Differential effects of lidocaine and remifentanil on response to the tracheal tube during emergence from general anaesthesia

Multimodal prevention of emergence cough following nasal endoscopic surgery under general anesthesia: a double-blind randomized trial

Purpose

Cough during emergence from anesthesia is a common problem and may cause adverse events. Monotherapy faces uncertainty in preventing emergence cough due to individual differences. We aimed to evaluate the efficacy and safety of multimodal intervention for preventing emergence cough in patients following nasal endoscopic surgery.

Methods

In this double-blind randomized trial, 150 adult patients undergoing nasal endoscopic surgery were randomly allocated into three groups. For the control group (n = 50), anesthesia was performed according to clinical routine, no intervention was provided. For the double intervention group (n = 50), normal saline 3 mL was sprayed endotracheally before intubation, 0.4 μg/kg dexmedetomidine was infused over 10 min after intubation, and target-controlled remifentanil infusion was maintained at an effect-site concentration of 1.5 ng/mL before extubation after surgery. For the multimodal intervention group (n = 50), 0.5% ropivacaine 3 mL was sprayed endotracheally before intubation, dexmedetomidine and remifentanil were administered as those in the double intervention group. The primary endpoint was the incidence of emergence cough, defined as single cough or more from end of surgery to 5 min after extubation.

Results

The incidences of emergence cough were 98% (49/50) in the control group, 90% (45/50) in the double group, and 70% (35/50) in the multimodal group, respectively. The incidence was significantly lower in the multimodal group than those in the control (relative risk 0.71; 95% CI 0.59 to 0.86; p < 0.001) and double (relative risk 0.78; 95% CI 0.63 to 0.95; p = 0.012) groups; the difference between the double and control groups was not statistically significant (relative risk 0.92; 95% CI 0.83 to 1.02; p = 0.20). The severity of sore throat was significantly lower in the multimodal group than that in the control group (median difference-1; 95% CI -2 to 0; p = 0.016). Adverse events did not differ among the three groups.

Conclusion

For adult patients undergoing endonasal surgery, multimodal intervention including ropivacaine topical anesthesia before intubation, dexmedetomidine administration after intubation, and remifentanil infusion before extubation after surgery significantly reduced emergence cough and was safe.

Preoperative lignocaine nebulisation for attenuation of the pressor response of laryngoscopy and tracheal intubation in patients with severe preeclampsia undergoing caesarean section delivery: A randomised double-blind controlled trial

Background and Aims

Following induction of general anaesthesia, direct laryngoscopy and endotracheal intubation usually cause tachycardia and hypertension due to increased sympathetic activity. This response is generally exaggerated in hypertensive patients. This study aimed to evaluate the effectiveness of preoperative lignocaine nebulisation in attenuating the pressor response to laryngoscopy and endotracheal intubation in patients with severe preeclampsia undergoing caesarean delivery.

Methods

After ethical approval, we conducted this randomised, double-blind study, which included 110 patients with severe preeclampsia who underwent caesarean delivery under general anaesthesia. These patients were randomly allocated into two groups to receive either preoperative nebulisation of lignocaine 2% in a dose of 4.5 mg/kg (not exceeding 400 mg) in the lignocaine group or nebulisation of an equivalent volume of 0.9% NaCl in the saline group. The primary objective was the systolic blood pressure after tracheal intubation. The secondary objectives included heart rate, maternal serum cortisol and blood glucose levels, grade of cough during emergence, postoperative sore throat and hoarseness of voice, neonatal Apgar score and umbilical blood gas.

Results

The systolic blood pressure was significantly lower in the lignocaine group compared to the saline group at 1, 3 and 5 min after endotracheal intubation and after delivery of the foetus (P = 0.001, 0.003, 0.002 and 0.019, respectively). Similarly, the heart rate was significantly lower in the lignocaine group versus saline group at 1 and 3 min after endotracheal intubation (P = 0.041 and 0.042, respectively).

Conclusion

Preoperative lignocaine nebulisation in a dose of 4.5 mg/kg effectively attenuated the pressor response to laryngoscopy and endotracheal intubation in patients with severe preeclampsia undergoing caesarean delivery.

Effects of lidocaine administration via the perforated outer cuff of a dual-cuff endotracheal tube and remifentanil administration on recovery from general anaesthesia for female patients undergoing thyroidectomy: a single centre, double-blind, randomised study

Background

Cough caused by endotracheal tube (ETT) placement is ubiquitous and correlates with adverse outcomes. Remifentanil administration via target-controlled infusion (TCI) is one of the cough prevention measures used during recovery. In a pilot study, lidocaine administered via the perforated outer cuff of a dual-cuff endotracheal tube was also found to prevent cough due to ETT placement. We therefore compared these two cough prevention approaches during recovery after thyroidectomy in a single-centre, double-blind, randomised study conducted in China during the period from 09/10/2020 to 30/04/2021.

Methods

Ninety-eight female patients aged 18–65 years with American Society of Anaesthesiologists Physical Status scores of I and II were scheduled to undergo thyroidectomy. The ETT contained an internal cuff covered by a perforated outer cuff to allow for lidocaine delivery. Patients were randomised to receive either 4 ml of saline solution (Group R, n = 49) or 4 ml of 2% lidocaine in the outer cuff (Group L, n = 49) at the beginning of skin suturing. Remifentanil (2 ng/ml) was maintained in Group R until extubation, while remifentanil was maintained in Group L until the end of skin suturing. The primary outcome was cough during patient transfer, at 1 min before extubation, and at extubation. The secondary outcomes were haemodynamics and other recovery parameters.

Results

Primary outcomes were compared between remifentanil vs. lidocaine application, namely, the incidence of cough during patient transfer (0% in Group R vs. 0% in Group L), at 1 min before extubation (22.45% in Group R vs. 4.08% in Group L; P = 0.015), and at extubation (61.22% in Group R vs. 20.41% in Group L; P < 0.001). Compared with remifentanil, lidocaine more effectively decreased heart rate elevation and hypoxemia at 5 min after extubation, the spontaneous respiration recovery time, the extubation time, the duration of post-anaesthesia care unit (PACU) stay, Richmond Agitation-Sedation Scale scores in the agitated range and Critical-Care Pain Observation Tool scores.

Conclusion

Lidocaine administered via the perforated outer cuff of the ETT significantly improved recovery from general anaesthesia compared to remifentanil in female patients after thyroidectomy.

Trial registration

Chinese Clinical Trial Registry (No. ChiCTR2000038653), registered on 27/09/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01734-1.

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.

Effect of intravenous lignocaine infusion on the quality of emergence in patients undergoing transsphenoidal resection of pituitary tumors - A prospective, randomized controlled trial

Background:

Emergence from anesthesia is a critical step in patients undergoing transsphenoidal pituitary surgery (TSS). The cough suppressant and anesthetic sparing properties of lignocaine makes it a favorable option for smooth extubation and maintaining stable hemodynamics intraoperatively. We aimed to evaluate the effect of lignocaine infusion on the quality of emergence (QOE) and intraoperative hemodynamics in patients undergoing transsphenoidal resection of pituitary tumors.

Methods:

Fifty patients scheduled to undergo TSS were randomly divided into ligocaine group (n = 25), receiving 1.5 mg/kg bolus dose of lignocaine followed by continuous infusion of 1.5 mg/kg/h and saline group (n = 25). Patients assigned to the control group received equal volume of saline receiving equal volume of saline. The four emergence parameters (mean arterial pressure [MAP], heart rate (HR), cough, and agitation) were abbreviated into an aggregated score for QOE. Time to emergence and intraoperative hemodynamics were also recorded.

Results:

The QOE was not found to be different between the two groups (P = 0.294). Lignocaine did not increase the time to emergence (P = 0.166). The intraoperative HR and MAP were comparable between the two groups. A lower minimum alveolar concentration of desflurane was required in lignocaine group during insertion of nasal speculum (P = 0.018) and at the time of seller ridge dissection (P = 0.043) compared to the saline group.

Conclusion:

Intraoperative lignocaine infusion of 1.5 mg/kg/h did not significantly improve the QOE with respect to hemodynamics, cough, and emergence agitation in patients undergoing transsphenoidal resection of pituitary tumors.

Effect-site concentration of remifentanil for smooth emergence from sevoflurane anesthesia in patients undergoing endovascular neurointervention

During emergence from general anesthesia, coughing caused by the endotracheal tube frequently occurs and is associated with various adverse complications. In patients undergoing endovascular neurointervention, achieving smooth emergence from general anesthesia without coughing is emphasized since coughing is associated with intracranial hypertension. Therefore, the up-and-down method was introduced to determine the effective effect-site concentration (Ce) of remifentanil to prevent coughing in 50% and 95% (EC₅₀ and EC₉₅) of patients during emergence from sevoflurane anesthesia for endovascular neurointervention. A total of 43 participants, American Society of Anesthesiologists class I or II participants, aged from 20 to 70 years who were undergoing endovascular neurointervention through transfemoral catheter for cerebrovascular disease were enrolled. Using the up-and-down method with isotonic regression, the EC₅₀ and EC₉₅ of remifentanil to prevent coughing during emergence from sevoflurane anesthesia were determined. We also investigated differences of hemodynamic and recovery profiles between the cough suppression group and the cough group. In total, 38 of 43 patients were included for estimation of EC₅₀ and EC₉₅. The EC₅₀ and EC₉₅ of remifentanil to prevent coughing were 1.42 ng/mL (95% confidence interval [CI], 1.28–1.56 ng/mL) and 1.70 ng/mL (95% CI, 1.67–2.60 ng/mL), respectively. There was comparable emergence and recovery data between the cough suppression group (n = 22) and the cough group (n = 16). However, the Ce of remifentanil and total dose of remifentanil were significantly higher in the cough suppression group (P = 0.002 and P = 0.004, respectively). Target-controlled infusion of remifentanil at 1.70 ng/mL could effectively prevent extubation-related coughing in 95% of neurointervention patients, which could ensure smooth emergence.

Efficacy of Single-Dose Dexmedetomidine Combined with Low-Dose Remifentanil Infusion for Cough Suppression Compared to High-Dose Remifentanil Infusion: A Randomized, Controlled, Non-Inferiority Trial

Background: Combination of dexmedetomidine and opioid may be an alternative to high-dose opioid in attenuating cough during emergence from anesthesia, while also reducing the adverse effects of high-dose opioid. We tested the hypothesis that a single-dose of dexmedetomidine combined with low-dose remifentanil infusion during emergence would not be inferior to high-dose remifentanil infusion alone in attenuating cough after thyroidectomy. Methods: One hundred sixty-nine patients undergoing thyroidectomy were enrolled and randomized in a 1:1 ratio into group DR or group R. Each patient received an infusion of dexmedetomidine (0.5 μg/kg) and low-dose remifentanil infusion of effect-site concentration (Ce) at 1 ng/mL or normal saline and high-dose remifentanil infusion of Ce at 2 ng/mL for 10 min at the end of surgery. Remifentanil was maintained until tracheal extubation. Primary endpoint was the severity of coughing, which was assessed for non-inferiority using a four-point scale at the time of extubation. For comparison of coughing incidence during emergence, coughing grade was also measured at three times: before extubation, at extubation, and after extubation. Time to awakening, hemodynamic and respiratory profile, pain, and postoperative nausea and vomiting were also evaluated for superiority. Results: The 95% confidence intervals for differences in cough grade during tracheal extubation were <0.9, indicating non-inferiority of the single dose of dexmedetomidine combined with low-dose remifentanil infusion. The incidence of coughing was similar in the two groups. Hemodynamic changes during tracheal extubation were attenuated, but emergence from anesthesia was delayed, in group DR. Use of rescue antiemetic was similar in both groups, but the incidence of vomiting was less in group DR. Conclusion: A single-dose of dexmedetomidine (0.5 μg/kg) combined with low-dose remifentanil infusion at 1 ng/mL of Ce during emergence from sevoflurane-remifentanil anesthesia was not inferior to high-dose remifentanil infusion alone at 2 ng/mL of Ce with regard to suppressing cough.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study

Background

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response and postoperative sore throat.

Methods

Fifty-four patients undergoing thyroidectomy were randomly assigned to two groups. The patients in Group R were received 0.75% ropivacaine, which was sprayed on the tracheal mucosa, epiglottis, tongue base, and glottis to achieve uniform surface anesthesia. As control, patients in Group C were received the same volume saline. The primiary outcome was the incidence and grade of cough during peri-extubation.

Results

The incidence (34.62% vs. 76.92%, P = 0.002) of cough during extubation were lower in Group R compared to Group C. Meanwhile, the sore throat visual acuity score at 12 h after surgery was lower in Group R than that in Group C (2.00 vs. 3.50, P = 0.040).

Conclusion

Topical anesthesia with 0.75% ropivacaine before intubation can significantly reduce the incidence of cough during peri-extubation. Meanwhile, it reduced hemodynamic fluctuations and postoperative throat pain without influence patients recovery.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800014412 (date of registration January 2018).

Dexmedetomidine facilitates extubation in children who require intubation and respiratory support after airway foreign body retrieval: a case-cohort analysis of 57 cases

PURPOSE

This study aimed to investigate whether dexmedetomidine had sedative weaning advantage for extubation after airway foreign body (FB) removal in children.

METHODS

A retrospective case-cohort comparison study with total of 57 critical children who required mechanical ventilation after rigid bronchoscopy was performed. After tracheal intubation, group D (received dexmedetomidine 1 µg/kg over 10 min, followed by an infusion of 0.8 µg/kg/h), and group RP (received remifentanil-propofol 6-10 µg/kg/h and 1-3 mg/kg/h, respectively). The primary outcome was successful extubation rate on first weaning trial. The minor outcomes included weaning time, emergency agitation, coughing score and the incidence of respiratory adverse complications on emergency.

MAIN RESULTS

All 57 patients were included in the analysis, with 30 patients in group D and 27 controlled cases in group RP. The success rate of first weaning trial in the D group was 96.7 vs 77.8% in the RP group, risk ratio (RR) 1.56, 95% CI [0.78-1.98]. Time for resuming spontaneous breathing after termination infusion was shorter in the D group (median 8 min, IQR 15 min) vs RP group (median 12 min, IQR 19 min, P = 0.02, RR 0.56, 95% CI 0.14-6.57).

CONCLUSIONS

In mechanical ventilation of pediatric patients following rigid bronchoscopy, in comparison to remifentanil-propofol, dexmedetomidine is proved to have high success rate for weaning strategy. WHAT IS ALREADY KNOWN?: Remifentanil is proved to be effective for weaning in ICU patients. Dexmedetomedine can provide similar rates of smooth extubation for pediatric patients who underwent airway surgery. WHAT THIS ARTICLE ADDS?: Invasive ventilation is used for patients with severe comorbidity after airway surgery, but the correct strategy for pediatric extubation after removal of airway foreign body remains unclear. For these patients with short-term mechanical ventilation, dexmedetomedine may improve the extubation rate, when compared with remifentanil-propofol.

Predicting effective remifentanil concentration in 95% of patients to prevent emergence cough after laryngomicroscopic surgery

Smooth emergence or cough prevention is a clinically important concern in patients undergoing laryngomicroscopic surgery (LMS). The purpose of this study was to estimate the effective concentration of remifentanil in 95% of patients (EC95) for the prevention of emergence cough after LMS under propofol anesthesia using the biased coin design (BCD) up-down method.A total of 40 adult patients scheduled to undergo elective LMS were enrolled. Anesthesia induction and maintenance were performed with target-controlled infusion of propofol and remifentanil. Effective effect-site concentration (Ce) of remifentanil in 95% of patients for preventing emergence cough was estimated using a BCD method (starting from 1 ng/mL with a step size of 0.4 ng/mL). Hemodynamic and recovery profiles were observed after anesthesia.According to the study protocol, 20 patients were allocated to receive remifentanil Ce of 3.0 ng/mL, and 20 patients were assigned to receive lower concentrations of remifentanil, from 1.0 to 2.6 ng/mL. Based on isotonic regression with a bootstrapping method, EC95 (95% CI) of remifentanil Ce for the prevention of emergence cough from LMS was found to be 2.92 ng/mL (2.72-2.97 ng/mL). Compared with patients receiving lower concentrations of remifentanil, the incidence of hypoventilation before extubation and extubation time were significantly higher in those receiving remifentanil Ce of 3.0 ng/mL. However, hypoventilation incidence after extubation and staying time in the recovery room were comparable between the 2 groups.Using a BCD method, the EC95 of remifentanil Ce for the prevention of emergence cough was estimated to be 2.92 ng/mL (95% CI: 2.72-2.97 ng/mL) after LMS under propofol anesthesia.

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.

Sex-related differences in effect-site concentration of remifentanil for preventing anesthetic emergence cough in elderly patients

Purpose

Cough on anesthetic emergence should be prevented considering its dangerous complications. Target-controlled infusion (TCI) of remifentanil can reduce emergence cough effectively, and sex-related differences in effect-site concentration (Ce) of remifentanil have been evaluated in young patients. In this study, we determined the Ce of remifentanil for preventing emergence cough following extubation in male and female elderly patients and evaluated the sex-related difference.

Patients and methods

Twenty-three male and 22 female elderly patients aged between 60 and 75 years were enrolled. Anesthesia was maintained with sevoflurane and remifentanil TCI. The Ce of remifentanil for preventing emergence cough was determined for each sex using isotonic regression method with a bootstrapping approach, following Dixon’s up-and-down method.

Results

The Ce of remifentanil for preventing emergence cough in 50% (EC₅₀) and 95% (EC₉₅) of the population was significantly lower in females than in males. Isotonic regression revealed the EC₅₀ (83% confidence interval [CI]) of remifentanil was 1.67 (1.55–1.83) ng/mL in females and 2.60 (2.29–2.91) ng/mL in males. The EC₉₅ (95% CI) of remifentanil was 2.30 (2.02–2.62) ng/mL in females and 3.41 (3.27–3.58) ng/mL in males. Dixon’s up-and-down method indicated that the mean EC₅₀ in females was lower than in males (1.56±0.26 ng/mL vs 2.56±0.37 ng/mL, P<0.001).

Conclusion

The remifentanil requirement for preventing emergence cough was lower in female than in male elderly patients, indicative of sex-related differences in Ce of remifentanil. Sex should be considered when using remifentanil TCI for preventing emergence cough in elderly patients.

Staggering the dose of sugammadex lowers risks for severe emergence cough: a randomized control trial

Background

Cough on emergence has been reported as a common adverse reaction with sugammadex reversal. We investigated if staggering the dose of sugammadex will reduce emergence cough in a single-center, randomized, double-blinded study.

Methods

A hundred and twenty ASA 1–3 adults were randomly reversed with 1 mg/kg sugammadex prior to extubation followed by another 1 mg/kg immediately after extubation (staggered group), single dose of 2 mg/kg sugammadex (single bolus group) or neostigmine 0.02 mg/kg with glycopyrrolate (neostigmine group).

Results

We found 70% of patients (n = 28) reversed with single boluses of sugammadex had Grade 3 emergence cough compared to 12.5% (n = 5) in the staggered sugammadex group and 17.5% (n = 7) in the neostigmine group (p < 0.001). Besides cough, emergence agitation also appeared highest in the single bolus sugammadex group (n = 14, 35%, p = 0.005). On the other hand, staggering sugammadex lowered risks of developing severe cough (RR 0.2, p < 0.001) and agitation (RR 0.43, p = 0.010) on emergence in addition to cough (RR 0.25, p = 0.039) and early sore throat (RR 0.70, p = 0.036) in the post-anesthetic care unit. The risks for severe emergence cough (RR 0.86, p = 0.762), severe cough in the post-anesthetic care unit (RR 1.0, p = 1.000) and sore throat (RR 1.17, p = 0.502) were also not different between the staggered sugammadex group and control given neostigmine. In terms of timing, there was no delay in time taken from discontinuing anesthetic agents to reversal and extubation if sugammadex was staggered (emergence time 6.0 ± 3.2 s, p = 0.625 and reversal time 6.5 ± 3.5, p = 0.809).

Conclusions

Staggering the dose of sugammadex for reversal will effectively decrease common emergence and early postoperative complications.

Trial registration

ANZCTR Number ACTRN12616000116426. Retrospectively registered on 2nd February 2016.

Alleviating Stress Response to Tracheal Extubation in Neurosurgical Patients: A Comparative Study of Two Infusion Doses of Dexmedetomidine

BACKGROUND

Tracheal extubation is almost always associated with increase in sympathoadrenal activity may result in hypertension, tachycardia, and arrhythmias. Attempts have been made to oppose the pressor response by the use of various drugs. Dexmedetomidine decreases norepinephrine which reduces the blood pressure and the heart rate (HR). We hypothesize that the infusion of dexmedetomidine may produce more stable hemodynamics during extubation as compared to boluses.

MATERIALS AND METHODS

Ninety adult patients aged 18-65 years, the American Society of Anesthesiologists Grade I-II undergoing intracranial surgeries for various neurologic problem at All India Institute of Medical Sciences were enrolled in this randomized controlled trial. Primary.

OBJECTIVES

(1) To observe the hemodynamic changes (HR and mean arterial pressure [MAP]) and airway responses during tracheal extubation following two infusion doses of dexmedetomidine.

SECONDARY OBJECTIVES

(1) Time to emergence and time to tracheal extubation, (2) Early postoperative complications such as laryngospasm and bronchospasm, and (3) adverse effects of the study drug. Patients were assigned into three groups - (1) Group D0.2 - 0.2 μg/kg/h diluted to 50 ml, (2) Group D0.4 - 0.4 μg/kg/h diluted to 50 ml and Group P (Placebo) - 0.9% NS 50 ml. The hemodynamics including the HR and MAP were recorded just before the loading dose of the study drug and then were recorded every 5 min till the infusion was stopped at tracheal extubation and every 1 min till 10 min postextubation. In addition, the airway, respiratory and cardiovascular complications along with postoperative nausea and vomiting, shivering, cough grading, Aldrete score, Ramsay sedation scale, and intraoperative awareness were recorded.

STATISTICAL ANALYSIS

Continuous variables such as HR and MAP were analyzed using analysis of variance and categorical variables were analyzed using the Chi-square test.

RESULTS

Patient demographics were comparable between the three groups. There was a significant reduction in HR and MAP just before extubation and up to 10 min post extubation in the D0.2 and D0.4 groups as compared to placebo (P < 0.001) but the difference among the dexmedetomidine groups were not significant. Patients belonging to D0.2 group emerged faster than D0.4 group, however, the results were comparable with placebo group. 73.3% patients of the placebo group had tachycardia and hypertension at emergence as compared to only 3.3% patients in the D0.4 group (P < 0.001). Eighty percentage patients of D0.2 and 100% patients of D0.4 group had a significant reduction in cough as compared to placebo (P < 0.001). No patient in either groups had intraoperative awareness, any respiratory complications, or allergic reactions to the study drug. Modified Aldrete scoring and Ramsay sedation scale were comparable in all the three groups.

CONCLUSION

Dexmedetomidine suppresses cough and hemodynamic responses (HR and MAP) to tracheal extubation significantly without delaying emergence.

Comparison of Dexmedetomidine and Remifentanil on Airway Reflex and Hemodynamic Changes during Recovery after Craniotomy

PURPOSE

During emergence from anesthesia for a craniotomy, maintenance of hemodynamic stability and prompt evaluation of neurological status is mandatory. The aim of this prospective, randomized, double-blind study was to compare the effects of dexmedetomidine and remifentanil on airway reflex and hemodynamic change in patients undergoing craniotomy.

MATERIALS AND METHODS

Seventy-four patients undergoing clipping of unruptured cerebral aneurysm were recruited. In the dexmedetomidine group, patients were administered dexmedetomidine (0.5 μg/kg) for 5 minutes, while the patients of the remifentanil group were administered remifentanil with an effect site concentration of 1.5 ng/mL until endotracheal extubation. The incidence and severity of cough and hemodynamic variables were measured during the recovery period. Hemodynamic variables, respiration rate, and sedation scale were measured after extubation and in the post-anesthetic care unit (PACU).

RESULTS

The incidence of grade 2 and 3 cough at the point of extubation was 62.5% in the dexmedetomidine group and 53.1% in the remifentanil group (p=0.39). Mean arterial pressure (p=0.01) at admission to the PACU and heart rate (p=0.04 and 0.01, respectively) at admission and at 10 minutes in the PACU were significantly lower in the dexmedetomidine group. Respiration rate was significantly lower in the remifentanil group at 2 minutes (p<0.01) and 5 minutes (p<0.01) after extubation.

CONCLUSION

We concluded that a single bolus of dexmedetomidine (0.5 μg/kg) and remifentanil infusion have equal effectiveness in attenuating coughing and hemodynamic changes in patients undergoing cerebral aneurysm clipping; however, dexmedetomidine leads to better preservation of respiration.

Optimal effect-site concentration of remifentanil for preventing cough during removal of the double-lumen endotracheal tube from sevoflurane-remifentanil anesthesia: A prospective clinical trial

Opioids are used as a treatment for coughing. Recent studies have reported an antitussive effect of remifentanil during recovery from general anesthesia by suppressed coughing. The coughing reflex may differ throughout the respiratory tract from the larynx to the bronchi. But the proper dose of remifentanil to prevent cough during double-lumen tube (DLT) extubation is unknown.Twenty-five ASA physical status 1 and 2 patients, 20 to 65 years of age who were undergoing video-assisted thoracoscopic lung surgery requiring 1-lung ventilation were enrolled. The effective effect-site concentration (Ce) of remifentanil for 50% and 95% of patients (EC50 and EC95) for preventing cough was determined using the isotonic regression method with a bootstrapping approach, following the Dixon up-and-down method. Recovery profiles and hemodynamic values after anesthesia were compared between patients with cough and patients without cough.EC50 and EC95 of remifentanil was 1.670 ng/mL [95% confidence interval (95% CI) 1.393-1.806] and 2.275 ng/mL (95% CI 1.950-2.263), respectively. There were no differences in recovery profiles and hemodynamic values after anesthesia between patients with/without cough. No patients suffered respiratory complications during the emergence period.Remifentanil can be a safe and reliable method of cough prevention during emergence from sevoflurane anesthesia after thoracic surgery requiring DLT. EC50 and EC95 of remifentanil that suppresses coughing is 1.670 and 2.275 ng/mL, respectively.

Anaesthetic considerations for pectus repair surgery

Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.

Determination of EC95 of remifentanil for smooth emergence from propofol anesthesia in patients undergoing transsphenoidal surgery

BACKGROUND

In patients undergoing pituitary surgery using a transsphenoidal approach, anesthesia emergence should be smooth with minimal coughing. Recent studies demonstrated that a target-controlled infusion of remifentanil effectively suppresses coughing induced by the endotracheal tube. We investigated the EC95 of remifentanil for smooth emergence without coughing from propofol anesthesia in patients undergoing transsphenoidal hypophysectomy.

MATERIALS AND METHODS

A total of 41 patients undergoing transsphenoidal hypophysectomy, aged 20 to 65 years, with an ASA physical status of I or II, were enrolled. For all participants, anesthesia was induced and maintained with a target-controlled infusion of remifentanil and propofol using predicted effect-site concentration (Ce). A biased coin design up-and-down sequential allocation and isotonic regression method were used to determine the remifentanil EC95 to prevent emergence coughing. In addition, we observed recovery profiles after anesthesia.

RESULTS

According to the study design, 19 patients received remifentanil 2.6 ng/mL Ce and 22 patients received a lower Ce, ranging from 1.0 to 2.2 ng/mL. The EC95 of remifentanil to prevent coughing was estimated as 2.51 ng/mL (95% confidence interval, 2.28-2.57 ng/mL). Despite the exclusion of 1 case because of delayed emergence, 17 of 18 patients receiving 2.6 ng/mL of remifentanil had bradypnea (<10 breaths/min) until 3 minutes after extubation. However, end-tidal carbon dioxide was maintained below 55 mm Hg during anesthetic emergence and respiratory rate recovered within 20 minutes of admission to the postanesthetic care unit.

CONCLUSIONS

The EC95 of remifentanil for smooth emergence from anesthesia was 2.51 ng/mL after transsphenoidal hypophysectomy.

I-gel Laryngeal Mask Airway Combined with Tracheal Intubation Attenuate Systemic Stress Response in Patients Undergoing Posterior Fossa Surgery

BACKGROUND

The adverse events induced by intubation and extubation may cause intracranial hemorrhage and increase of intracranial pressure, especially in posterior fossa surgery patients. In this study, we proposed that I-gel combined with tracheal intubation could reduce the stress response of posterior fossa surgery patients.

METHODS

Sixty-six posterior fossa surgery patients were randomly allocated to receive either tracheal tube intubation (Group TT) or I-gel facilitated endotracheal tube intubation (Group TI). Hemodynamic and respiratory variables, stress and inflammatory response, oxidative stress, anesthesia recovery parameters, and adverse events during emergence were compared.

RESULTS

Mean arterial pressure and heart rate were lower in Group TI during intubation and extubation (P < 0.05 versus Group TT). Respiratory variables including peak airway pressure and end-tidal carbon dioxide tension were similar intraoperative, while plasma β-endorphin, cortisol, interleukin-6, tumor necrosis factor-alpha, malondialdehyde concentrations, and blood glucose were significantly lower in Group TI during emergence relative to Group TT. Postoperative bucking and serious hypertensions were seen in Group TT but not in Group TI.

CONCLUSION

Utilization of I-gel combined with endotracheal tube in posterior fossa surgery patients is safe which can yield more stable hemodynamic profile during intubation and emergence and lower inflammatory and oxidative response, leading to uneventful recovery.

Effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia

BACKGROUND AND AIMS

Lignocaine in intravenous (IV) bolus dose has been used for minimising haemodynamic changes associated with intubation and extubation. Furthermore, IV infusion has been used for post-operative analgesia. We investigated whether IV peri-operative lignocaine (bolus and infusion) would be able to produce both the effects simultaneously in elective laparoscopic cholecystectomies.

METHODS

In this randomised prospective study, 60 patients undergoing elective laparoscopic cholecystectomy were randomly divided into two groups of 30 each. In Group A, patients received 6 ml normal saline as bolus over 10 min followed by 6 ml/h infusion whereas in Group B, patients received preservative free 2% lignocaine 1.5 mg/kg IV bolus (made to a volume of 6 ml with normal saline) administered over a period of 10 min and thereafter an infusion at a rate of 1.5 mg/kg/h (pre-diluted in normal saline made to a volume of 6 ml/h. P < 0.05 was considered as significant.

RESULTS

The rise in pulse rate (PR) and mean arterial pressure (MAP) were less in Group B as compared to the Group A (P < 0.05) during intubation as well as during extubation. Furthermore, the Group B had significant longer mean pain-free post-operative period of 5½ h as compared to 54.43 min in the Group A (P < 0.05).

CONCLUSION

Administration of lignocaine infusion attenuates the rise in PR as well as MAP during the peri-intubation and peri-extubation period. Furthermore, infusion of lignocaine significantly increases the mean pain-free period post-operatively.

Lidocaine for preventing postoperative sore throat

BACKGROUND

Sore throat is a common side-effect of general anaesthesia and is reported by between 30% and 70% of patients after tracheal intubation. The likelihood of a sore throat varies with the type, diameter, and cuff pressure of the endotracheal tube used. If intubation is essential, it may be helpful to give drugs prophylactically to alleviate postoperative sore throat. Local anaesthetics and steroids have been used for this purpose. This review was originally published in 2009 and was updated in 2015.

OBJECTIVES

The objective of this review was to evaluate the efficacy and any harm caused by topical and systemic lidocaine used prophylactically to prevent postoperative sore throat in adults undergoing general anaesthesia with endotracheal intubation.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2013, Issue 9), MEDLINE (January 1966 to October 2013), and EMBASE (1980 to October 2013). We also contacted manufacturers and researchers in the field. The original search was undertaken in June 2007. We reran the search in February 2015 and found four studies of interest. We will deal with those studies when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of topical and systemic prophylactic lidocaine therapy versus control (using air or saline) that reported on the risk and severity of postoperative sore throat as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information, such as the risk of any adverse effects.

MAIN RESULTS

We included 19 studies involving 1940 participants in this updated review. Of those 1940 participants, 952 received topical or systemic lidocaine therapy and 795 were allocated to the control groups. Topical and systemic lidocaine therapy appeared to reduce the risk of postoperative sore throat (16 studies, 1774 participants, risk ratio (RR) was 0.64 (95% confidence interval (CI) 0.48 to 0.85), the quality of the evidence was low), although when only high-quality trials were included (eight studies, 814 participants) the effect was no longer significant (RR 0.71, 95% CI 0.47 to 1.09). Lidocaine given systemically in two studies (320 participants) did not reveal evidence of an effect (RR 0.44, 95% CI 0.19 to 1.05 ). The severity of sore throat as measured on a visual-analogue scale (VAS) was reduced by lidocaine therapy (six trials, 611 participants, (mean difference (MD) -10.80, 95% CI -14.63 to -6.98). The adverse effects of lidocaine were not reported in these studies, though toxicity is generally rare.

AUTHORS' CONCLUSIONS

In our revised systematic review, although the results of included studies show generally positive results, they should be interpreted carefully. The effect size of lidocaine appeared to be affected by study quality; drug concentration; route of administration; management of cuff pressure during anaesthesia; the included population; and the type of outcome measured.

Does the type of anesthetic agent affect remifentanil effect-site concentration for preventing endotracheal tube-induced cough during anesthetic emergence? Comparison of propofol, sevoflurane, and desflurane

STUDY OBJECTIVE

To investigate whether the type of anesthetic agent administered affects the antitussive effect of remifentanil.

DESIGN

Prospective randomized study.

SETTING

Operating room of a university hospital.

PATIENTS

78 ASA physical status 1 and 2 women, aged 20 to 65 years, who were scheduled to undergo a thyroidectomy.

INTERVENTIONS

Patients were randomly assigned to three groups to receive anesthesia with propofol (Group P), sevoflurane (Group S), or desflurane (Group D). The main anesthetics were titrated to maintain a target Bispectral Index for hypnosis of 40 to 60. Remifentanil was administered via effect-site target-controlled infusion (TCI). To determine the effective remifentanil effect-site concentration (Ce) to suppress coughing in each group, the up-and-down sequential allocation design was used.

MEASUREMENTS

The half maximal effective concentration (EC50) values of remifentanil for preventing coughing in the groups were estimated using isotonic regression and compared among the groups.

MAIN RESULTS

The EC50 of remifentanil for cough suppression in Group P [1.60 ng/mL (98.3% CI, 0.92-1.75 ng/mL)] was statistically lower than in Group D [1.96 ng/mL (98.3% CI, 1.81-2.50 ng/mL)]. The EC50 in Group S was 1.75 ng/mL (98.3% CI, 1.39-2.13 ng/mL), which was higher than in Group P and lower than in Group D, but did not differ significantly from either group.

CONCLUSIONS

Remifentanil administration for cough suppression during emergence should be customized to the anesthetic agent.

Attenuation of Hemodynamic Responses to Laryngoscopy and Tracheal Intubation: Propacetamol versus Lidocaine-A Randomized Clinical Trial

The purpose of this study is to assess the effects of propacetamol on attenuating hemodynamic responses subsequent laryngoscopy and tracheal intubation compared to lidocaine. In this randomized clinical trial, 62 patients with the American Anesthesiologists Society (ASA) class I/II who required laryngoscopy and tracheal intubation for elective surgery were assigned to receive propacetamol 2 g/I.V./infusion (group P) or lidocaine 1.5 mg/kg (group L) prior to laryngoscopy. Systolic and diastolic blood pressures (SBP, DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded at baseline, before laryngoscopy and within nine minutes after intubation. In both groups P and L, MAP increased after laryngoscopy and the changes were statistically significant (P < 0.001). There were significant changes of HR in both groups after intubation (P < 0.02), but the trend of changes was different between two groups (P < 0.001). In group L, HR increased after intubation and its change was statistically significant within 9 minutes after intubation (P < 0.001), while in group P, HR remained stable after intubation (P = 0.8). Propacetamol 2 gr one hour prior intubation attenuates heart rate responses after laryngoscopy but is not effective to prevent acute alterations in blood pressure after intubation.

The effect of a subhypnotic dose of propofol for the prevention of coughing in adults during emergence from anesthesia with sevoflurane and remifentanil

BACKGROUND

Coughing during emergence from general anesthesia may be detrimental. Propofol is known to inhibit airway reflexes. We evaluated the incidence and severity of coughing in adults who received a subhypnotic dose of propofol at the end of sevoflurane-remifentanil anesthesia.

METHODS

Sixty patients, aged 18-65 years, undergoing elective nasal surgery under general anesthesia using sevoflurane and remifentanil were randomly allocated to the propofol group (n = 30) or the control group (n = 30). At the end of surgery, sevoflurane and remifentanil infusion was stopped. After 3 min, the propofol group received propofol 0.3 mg/kg and the control group received normal saline 0.03 ml/kg. The incidence and severity of cough, recovery time and hemodynamic parameters were evaluated during the emergence period.

RESULTS

During emergence, the propofol group had the significantly lower incidence (60 vs. 87%) and severity of coughing compared with the control group (P = 0.04, P = 0.02, respectively). There were no significant differences in mean arterial pressure, heart rate, and recovery time during emergence between the two groups.

CONCLUSIONS

During emergence from sevoflurane-remifentanil anesthesia, a subhypnotic dose (0.3 mg/kg) of propofol decreases the incidence and severity of coughing without delaying wake up in adults undergoing nasal surgery.

The incidence of intraoperative hypertension and risk factors for its development during thyroid surgery

We studied the influence of demographic characteristics, comorbidity, and type and duration of surgery and anesthesia on the occurrence of intraoperative hypertension (IOHTA). Logistic regression analyses were used in order to determine the predictors of occurrence of IOHTA. More than 60% of our patients had IOHTA. Multivariate analysis showed that independent predictors for IOHTA were older age, BMI 25 kg/m(2), and hypertension as a coexisting disease. Hypertension is common during thyroid surgery, and a significant number of patients remained hypertensive during the postoperative period.

Sufentanil infusion before extubation suppresses coughing on emergence without delaying extubation time and reduces postoperative analgesic requirement without increasing nausea and vomiting after desflurane anesthesia

Background

Coughing, hypertension, tachycardia, and even laryngospasm can occur due to airway irritation during emergence from anesthesia. We investigated the effect of maintaining a sufentanil infusion during emergence from anesthesia by evaluating the incidence of cough and recovery profiles at extubation.

Methods

In total, eighty-four patients undergoing an elective laparoscopic hysterectomy were randomly divided into two sufentanil groups and a control group. During emergence, sufentanil was administered in the sufentanil groups at a rate of 0.2 µg/kg/hr (Group S1) or 0.3 µg/kg/hr (Group S2), and saline was administered to the control group. Cough score, hemodynamic changes, and recovery profiles, such as duration from skin closure to a bispectral index of 80, to eye opening at verbal command, to tracheal extubation and the total duration of study solution infusion, were recorded. The pain score, the total volume of administered patient-controlled analgesia (PCA), and the postoperative nausea and vomiting (PONV) score were evaluated 1, 6, and 24 hours after surgery.

Results

Groups S1 and S2 showed significantly lower cough scores and smaller hemodynamic changes on extubation compared to Group C. Recovery profiles showed no significant differences among the three groups. Pain score, PONV at 1 hour postoperatively, and the total volume of PCA administered at all evaluation times were significantly lower in Groups S1 and S2 than in the control group. However, pain score, and PONV at 6 hours and 24 hours postoperatively showed no significant differences.

Conclusions

A sufentanil infusion (0.2-0.3 µg/kg/hr) during emergence from desflurane anesthesia may suppress coughing on extubation in patients with body mass indexes (BMI) of 21-26 without delaying extubation time. It may also reduce the postoperative analgesic requirement without increasing PONV.

Comparison of the antitussive effect of remifentanil during recovery from propofol and sevoflurane anaesthesia

This prospective randomised study compared the antitussive effect of remifentanil during recovery from either propofol or sevoflurane anaesthesia. Seventy-four female patients undergoing thyroidectomy were anaesthetised with either propofol and remifentanil or sevoflurane and remifentanil. During recovery, remifentanil was maintained at an effect-site concentration of 2 ng.ml(-1) until extubation and the occurrence of coughing, haemodynamic parameters and recovery profiles were compared between the two groups. During recovery, neither the incidence nor the severity of cough (incidence 20% with propofol; 24% with sevoflurane, p = 0.77), nor the haemodynamic parameters were different between the two groups. Time to awakening and time to extubation were significantly shorter in the propofol group (4.7 min, 6.1 min min, respectively) compared with the sevoflurane group (7.9 min and 8.9 min respectively) (p < 0.001 and p = 0.002, respectively). An effect-site concentration of 2 ng.ml(-1) of remifentanil was associated with smooth emergence from both propofol and sevoflurane anaesthesia.

Difficult Airway Society Guidelines for the management of tracheal extubation

Tracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care.

Target controlled remifentanil infusion for smooth laryngeal mask airway removal during emergence from desflurane-remifentanil anesthesia

PURPOSE

Administration of remifentanil can be a reliable method for preventing airway reflex responses during emergence. We therefore investigated the effect of maintaining target controlled infusion (TCI) of remifentanil for smooth cLMA removal during emergence from desflurane-remifentanil anaesthesia.

METHODS

Forty-one patients undergoing uretero-renoscopy under general anesthesia with desflurane and at 1-4 ng/ml TCI remifentanil infusion were randomly assigned to a control group (n = 20) or a remifentanil group (n = 21). At the end of the surgery, desflurane and remifentanil infusion were stopped in group C and remifentanil was maintained at the effect-site concentration of 1.5 ng/ml TCI in group R. When LMA removal was accomplished without coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, and desaturation to SpO(2) less than 90%, removal was regarded as smooth (successful). The emergence and recovery profiles were also evaluated.

RESULTS

The incidence and number of complications (coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, desaturation to SpO(2) <90%) were significantly higher in the control group than in the remifentanil group (p = 0.002).

CONCLUSION

Maintaining effect-site TCI of remifentanil at 1.5 ng/ml during emergence from anaesthesia enabled smooth removal of cLMA without any delay in recovery time.

Comparison of the Optimal Effect-Site Concentrations of Remifentanil for Preventing Cough during Emergence from Desflurane or Sevoflurane Anaesthesia

OBJECTIVE: To compare the effect-site concentrations of remifentanil target-controlled infusion (TCI) that produced 50% and 95% of the maximal effect (EC50 and EC95, respectively) for preventing cough during emergence from desflurane or sevoflurane anaesthesia, in patients undergoing elective thyroidectomy. METHODS: Adults undergoing elective thyroidectomy were randomized to receive anaesthesia with desflurane or sevoflurane. The EC50 and EC95 values for remifentanil TCI were determined using Dixon's up-and-down method and probit analysis with sigmoid curve. RESULTS: In total, 48 patients aged 20 – 64 years were enrolled in the study. The EC50 ± SD of remifentanil TCI, determined by Dixon's up-and-down method, were 1.54 ± 0.70 and 1.11 ± 0.24 ng/ml for desflurane and sevoflurane, respectively. The EC95 of remifentanil TCI, analysed by probit analysis, were 2.88 ng/ml and 2.29 ng/ml for desflurane and sevoflurane, respectively. The effect-site concentration of remifentanil TCI for preventing cough during emergence from desflurane anaesthesia was not significantly higher than that observed for sevoflurane. CONCLUSIONS: During emergence from anaesthesia, variations in effect-site concentrations of remifentanil for preventing cough are of limited importance as they do not generate significant differences in results.