the diaphragm, can evoke laryngospasm. To reduce airway reflexes, tracheal extubation should be performed while the patient is deeply anesthetized or with drugs that do not depress ventilation. However, tracheal extubation during rhinoplasty may be difficult because of the aspiration of blood and the possibility of laryngospasm. Dexmedetomidine and fentanyl both have sedative and analgesic effects, but dexmedetomidine has been reported to induce sedation without affecting respiratory status.

OBJECTIVE

The aim of this study was to compare the effects of dexmedetomidine and fentanyl on airway reflexes and hemodynamic responses to tracheal extubation in patients undergoing rhinoplasty.

METHODS

This double-blind, randomized, controlled study was conducted at the Erciyes University Medical Center, Kayseri, Turkey. Patients classified as American Society of Anesthesiologists physical status I or II who were undergoing elective rhinoplasty between January 2007 and June 2007 with general anesthesia were eligible for study entry. Using a sealed-envelope method, the patients were randomly divided into 2 groups (20 patients per group). Five minutes before extubation, patients received either dexmedetomidine 0.5 μg/kg in 100 mL of isotonic saline or fentanyl 1 μg/kg in 100 mL of isotonic saline intravenously. All patients were extubated by anesthesiologists who were blinded to the study drugs, and all were continuously monitored for 15 minutes after extubation. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and oxygen saturation using pulse oximetry (SpO2) were recorded before anesthesia, after drug administration, after skin incision, at the completion of surgery, and 1, 5, and 10 minutes before and after tracheal extubation. Any prevalence of laryngospasm, bronchospasm, or desaturation was recorded.

RESULTS

Forty patients (25 men, 15 women; mean [SD] age, 24.86 [7.43] years) were included in the study. Dexmedetomidine was associated with a significant increase in extubation quality compared with fentanyl, reflected in the prevalence of cough after extubation (85% [17/20] vs 30% [6/20] of patients, respectively; P = 0.001). There were no clinically significant decreases in HR, SBP, DBP, or SpO2 after extubation with dexmedetomidine or fentanyl. In the dexmedetomidine group, HR was not significantly increased after extubation; however, in the fentanyl group, HR was significantly increased compared with the preextubation values (all, P = 0.007). HR was significantly higher in the fentanyl group compared with the dexmedetomidine group at 1, 5, and 10 minutes after extubation (all, P = 0.003). Compared with preextubation values, SBP was significantly increased at 1 and 5 minutes after extubation in the dexmedetomidine group (both, P = 0.033) and at 1, 5, and 10 minutes after extubation in the fentanyl group (all, P = 0.033). The postoperative sedation scores and the extubation, awakening, and orientation times were not significantly different between the 2 groups. In the dexmedetomidine group, bradycardia (HR <45 beats/min) was observed in 2 patients and emesis was observed in 2 patients. In the fentanyl group, emesis was observed in 3 patients, bradycardia in 2 patients, vomiting in 1 patient, and shivering in 1 patient; vertigo was reported in 1 patient. There were no significant differences in the prevalence of adverse events between the 2 groups.

CONCLUSION

The findings in the present study suggest that dexmedetomidine 0.5 μg/kg IV, administered before extubation, was more effective in attenuating airway reflex responses to tracheal extubation and maintaining hemodynamic stability without prolonging recovery compared with fentanyl 1 μg/kg IV in these patients undergoing rhinoplasty.

Efficacy of Evolving Early-Extubation Strategy on Early Postoperative Functional Recovery in Pediatric Open-Heart Surgery

There has been a paradigm shift toward “fast-track” management with early extubation (EE) in cardiac surgery. Our retrospective, matched case-control study wishes to define the benefits of EE in pediatric congenital heart surgery. We examined 50 consecutive pediatric cardiac surgery patients extubated in the operating room (February 2009 to July 2009) against a control group of delayed-extubation patients. No significant differences were found in preoperative variables except heart failure medication. Significant intraoperative variables included the following: blood products (363 vs 487 mL, P = .023), morphine (62% vs 6%, P < .0001), and inotropes (16% vs 60%, P < .0001) given. Postoperatively significant differences included hospital stay and lower inotrope scores in the early-extubation group (14.89 vs 31.68, P < .0001). The reintubation rate was not significant. EE patients have equivalent hemodynamic profiles shown by a decreased necessity for inotropic support. We conclude that EE is feasible in low-/medium-risk pediatric congenital heart surgery patients.

Low-Dose Remifentanil Infusion during Ventilator Weaning and Tracheal Extubation in Postoperative Intensive Care Unit Patients Sedated with Propofol-Remifentanil: A Randomised Clinical Trial

Discontinuation of sedatives for ventilator weaning and extubation can be associated with hyperdynamic responses, including hypertension and tachycardia. We examined the effects of a maintained low dose of remifentanil infusion on cardiovascular responses and coughing during extubation in postoperative intensive care unit patients sedated with propofol-remifentanil.

Fifty patients who required mechanical ventilation after major abdominal surgery were randomised into remifentanil group (n=25) or control group (n=25). Sedation during mechanical ventilation was maintained with remifentanil and propofol via a target-controlled infusion system. These drugs were titrated to the target sedation range, bispectral index values of 60 to 75 and Richmond Agitation Sedation Scale values of −3 to −2. When weaning was initiated, propofol was stopped in both groups. In the control group, remifentanil infusion was also stopped; in the remifentanil group, remifentanil infusion was maintained until extubation at a target effect site concentration of 1.0 ng/ml. Extubation was performed if the patient's respiratory, haemodynamic states were stable and if the patient was able to follow commands. Heart rate, mean arterial pressure and cough severity were evaluated.

The mean arterial pressure, heart rate and cough severity did not differ between the two groups during extubation. The time from stopping of propofol infusion to extubation was significantly longer in the remifentanil group compared to that in the control group (P=0.020).

Maintaining a low-dose remifentanil infusion during ventilator weaning delayed tracheal extubation without any differences in haemodynamic changes or coughing in postoperative intensive care unit patients.

Evaluation of "no touch" extubation technique on airway-related complications during emergence from general anesthesia

Background and Objectives:

Awake “no touch” extubation requires performing extubations only when the patient spontaneously wakes up without any kind of stimulation during emergence from general anesthesia. The aim of this study was to evaluate absolutely awake extubation “no touch” technique in adult patients, scheduled for elective nasal and paranasal sinus surgeries under general anesthesia as regard to emergence airway complications.

Methods:

A total of 60 adult patients were randomly allocated into one of two equal groups according to the method of extubation: Group I: Standard fully awake, Group II: Absolutely “no touch” awake extubation (absolutely no stimulation no touch was allowed until patients were able to open their eyes). The incidence of laryngospasm and its grade according to a four-point scale was reported. Occurrence of airway events (excessive secretions, breath-holding, coughing, hoarseness, biting, as well as the number and severity of any desaturation episodes), oozing from the wound, and postoperative sore throat were also recorded. The heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure measured at the end of surgery served as baseline values, and subsequent measurements were taken within 30 minutes after the end of surgery.

Results:

There was absolutely no case of laryngeal spasm or episode of desaturation among patients who were extubated with the “no touch” technique. On the other hand, there were 3 cases of laryngeal spasm in standard fully awake group. Severity of coughing, excessive secretions and breath holding, hoarseness, biting, and occurrence of non-purposeful movements of the limbs were significantly less in the absolutely “no touch” technique awake technique. The changes in HR, SBP, and DBP during emergence extubation were significantly less in “no touch” technique technique group. However, oozing from the wound was significantly higher with standard fully awake extubation. However, there were no significant differences between the two groups regarding the incidence of postoperative sore throat (39 and 36%, respectively).

Conclusion:

The results of the present study showed that awake “no touch” technique technique for tracheal extubation produces less airway-related complications, as well as minimal hemodynamic response during emergence from general anesthesia in nasal and paranasal surgeries. It could be a safe alternative for tracheal extubation in airway surgery.

The effects of volatile induction and maintenance of anesthesia and selective spinal anesthesia on QT interval, QT dispersion, and arrhythmia incidence

OBJECTIVE

The effects of sevoflurane general anesthesia and bupivacaine selective spinal anesthesia on QT dispersion (QTd) and corrected QT (QTc) interval were investigated.

METHODS AND MATERIALS

This prospective, randomized, double-blind study was conducted between July and September 2009 in the Urology and General Surgery operating rooms. Forty ASA I-II patients undergoing noncardiac surgery were randomized into two groups: Group R (n=20) and Group V (n=20). In Group R, 5 mg bupivacaine was administered into the spinal space. Anesthesia induction in Group V was established with sevoflurane + 0.1 mg/kg vecuronium using the maximum vital capacity technique. Anesthesia was maintained with 2-3% sevoflurane + 50% N2O/O2 inhalation. All patients were tested with a 24-hour Holter ECG device. QT, QTc, and QTd intervals were measured using 12-lead ECG records at 1 and 3 minutes during preinduction, postinduction, postincision and postextubation periods. Mean arterial pressure (MAP), heart rate and ECG records were measured simultaneously.

RESULTS

None of the patients displayed arrhythmia. There was no significant difference between the groups with regard to QTd values (p>0.05). However, QTc was longer in Group V than in Group R after the induction of anesthesia at 3 minutes, after the intubation at 1 and 3 minutes, and after the incision at 1 and 3 minutes. MAP and heart rate were generally higher in Group V (p<0.05).

CONCLUSION

Although Volatile Induction and Maintenance of Anesthesia (VIMA) with sevoflurane might prolong the QTc interval and did not result in arrhythmia, selective spinal anesthesia with bupivacaine was not associated with alterations in the QT interval or arrhythmia.

Effects of maintaining a remifentanil infusion on the recovery profiles during emergence from anaesthesia and tracheal extubation

BACKGROUND

Emergence from anaesthesia and tracheal extubation can be associated with hyperdynamic circulatory responses. We examined the effects of maintaining a remifentanil infusion on recovery profiles such as coughing and cardiovascular responses after general anaesthesia.

METHODS

Forty patients undergoing endoscopic sinus surgery under general anaesthesia using total i.v. anaesthesia (propofol and remifentanil) were randomly allocated to a control group (n=20) or remifentanil group (n=20) during emergence from anaesthesia. At the end of surgery, propofol was ceased and the infusion of remifentanil was stopped in the control group and maintained in the remifentanil group at a target organ concentration of 1.5 ng ml(-1) until extubation. Heart rate (HR), mean arterial pressure (MAP), and recovery profiles were measured and evaluated.

RESULTS

There was no significant difference in sex ratio, age, weight, height, time to eye opening, time to extubation, nausea, visual analogue scale, and time to discharge. Increases in HR and MAP occurred during emergence in the control group compared with baseline values. Increases in HR were attenuated in the remifentanil group and MAP decreased during recovery compared with baseline values. HR and MAP values were significantly higher in the control group [103 (23) beats min(-1), 129 (17) mm Hg] compared with the remifentanil group [79 (17) beats min(-1), 112 (15) mm Hg] during emergence and tracheal extubation. Moderate or severe coughing was observed only in the control group (8/20 vs 0/20, P<0.001).

CONCLUSIONS

Maintaining a remifentanil infusion reduced haemodynamic changes and coughing associated with tracheal extubation almost without significantly delaying recovery from anaesthesia.

Comparison of Nicardipine Versus Esmolol in Attenuating the Hemodynamic Responses to Anesthesia Emergence and Extubation

OBJECTIVE

The purpose of this study was to compare the effectiveness of intravenous (IV) nicardipine versus esmolol in controlling heart rate (HR) and blood pressure (BP) responses to emergence and extubation.

DESIGN

Prospective, randomized, double blind.

SETTING

University hospital, single institution.

PARTICIPANTS

Twenty-two American Society of Anesthesiologists physical class 1 to 3 adult inpatients scheduled for general anesthesia.

INTERVENTIONS

General endotracheal anesthesia with oxygen/isoflurane and muscle relaxation. At end of surgery, with at least 2 twitches by nerve stimulator and end-tidal isoflurane <0.4%, muscle relaxant reversal was accomplished with neostigmine and glycopyrrolate. Two minutes postreversal, the IV study drug nicardipine, 0.03 mg/kg, or esmolol, 1.5 mg/kg, was administered. HR and BP were measured every minute up to 10 minutes and at minute 15 postreversal.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences between groups in age, weight, gender, American Society of Anesthesiologists physical class or preoperative hemodynamics (HR, BP, mean arterial pressure [MAP]). Compared with nicardipine, 0.03 mg/kg IV, esmolol, 1.5 mg/kg IV, significantly (p < 0.05) attenuated HR more than nicardipine for the 15-minute time period poststudy drug. Compared with esmolol, nicardipine was significantly (p < 0.05) more effective in controlling MAP and systolic BP for the 1- to 3-minute and diastolic BP for the 1- to 2-minute time periods poststudy drug. There were no episodes of hypotension or adverse events.

CONCLUSIONS

Although esmolol, 1.5 mg/kg, IV was more effective than nicardipine, 0.03 mg/kg, IV for attenuating the HR response to extubation, nicardipine was more effective in controlling the BP response.

Extubation failure: magnitude of the problem, impact on outcomes, and prevention

Extubation failure, defined as the need for reinstitution of ventilatory support within 24 to 72 hours of planned endotracheal tube removal, occurs in 2 to 25% of extubated patients. The pathophysiologic causes of extubation failure include an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy, and cardiac dysfunction. Compared with patients who tolerate extubation, those who require reintubation have a higher incidence of hospital mortality, increased length of ICU and hospital stay, prolonged duration of mechanical ventilation, higher hospital costs, and an increased need for tracheostomy. Given the lack of proven treatments for extubation failure, clinicians must be aware of the factors that predict extubation outcome to improve clinical decision making. Risk factors for extubation failure include being a medical, multidisciplinary, or pediatric patient; age greater than 70 years; a longer duration of mechanical ventilation; continuous intravenous sedation; and anemia. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough can help to improve prediction of extubation failure. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.

Combined administration of diltiazem and nicardipine attenuates hypertensive responses to emergence and extubation

Diltiazem and nicardipine, when injected as a mixture during anesthesia, reduce blood pressure in an additive manner without changing heart rate. The author evaluated the use of this mixture for controlling the blood pressure during emergence from general anesthesia and at extubation. The subjects included 15 preoperative hypertensive (HT) patients who underwent various types of surgery and 18 patients with subarachnoid hemorrhage (SAH) who underwent clipping of a cerebral aneurysm. General anesthesia was maintained with isoflurane or sevoflurane, supplemented with fentanyl. A mixed solution containing 2.5 mg diltiazem plus 0.5 mg nicardipine in 1 mL was injected intermittently every 2 to 4 minutes to bring the blood pressure to its resting level from cessation of inhaled anesthetics to extubation. Untreated patients who underwent similar types of surgery and anesthesia were selected for comparison. The average systolic blood pressure during emergence and at extubation increased to 156 +/- 19 mm Hg (mean +/- standard deviation) and 170 +/- 10 mm Hg in the untreated HT group, and increased to 157 +/- 16 mm Hg and 170 +/- 5mm Hg in the untreated SAH group. Systolic blood pressure was well controlled at 127 +/- 14 mm Hg and 145 +/- 14 mm Hg in the treated HT group with 3.7 +/- 1.9 mL of the mixture, and at 120 +/- 9 mm Hg and 137 +/- 20 mm Hg in the treated SAH group with 7.1 +/- 2.5 mL of the mixture. No significant difference (P < .05) in the heart rate was found between the untreated and the treated HT or SAH groups. Two patients in the treated SAH group exhibited tachycardia. The combined administration of diltiazem and nicardipine can help control blood pressure in patients with a possible HT response to emergence from general anesthesia and extubation.

Comparison of nicardipine versus placebo to control hemodynamic responses during emergence and extubation

OBJECTIVE

To compare 2 different doses of intravenous nicardipine versus placebo to control heart rate and blood pressure responses to emergence and extubation.

DESIGN

Prospective, randomized, double-blind, placebo-controlled.

SETTING

University hospital, single-institutional.

PARTICIPANTS

Forty-five American Society of Anesthesiologists (ASA) class I through III adult patients.

INTERVENTIONS

General endotracheal anesthesia was with oxygen and isoflurane and muscle relaxation. At the end of surgery, with at least 2 twitches present by nerve stimulator and end-tidal isoflurane <0.4%, reversal was accomplished with neostigmine and glycopyrrolate. Two minutes post-reversal, the study drug (nicardipine, 0.015 mg/kg; nicardipine, 0.03 mg/kg; or a saline placebo) was given. Heart rate and blood pressure were measured for every minute up to 10 minutes and at 15 minutes postreversal.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences among groups in age, gender, ASA class, weight, or heart rate. The nicardipine groups, 0.015 and 0.03 mg/kg, had lower blood pressure values than the placebo group. There was a significant difference in blood pressure among groups, with greater and more consistent attenuation of blood pressure occurring with the larger nicardipine dose. There were no episodes of hypotension or adverse events.

CONCLUSIONS

Compared with placebo, both nicardipine doses attenuated blood pressure but not heart rate responses during emergence and extubation. Greater blood pressure control occurred with the larger nicardipine dose of 0.03 mg/kg.

Preoperative clonidine attenuates stress response during emergence from anesthesia

STUDY OBJECTIVES

To investigate whether a single preoperative IV dose of clonidine blunts the hemodynamic and hyperadrenergic responses not only to intubation, but also to extubation.

DESIGN

Randomized, double-blind, placebo-controlled study.

PATIENTS

29 ASA physical status I and II patients (ages 18-65) who were scheduled for noncardiac, elective surgery. Patients were randomly assigned to either receive clonidine 3 microg/kg IV immediately before anesthesia induction or placebo.

INTERVENTIONS

Insertion of a 14 G cannula in a large cubital vein for the determination of plasma catecholamines using local anesthesia. Insertion of a radial artery catheter for measuring blood pressure (BP) using local anesthesia. Transthoracic echocardiography to determine cardiac output (CO).

MEASUREMENTS

Heart rate (HR), mean arterial pressure (MAP), CO, and plasma catecholamine concentrations. Measurements were performed: before induction (baseline), during intubation, 10 min after intubation, after surgery, during extubation, and 10 min after extubation.

MAIN RESULTS

During intubation MAP, HR, and CO were lower in the clonidine group. Compared with baseline measurements, MAP and CO increased less in the clonidine group during intubation. During extubation, MAP was lower in the clonidine group. CO and MAP increased less as compared with baseline measurements in the clonidine group. Compared with the measurements after surgery CO less in the clonidine group during extubation (p < 0.05 for all results).

CONCLUSIONS

A single preoperative IV dose of clonidine (3 microg/kg) blunts the hemodynamic responses due to extubation in noncardiac surgery of intermediate duration.

Pretreatment with oral clonidine attenuates cardiovascular responses to tracheal extubation in children

This study was designed to evaluate the effects of diazepam and clonidine orally given preoperatively on cardiovascular responses to tracheal extubation in children. Fifty children, ASA physical status I, aged 4-10 years, undergoing minor elective surgery (inguinal hernia, phimosis) received orally, in a randomized, double-blind manner, diazepam 0.4 mg.kg-1 or clonidine 4 microgram.kg-1 (n=25 of each). These drugs were administered 105 min before an inhalational induction of anaesthesia. The same standard general anaesthetic technique was employed throughout. The maximum changes in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were less in patients who had received clonidine than in those who had received diazepam (HR, 12 vs 24; SBP, 14 vs 26; DBP, 9 vs 16; mean, P < 0.05). In conclusion, compared to diazepam given orally, pretreatment with oral clonidine attenuates haemodynamic changes associated with tracheal extubation in children.

Combined diltiazem and lidocaine reduces cardiovascular responses to tracheal extubation and anesthesia emergence in hypertensive patients

PURPOSE

Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to compare the efficacy of combined diltiazem and lidocaine with each drug alone in suppressing the hemodynamic changes during tracheal extubation.

METHODS

Sixty hypertensive patients (ASA II), defined as systolic blood pressure > 160 mmHg and/or diastolic blood pressure > 95 mmHg (WHO), undergoing elective orthopedic surgery received, in a randomized, double-blind manner, 0.2 mg x kg(-1) diltiazem, 1.0 mg x kg(-1) lidocaine, or 0.2 mg x kg(-1) diltiazem plus 1.0 mg x kg(-1) lidocaine (n=20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation.

RESULTS

Hemodynamic changes during tracheal extubation were less in patients receiving diltiazem plus lidocaine than in those receiving diltiazem or lidocaine as a sole medicine (RPP; 10322 +/- 1674 (combined) vs 11532 +/- 1802 (diltiazem), 15388 +/- 2050 (lidocaine), mean +/- SD, P < 0.05).

CONCLUSION

Combined diltiazem and lidocaine is more effective prophylaxis than diltiazem or lidocaine alone for attenuating the cardiovascular responses to tracheal extubation and emergence from anesthesia in hypertensive patients.

Metabolic and hemodynamic changes during recovery and tracheal extubation in neurosurgical patients: immediate versus delayed recovery

Delayed recovery has been advocated to limit the postoperative stress linked to awakening from anesthesia, but data on this subject are lacking. In this study, we measured oxygen consumption (V(O2)) and plasma catecholamine concentrations as markers of postoperative stress. We tested the hypothesis that delayed recovery and extubation would attenuate metabolic changes after intracranial surgery. Thirty patients were included in a prospective, open study and were randomized into two groups. In Group I, the patients were tracheally extubated as soon as possible after surgery. In Group II, the patients were sedated with propofol for 2 h after surgery. V(O2), catecholamine concentration, mean arterial pressure (MAP), and heart rate (HR) were measured during anesthesia, at extubation, and 30 min after extubation. V(O2) and noradrenaline on extubation and mean V(O2) during recovery were significantly higher in Group II than in Group I (V(O2) for Group I: preextubation 215 +/- 46 mL/min, recovery 198 +/- 38 mL/min; for Group II: preextubation 320 +/- 75 mL/min, recovery 268 +/- 49 mL/min; noradrenaline on extubation for Group I: 207 +/- 76 pg/mL, for Group II: 374 +/- 236 pg/ mL). Extubation induced a significant increase in MAP. MAP, HR, and adrenaline values were not statistically different between groups. In conclusion, delayed recovery after neurosurgery cannot be recommended as a mechanism of limiting the metabolic and hemodynamic consequences from emergence from general anesthesia.

IMPLICATIONS

In this study, we tested the hypothesis that delayed recovery after neurosurgery would attenuate the consequences of recovery from general anesthesia. As markers of stress, oxygen consumption and noradrenaline blood levels were higher after delayed versus early recovery. Thus, delayed recovery cannot be recommended as a mechanism of limiting the metabolic and hemodynamic consequences from emergence after neurosurgery.

Hemodynamic and catecholamine stress responses to insertion of the Combitube, laryngeal mask airway or tracheal intubation

In a prospective, randomized, and controlled trial, we compared the stress responses after insertion of the Combitube (CT; Kendall-Sheridan Catheter Corp., Argyle, NY), the laryngeal mask airway (LMA), or endotracheal intubation (ET). Seventy-five patients scheduled for routine urological or gynecological surgery were randomly allocated to one of three groups and were ventilated via either an ET, a LMA, or a CT. All three devices could be inserted easily and rapidly, providing adequate ventilation and oxygenation. Insertion of the CT was associated with a significant increase in mean maximal systolic arterial pressure (160+/-32 mm Hg) and diastolic arterial pressure (91+/-17 mm Hg) compared with ET (140+/-24, 78+/-11 mm Hg; P < 0.05, P < 0.01, respectively) or insertion of the LMA (115+/-33,63+/-22 mm Hg, both P < 0.001). The mean maximal epinephrine and norepinephrine plasma concentrations after insertion of the CT (37.3+/-31.1 and 279+/-139 pg/mL, respectively) were significantly higher than those after ET (35.8+/-89.8 and 195+/-58 pg/mL, respectively) or insertion of a LMA (17.3+/-13.3 and 158+/-67 pg/mL, respectively). This might be attributed to the pressure of the pharyngeal cuff of the CT on the anterior pharyngeal wall. We conclude that insertion of the CT causes a pronounced stress response and that precautions should be taken when used in patients at risk of hypertensive bleeding.

IMPLICATIONS

In this study, we showed that the hemodynamic and catecholamine stress responses after insertion of the Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY) were significantly higher compared with laryngeal mask airway or endotracheal intubation. We conclude that the increased stress response to insertion of a Combitube may represent a serious hazard to patients with cardiovascular disease.

Calcium channel blockers attenuate cardiovascular responses to tracheal extubation in hypertensive patients

PURPOSE

Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to examine the inhibitory effects of calcium channel blockers, nicardipine and diltiazem, on haemodynamic changes after tracheal extubation.

METHODS

Sixty hypertensive patients (ASA physical status II) undergoing elective orthopaedic (upper and lower extremity) surgery received, in a randomized, double-blind manner, 30 micrograms.kg-1 nicardipine, 0.2 mg.kg-1 diltiazem or saline (as a control) (n = 20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation.

RESULTS

The HR, MAP and RPP increased after tracheal extubation in the control group (P < 0.05). The increases in these haemodynamic variables were attenuated with nicardipine or diltiazem. The inhibitory effects of diltiazem on these cardiovascular responses to tracheal extubation were greater than those of nicardipine (HR; 86 +/- 7 vs 101 +/- 10, RPP; 11,437 +/- 1,575 vs 14,675 +/- 2,874, mean +/- SD, P < 0.05).

CONCLUSION

Compared with nicardipine, administration of diltiazem produced greater attenuating the circulatory responses to tracheal extubation in hypertensive patients.

Cardiovascular responses to tracheal extubation or LMA removal in children

PURPOSE

This study was designed to investigate the cardiovascular effects related to tracheal extubation or laryngeal mask airway (LMA) removal in children.

METHODS

Sixty children, ASA physical status 1, 4-10 yr of age, undergoing minor elective surgery (inguinal hernia and phimosis) were allocated randomly to have their surgery performed with endotracheal intubation (Group ET, n = 30) or LMA (Group LMA, n = 30) and were studied for cardiovascular responses related to extubation or LMA removal. Changes in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured before and 1, 2, 3, 5, and 10 min after tracheal extubation or LMA removal when the patients were awake.

RESULTS

The maximal changes in HR, SBP and DBP were less in Group LMA than in Group ET during the observation period (HR; 12 vs 26, SBP; 14 vs 28, DBP; 9 vs 13, median, P < 0.05).

CONCLUSION

Laryngeal mask airway removal elicited less haemodynamic change than tracheal extubation in paediatric patients.

Attenuation of cardiovascular responses to tracheal extubation: comparison of verapamil, lidocaine, and verapamil-lidocaine combination

We recently showed that verapamil attenuated hemodynamic responses to tracheal extubation. The aim of the current study was to compare the efficacy of a combination of intravenous (I.V.) verapamil (0.1 mg/kg) and I.V. lidocaine (1 mg/kg) with that of each drug alone in suppressing the cardiovascular changes during tracheal extubation and emergence from anesthesia. One hundred adult patients (ASA physical status I) who were to undergo elective minor surgery were randomly assigned to one of four groups (n = 25 each): Group S = saline plus saline (control), Group V = verapamil 0.1 mg/kg I.V. plus saline, Group L = lidocaine 1 mg/kg I.V. plus saline, and Group V-L = verapamil 0.1 mg/kg I.V. plus lidocaine 1 mg/kg I.V. These medications were given 2 min before tracheal extubation. Anesthesia was maintained with 1.0%-2.0% sevoflurane and 60% nitrous oxide (N2O) in oxygen. Muscle relaxation was achieved with vecuronium, and a residual neuromuscular blockade was reversed with neostigmine 0.05 mg/kg (combined with atropine 0.02 mg/kg). Changes in heart rate (HR) and arterial blood pressure (AP) were measured during and after tracheal extubation. In the control group, the HR and systolic and diastolic AP increased significantly during tracheal extubation. Verapamil, lidocaine, and their combination attenuated the increases in these variables. The beneficial effect was the greatest with the combination of verapamil and lidocaine. These findings suggest that verapamil 0.1 mg/kg and lidocaine 1 mg/kg given I.V. concomitantly 2 min before tracheal extubation is a simple and more effective prophylaxis than verapamil or lidocaine alone for attenuating the cardiovascular changes associated with tracheal extubation.

IMPLICATIONS

Tachycardia and hypertension associated with tracheal extubation, which may lead to myocardial ischemia, represent a potential risk for patients with coronary arterial disease. To seek effective pharmacological prophylaxis against these complications, we compared the attenuation of hemodynamic changes among verapamil, lidocaine, and a verapamil/lidocaine combination using ASA physical status I patients and found the combination to be effective.

Cardiovascular responses to tracheal extubation or LMA removal in normotensive and hypertensive patients

PURPOSE

This study was undertaken to evaluate the haemodynamic changes of tracheal extubation or removal of a laryngeal mask airway (LMA) in normotensive and hypertensive patients.

METHODS

In a randomized trial of normotensive and hypertensive patients (n = 40 of each), tracheal extubation or LMA removal was performed. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and 1, 2, 3, 5, and 10 min after tracheal extubation or LMA removal.

RESULTS

In normotensive patients, HR, MAP and RPP increased following tracheal extubation or LMA removal, and remained elevated for a maximum three minutes (P < 0.05). In hypertensive patients, the haemodynamic increases in response to extubation or LMA removal were observed for up to five minutes (P < 0.05). The immediate cardiovascular responses to extubation were greater than those related to LMA removal in both normotensive and hypertensive patients (normotensive: HR; 95 +/- 14 vs 81 +/- 11, MAP; 124 +/- 18 vs 106 +/- 10, RPP; 14,951 +/- 2720 vs 10,654 +/- 1898, hypertensive: HR 105 +/- 10 vs 87 +/- 13, MAP; 146 +/- 17 vs 119 +/- 12, RPP; 20,492 +/- 1674 vs 12,862 +/- 2115, mean +/- SD, P < 0.05). Following extubation or LMA removal, these haemodynamic variables increased more markedly in hypertensive patients than in normotensive patients (P < 0.05).

CONCLUSION

Removal of LMA is associated with less cardiovascular change than tracheal extubation in both normotensive and hypertensive patients.

The effects of epidural fentanyl on hemodynamic responses during emergence from isoflurane anesthesia and tracheal extubation: a comparison with intravenous fentanyl

To investigate the effects of epidural fentanyl infusion on hemodynamic responses to recovery of consciousness and tracheal extubation, we studied 50 unpremedicated patients scheduled for abdominal hysterectomy. All patients underwent epidural catheterization and blind infusion of placebo and study drug. Patients were assigned randomly to three groups: Group I received epidural and intravenous (i.v.) bolus injections and infusion of saline at the rate of 0.2 mL x kg(-1) x h(-1); Group II received an i.v. injection of fentanyl 2 microg/kg for 30 s followed by 25 ng x kg(-1) x min(-1), and Group III received epidural injection and infusion using the same administration regimen as Group II. Anesthesia was induced with and maintained by isoflurane alone in an air-oxygen mixture. The study drug was administered at the start of retroperitoneal suturing. Hemodynamic variables, including systolic and diastolic arterial pressures (SAP and DAP, respectively) and heart rate (HR), were recorded every minute between the start of administration of the study and 5 min after tracheal extubation. During emergence from anesthesia and tracheal extubation, the increases in SAP, DAP, and HR in Groups II and III were significantly diminished (P < 0.05) compared with those in Group I. Arterial pressures, but not HR, were attenuated more significantly in Group III than in Group II during and after tracheal extubation, although the plasma fentanyl concentration was significantly lower (P < 0.01) in Group III (0.64 +/- 0.03 ng/ mL, [mean +/- SD]) than in Group II (1.15 +/- 0.09 ng/mL). The incidence of coughing during and after extubation was also lower with Group III. Suppression of respiratory rate prior to tracheal extubation was similar in the two groups receiving fentanyl. These findings suggest that the significant reduction in arterial pressures responses to tracheal extubation due to epidural fentanyl infusion may arise from more suppression of cough reflex than i.v. fentanyl infusion, which could be provided by the spinal action of epidural fentanyl as well as the supraspinal action.

Prostaglandin E1 attenuates the hypertensive response to tracheal extubation

PURPOSE

Tracheal extubation causes hypertension and tachycardia, which may cause imbalance between myocardial oxygen demand and supply in patients at risk of coronary artery disease. We conducted a randomized, controlled study to evaluate the effects of 0.05 or 0.1 microgram.kg-1.min-1 prostaglandin E1 (PGE1) iv on haemodynamic variables occurring during tracheal extubation and emergence from anaesthesia and compared them in patients receiving either lidocaine or saline.

METHODS

Eighty ASA physical status 1 patients undergoing elective surgery were enrolled in the current study. Anaesthesia was maintained with sevoflurane 1.0%-2.5% (ET concentration) and nitrous oxide 60% in oxygen. Muscle relaxation was achieved with vecuronium. The patients were randomly assigned to receive one of four treatments (n = 20 each): saline (control), 0.05 microgram.kg-1.min-1 PGE1, 0.1 microgram.kg-1.min-1 PGE1, or 1 mg.kg-1 lidocaine. PGE1 was infused from completion of surgery until five minutes after tracheal extubation. Changes in heart rate (HR) and blood pressure (BP) were measured during and after tracheal extubation.

RESULTS

In the control group, the HR, systolic BP, and diastolic BP increased during tracheal extubation. Administration of 0.1 microgram.kg-1.min-1 PGE1 and 1 mg.kg-1 lidocaine attenuated the increases in BP although 0.05 microgram.kg-1.min-1 PGE1 failed to do so. The inhibitory effect of the 0.1 microgram.kg-1.min-1 PGE1 on BP was similar to that of lidocaine 1 mg.kg-1 iv. The increase in HR was attenuated by lidocaine but not by PGE1.

CONCLUSION

The intravenous infusion of 0.1 microgram.kg-1.min-1 PGE1 given during emergence from anaesthesia and tracheal extubation is a useful method for attenuating the hypertension associated with noxious stimuli during this period.