Droperidol and endotracheal intubation. Attenuation of pressor response to laryngoscopy and intubation

A Comparison of the Effects of Dexmedetomidine and Propofol in Controlling the Hemodynamic Responses after Intubation: A Double-Blind, Randomized, Clinical Trial Study

AIM:

This study aimed to compare the effects of dexmedetomidine and propofol in controlling the hemodynamic response following intubation of patients’ candidate intubation in the emergency department

METHODS:

A total of 114 patients were randomly assigned to one of 2 groups to receive one of the following treatments: dexmedetomidine 0.4 µg/kg (Group D, n = 57) and propofol 1–1.5 mg/kg/h (Group P, n = 57). Hemodynamic data such as the systolic blood pressure, diastolic blood pressure, arterial oxygen saturation and heart rate (HR) were recorded from the entrance to operation room to 5, 10 and 15 min after tracheal intubation

RESULTS:

Compared with group D, group P exhibited increases in mean arterial blood pressure (MAP), and systolic blood pressure significantly at all times and immediately after the endotracheal intubation. Moreover, the mean diastolic blood pressure changes due to tracheal intubation in group P were significantly more than group D immediately after the intubation. Furthermore, the mean heart rate changes immediately and 5 min after tracheal intubation was significantly higher in group P

CONCLUSION:

Our data suggest that the benefits of dexmedetomidine more than propofol in hemodynamic stability because propofol was associated with more variability in systolic/diastolic blood pressure, HR and MAP after endotracheal intubation.

The comparison of Alfentanil and Remifentanil infusion during anesthesia on post-anesthesia recovery

Background and Objective:

With consideration the daily increased development of outpatient surgeries and high rate of these surgeries in elderly patients, rapid and safe recovery of patients is necessary. In this clinical trial study, recovery time and nausea and vomiting after the use of two rapid-onset narcotics, Alfentanil and Remifentanil, in elderly patients were evaluated.

Methods:

In this double-blind prospective clinical trial, 40 elderly patients (age above 65 years) candidate to cataract surgery with general anesthesia were studied. The patients were divided randomly into two groups and for first group, 10 μg/kg of Alfentanil was injected and for second group Remifentanil 0.5 μg/kg was injected intravenously during 30 seconds one minute before induction. Both two groups were under general anesthesia with same method and during the anesthesia, first group took infusion of Alfentanil 1 μg/kg/min and second group took Remifentanil 0.1 μg/kg/min. In the end of surgery, the time intervals between end of anesthesia drug administration and spontaneous respiration, eyes opening with stimulation, verbal response and discharge of recovery room, also the incidence of complications related to narcotic drugs, especially nausea and vomiting, was recorded. The data were analyzed in SPSS software using descriptive and analytical statistics such as T-test and chi square test.

Results:

The time of spontaneous respiration in Alfentanil group was 2 minutes and in Remifentanil group was 3.3 minutes, the difference was not statistically significant (P=0.08). The time of eyes opening with stimulation, verbal response, and discharge of recovery room were not significantly different. During recovery, incidence of nausea and vomiting in Remifentanil group (30% of patients) was significantly more than Alfentanil group (5% of patients) (P=0.045).

Conclusions:

Recovery time between Alfentanil and Remifentanil group was not significantly different, but incidence of nausea and vomiting in Remifentanil group was higher than Alfentanil group significantly. It seems that using Alfentanil in the anesthesia for surgical treatment of the elderly people can be preferred.

[Consequences and prevention methods of hemodynamic changes during laryngoscopy and intratracheal intubation]

In patients ranked ASA 1, laryngoscopy and intubation lead to an average increase in blood pressure of 40 to 50%, and a 20% increase in heart rate. These changes, which are greatest one minute after intubation, last for 5 to 10 min. They are due to sympathetic and adrenal stimulation, which may also result in some arrhythmias. About half the patient with coronary artery disease experience episodes of myocardial ischaemia during intubation when no specific prevention is undertaken. Among the different means available for this, narcotics seem to have a reliable and constant effect, but they may be responsible for postoperative respiratory depression. The protective effect of fentanyl starts at 2 micrograms.kg-1, and is at a maximum at 8 micrograms.kg-1. Lidocaine is the drug used most. Recent studies have questioned its efficacy. In clinical practice, it is particularly effective in preventing the pressor response to tracheal intubation, whatever its route of administration (intravenous or intratracheal), but not the increase in heart rate. Beta blockers with bradycardic, antihypertensive, antiarrhythmic and antiischaemic properties, have been advocated. As opposed to lidocaine, these agents are more effective in preventing the changes in heart rate than the pressor response. Because of their depressor effect on the myocardium, their place still remains to be defined, especially in the cardiac risk patient. Short-acting beta blockers should be preferred. Nitroglycerin is specifically indicated in coronary artery disease. Other agents, such as clonidine or calcium blockers, seem to be less effective or less convenient in preventing the haemodynamic alterations. In clinical practice, prevention will first rely on a sufficient dose of narcotics. In some cases, nitroglycerin or beta blockers may be used so as to decrease the doses of narcotics, without altering their efficacy; however, the risk of hypotension should be constantly borne in mind. If preventing measures have not been taken, short-acting antihypertensive agents (beta blockers, calcium blockers) should be used in patients who develop major hypertension during laryngoscopy and intubation.

Isosorbide dinitrate spray. Attenuation of cardiovascular responses to laryngoscopy and intubation

We evaluated the efficacy of isosorbide dinitrate buccal spray (Isomack) in attenuating the cardiovascular response to laryngoscopy and tracheal intubation in 60 patients undergoing elective surgery under general anaesthesia. Patients were allocated to one of three groups of 20 patients each. Group 1 patients were administered placebo buccal spray 90 s before induction of anaesthesia. Groups 2 and 3 had isosorbide dinitrate spray 30 and 90 s before induction of anaesthesia. Systolic, diastolic and mean arterial pressures and heart rate were monitored. After the spray, group 3 patients had a significant decrease in systolic arterial pressure (p less than 0.01). At 1 min after intubation, systolic, diastolic and mean arterial pressures showed a significant increase in group 1 patients (24.9 mmHg, 14.2 mmHg and 18.7 mmHg respectively). In contrast, groups 2 and 3 showed a significant decrease in these parameters (p less than 0.01). Although significant tachycardia was present following intubation in all the three groups, the degree of tachycardia was greater in groups 2 and 3 (p less than 0.01).

[Effects of urapidil on the cardiovascular response to intratracheal intubation]

The effects of urapidil on the haemodynamic response to endotracheal intubation were compared to that of placebo in two groups of 25 patients scheduled for general surgery. Normal saline solution or 0.4 mg.kg-1 urapidil were injected 3 min before induction of anaesthesia with 3 micrograms.kg-1 fentanyl, 0.3 mg.kg-1 etomidate and 0.1 mg.kg-1 vecuronium. Blood pressure (Pasys, Padia, Pa) and heart rate were measured continuously by servoplethysmomanometry before giving the test drug (T0), at the time when the lowest blood pressure was recorded during the three minute period between giving the drug and induction (T1), at the time when the lowest blood pressure was recorded during the three minute period between induction and endotracheal intubation (T2), at the time when the highest blood pressure was recorded immediately after intubation (T3), three minutes after intubation (T4), five minutes after intubation (T5), and at the time when the lowest blood pressure was recorded after surgery had been started (T6). It was planned to give a 25 mg urapidil dose to any patient, from either group, who had a Pasys greater than 200 mmHg for more than 60 sec. Giving urapidil lowered Pasys (T1) by 16%, whilst heart rate increased by 12%. The blood pressure peak due to endotracheal intubation was lower in those patients who had been given urapidil than in the placebo group (T3; p less than 0.05). Six patients in the latter group required the 25 mg urapidil dose, versus 2 in the urapidil group. The preventive effects of urapidil seem to be similar to those obtained with other antihypertensive agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of buprenorphine on the cardiovascular response to tracheal intubation

The effects of buprenorphine on the haemodynamic responses to tracheal intubation were studied in a placebo-controlled double-blind trial in 40 patients who had elective surgery. In one group saline was administered intravenously 8 minutes before induction, whereas the others received buprenorphine 2.5 micrograms/kg intravenously. Anaesthesia was induced in both groups with thiopentone 4 mg/kg followed by suxamethonium 1.5 mg/kg after 90 seconds. In the buprenorphine group, the maximum increase in systolic and diastolic arterial blood pressures, heart rate and rate pressure product were significantly lower compared to the control group. It is concluded that buprenorphine is partially effective in attenuating the cardiovascular response to laryngoscopy and intubation, but does not obliterate it.

Topical nitroglycerin. A safeguard against pressor responses to tracheal intubation

In order to attenuate the pressor response to intubation of the trachea we have studied the effects of 2% nitroglycerin ointment rubbed on the forehead approximately 12 minutes prior to intubation. A double blind, randomized design was used in 56 consecutive patients. Of these, 30 patients received the ointment while 26 patients formed the control group. The maximum rise in the systolic arterial pressure was significantly lower (p less than 0.001) in the group (7.66 mmHg, 6.2%) as compared to the control group (25.7 mmHg, 20.2%). The rise in arterial pressure persisted for up to 4 minutes in the control group, but lasted for only one minute in the nitroglycerine group. The pulse rate, however, increased in both groups to an equal extent. We have found the application of 2% nitroglycerine ointment to be a safe, inexpensive, comfortable and effective means of attenuating the pressor response to intubation of the trachea.

Outcome from "rescue clipping" of ruptured intracranial aneurysms during induction anaesthesia and endotracheal intubation

Eight patients with ruptured aneurysms during induction anaesthesia and endotracheal intubation underwent an emergency "rescue clipping" of their lesion. Three patients died. Of the five survivors three made a good final recovery, one patient was moderately disabled and one remained in coma. Conservative management of this crisis is doomed to failure but the comparatively good outcome of the operative cases supports emergency "rescue clipping".

Circulation, respiration and serotonin levels in carcinoid patients during neurolept anaesthesia

Release of hormones peri-operatively in patients with metastatic carcinoids may lead to severe circulatory and respiratory disturbances. Fourteen patients with liver metastases were studied during 16 operations with a modified neurolept anaesthesia in order to evaluate the central haemodynamic and respiratory functions as well as plasma serotonin levels. The premedication in five patients was supplemented with levopromazine. During the 11 operations performed on patients not pretreated with levopromazine, no major significant fluctuations in circulatory or respiratory functions were recorded although big variations in serotonin plasma levels were measured. In the patients treated with levopromazine, however, significant changes were observed in heart rate, mean pulmonary artery pressure, cardiac index, and left and right ventricular stroke work especially during flushing episodes. However, these changes did not correlate with the changes in plasma serotonin levels. Modified neurolept anaesthesia without levopromazine pretreatment combined with careful monitoring seems to be a safe procedure for carcinoid patients. Using this type of anaesthetic procedure only one major complication occurred in connexion with 16 major operations and then in the postoperative period.