Effect-site concentration of propofol for reduction of remifentanil-induced cough

Effect of Optimizing the Induction Regimen in Preventing Cough Reactions in Patients Undergoing General Anesthesia: A Prospective Randomized Controlled Study

PURPOSE

During the induction of general anesthesia, opioids and endotracheal intubation may cause coughing. This study aimed to investigate the safety and effectiveness of an optimized drug induction scheme for general anesthesia to prevent coughing in patients.

METHODS

A total of 220 patients aged 18 to 65 years who underwent surgery under general anesthesia with endotracheal intubation were randomly assigned to two groups, each with 110 patients. One group was administered a divided sufentanil bolus (group A) and the other with a single sufentanil bolus (group B). Anesthesia induction was performed according to the drug induction scheme of 1st, 2nd, and 3rd minutes. The primary outcome was a coughing episode associated with the administration of opioids during anesthesia induction. We also recorded the pain associated with drug injection, hemodynamics, and blood oxygen saturation during the induction of anesthesia.

FINDINGS

All patients were included in the final statistical analysis. Compared with group B, the incidence of opioid induced cough (OIC) was significantly higher in group A (9.1% vs. 0, P = 0.001). There was no cough reaction of tracheal intubation in either group. There was no severe pain due to propofol and rocuronium injection in either group (P > 0.05). The mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2) values were within the normal range at each time point during the induction period in both groups.

IMPLICATIONS

According to the optimized 1st, 2nd, and 3rd minutes anesthesia induction regimen, with a single final intravenous bolus of sufentanil after the diluted rocuronium bromide administration, no sufentanil and tracheal intubation induced coughing reactions were observed.

TRIAL REGISTRATION

The study protocol was registered in the Chinese Clinical Trial Registry (ChiCTR2200062749, http://www.chictr.org.cn/showproj.aspx?proj=175018) on August 17, 2022.

Comparison of a Small Dose of Oxycodone and Sufentanil for the Prevention of Sufentanil-Induced Cough during General Anesthesia Induction: A Prospective Randomized Controlled Trial

Background

Sufentanil is widely used during anesthesia induction. However, it can cause coughing via different mechanisms. This study is aimed at evaluating the effectiveness of a small dose of oxycodone and sufentanil in suppressing sufentanil-induced cough (SIC) during general anesthesia induction.

Methods

Of the 174 patients scheduled for elective surgery, 144 were eligible and randomly divided into 3 groups (n = 48). Five minutes before sufentanil bolus (0.4 μg/kg), patients in group O received 0.02  mg/kg oxycodone intravenously within 5 s, those in group S received 0.02 μg/kg sufentanil within 5 s, and those in group N received an equal volume of 0.9% normal saline within 5 s. Sufentanil was diluted to 5 μg/ml and administered within 5  s after pretreatment. The incidence and severity of cough in the three groups were evaluated within 1 minute after sufentanil injection during the anesthesia induction. Their mean arterial pressure (MAP) and heart rate (HR) were recorded at T0 (after entering the operation), T1 (3 minutes after pretreatment), T2 (before intubation), and T3 (1 minute after intubation).

Results

The incidences of cough in group N, group O, and group S were 20 (41.6%), 7 (14.5%), and 6 (12.5%), respectively. Compared with group N, patients from group O and group S exhibited significantly reduced incidence and severity of cough, and the severity of cough in group O and group S was significantly reduced compared with group N (P < 0.05). No significant differences in the rangeability of MAP and HR were noted at the four time points in the three groups (P > 0.05). Conclusion. Preconditioning using intravenous oxycodone (0.02 mg/kg) or sufentanil (0.02 μg/kg) could represent an effective approach to reducing SIC in anesthesia induction and was associated with relatively stable hemodynamic state during general anesthesia. This trial is registered at Chinese Clinical Trial Registry with registration number ChiCTR1900021087.

Efficacy of dezocine on preventing opioid-induced cough during general anaesthesia induction: a PRISMA-compliant systematic review and meta-analysis

OBJECTIVES

To systematically review the effects of dezocine (DZC) on the occurrence rate and severity of opioid-induced cough (OIC).

DESIGN

Systematic review and meta-analysis DATA SOURCES: PubMed, Embase, Cochrane Library, Ovid, Web of Science as well as Chinese BioMedical Literature & Retrieval System, China National Knowledge Infrastructure, Wanfang and VIP Data were searched from 1978 to 31 December 2020.

INCLUSION CRITERIA

All randomised controlled trials (RCTs) comparing DZC with placebo on the occurrence rate and severity of OIC.

DATA ANALYSIS

All data were analysed by using RevMan V.5.3. Each outcome was tested for heterogeneity, and randomised-effects or fixed-effects model was used in the presence or absence of significant heterogeneity.

RESULTS

Our search yielded 33 RCTs including 4442 patients, and 2521 patients were allocated into the DZC group and 1921 into the control group. Fentanyl was administrated in 1880 patients and sufentanil in 2562 patients during the induction of general anaesthesia. The meta-analysis demonstrated that DZC significantly reduced the occurrence rate of OIC induced by either fentanyl (8.8% vs 49.7%, OR=0.07, 95% CI 0.04 to 0.12, p<0.00001) or sufentanil (5.0% vs 41.5%, OR=0.07, 95% CI 0.04 to 0.12, p<0.00001). The meta-analysis also indicated that the occurrence rate of mild, moderate and severe OIC in the DZC group was remarkably lower than that of the control group (mild: 3.6% vs 13.6%, OR=0.19, 95% CI 0.14 to 0.25, p<0.00001; moderate: 2.0% vs 13.6%, OR=0.12, 95% CI 0.09 to 0.18, p<0.00001; severe: 1.0% vs 13.9%, OR=0.08, 95% CI 0.05 to 0.12, p<0.00001). Additionally, the current meta-analysis indicated that DZC pretreatment was not associated with increased occurrence rate of adverse effects (7.0% vs 4.2%, OR=2.34, 95% CI 0.60 to 9.14, p=0.22) except for dizziness (11.8% vs 0%, OR=8.06, 95% CI 1.40 to 46.35, p=0.02).

CONCLUSION

This meta-analysis demonstrated that DZC significantly inhibited OIC and may be used to manage OIC. More high-quality RCTs are needed to complement the safety of DZC.

PROSPERO REGISTRATION NUMBER

CRD42019141255.

Effects of prophylactic atropine on the time to tracheal intubation with the pre-administration of remifentanil

BACKGROUND

Pre-administration of remifentanil in target-controlled propofol and remifentanil anaesthesia could prolong the time of onset of muscle relaxation owing to haemodynamic effects, thereby prolonging the time to tracheal intubation. Although the sympatholytic effects of remifentanil result in bradycardia and hypotension, these responses can be attenuated by the administration of atropine. Therefore, we investigated whether prophylactic administration of atropine could prevent the prolongation of the time to tracheal intubation.

METHODS

Sixty-four patients were included in this study. They were randomised into Group A (atropine 0.5 mg, n = 32) and Group S (saline 0.9%, n = 32), immediately before the pre-administration of remifentanil. The primary outcome was the time to tracheal intubation and the secondary outcomes were rocuronium onset time, time to loss of consciousness (LOC), time to reach a value of 60 on the bispectral index (BIS) and haemodynamic variables.

RESULTS

The median [Interquartile range] of the time to tracheal intubation was 240 [214, 288]s in Group S and 190 [176, 212]s in Group A(median difference: 50 s, 95% confidence interval: 27-80 s, P = .001). Rocuronium onset time was significantly decreased in Group A compared to that in Group S (129 [110, 156] vs 172 [154, 200], P = .001). The times to LOC and reach 60 on the BIS were not significantly different between the two groups. Cardiac output(CO) and heart rate were less decreased in Group A than in Group S (P = .02, P < .001, respectively).

CONCLUSIONS

Prophylactic administration of atropine could compensate for the reduction in CO in cases pre-administered with remifentanil in target-controlled propofol and remifentanil anaesthesia. This in turn prevented the prolongation of rocuronium onset time and reduced the time to tracheal intubation.

A small dose of dezocine suppresses remifentanil-induced cough in general anesthesia induction: a prospective, randomized, controlled study

Background

The aim of this prospective randomized controlled study was to evaluate whether pretreatment with a small dose of dezocine could prevent remifentanil-induced cough in general anesthesia induction.

Trial design

a prospective, randomized, controlled study.

Methods

A total of 210 patients receiving elective operative hysteroscopy from December 2018 to April 2019 were enrolled in the present study. They were randomly equally separated into dezocine group (n = 105) and control group (n = 105). Patients were intravenously pre-administrated with dezocine 0.03 mg/kg (diluted to 5 mL) or the same volume of normal saline 1 min prior to remifentanil infusion. One minute later, intravenous injection of propofol 1.5 mg/kg and cisatracurium 0.1 mg/kg were given to all patients for induction of general anesthesia. The counts of coughs occurred during the anesthesia induction period were recorded and the severity of cough was scaled.

Results

There were 7 cases of mild cough in dezocine group and 18 cases of mild cough, 12 cases of moderate cough and 4 cases of severe cough in control group. The incidence rate of cough was significantly lower and the severity of cough was obviously relieved in dezocine group compared to control group (6.67% vs. 32.38%, P <  0.001). The two groups were not significantly different in heart rate and mean arterial pressure before the induction, before and after the intubation, and in operating time and postoperative visual analog scale pain scores.

Conclusion

This study recommends the efficacy and safety of a pretreatment with a small dose of dezocine in reducing remifentanil-induced cough during general anesthesia.

Trial Registration

ChiCTR2000032035.

Date of registration: Retrospectively registered on 2020/04/18.

Is dezocine effective and safe in preventing opioids-induced cough during general anaesthesia induction? A protocol for systematic review and meta-analysis

INTRODUCTION

Cough is often observed when administrating a bolus of opioids. Opioid-induced cough (OIC) is mostly transient, benign and self-limiting, but could be associated with adverse effects. Numerous pharmacological and non-pharmacological interventions have been used to manage OIC with controversial efficacy and safety. Recent studies suggested that, pretreatment of intravenous dezocine (DZC) could completely suppress OIC during anaesthesia induction. To address this knowledge lack, we will perform a systemic review and meta-analysis to evaluate the efficacy of DZC on OIC and possible complications. We provide here a protocol that will outline the methods and analyses planned for the systematic review.

METHODS

PubMed, Embase, Cochrane Library, Web of Science as well as Chinese BioMedical Literature & Retrieval System (SinoMed), China National Knowledge Infrastructure, Wanfang Data and VIP Data will be searched from 1978 to 31 December 2019 to identify all randomised controlled trials comparing DZC with placebo on the incidence and severity of OIC. Primary outcomes of interest include the incidence and severity of OIC. Secondary outcomes of interest include possible complications or adverse effects of DZC. Two authors will independently extract relevant variables and outcome data. For continuous variables, treatment effects will be calculated as weighted mean difference and 95% CI. For dichotomous data, treatment effects will be calculated as OR and 95% CI. Each outcome will be tested for heterogeneity, and randomised-effects or fixed-effects model will be used in the presence or absence of significant heterogeneity. Sensitivity analyses will be done by examining the influence of statistical model and individual trial(s) on estimated treatment effects. Publication bias will be explored through visual inspection of funnel plots of the outcomes. Statistical significance will be defined as p<0.05.

ETHICS AND DISSEMINATION

This study is a protocol of meta-analysis of previously published literatures, ethical approval was not necessary according to the Ethical Committee of Fuwai Hospital. The study will be submitted to a peer-reviewed journal and disseminated via research presentations.

PROSPERO REGISTRATION NUMBER

CRD42019141255.

Pre-administration of remifentanil in target-controlled propofol and remifentanil anesthesia prolongs anesthesia induction in neurosurgical patients: A double-blind randomized controlled trial

BACKGROUND

Pre- and co-administration of remifentanil in target-controlled propofol and remifentanil anesthesia are the most common methods in clinical practice. However, anesthesia induction time by timing remifentanil administration was not identified. Therefore, we investigated the induction time of anesthesia based on type of remifentanil administration in target-controlled anesthesia.

METHODS

A total of 60 patients were randomly assigned to 1 of 2 groups: Pre-administered with remifentanil before propofol infusion (Group R, n = 30) and co-administered with remifentanil with propofol (Group N, n = 30). The primary outcome was total induction time based on the order of remifentanil administration. Secondary outcomes were from start of the propofol infusion time to loss of consciousness (LOC), rocuronium onset time, time to Bispectral index (BIS) 60, and hemodynamic variables.

RESULTS

The mean ± SD of total induction time was 180.5 ± 49.0 s in Group N and 246.3 ± 64.7 s in Group R (mean difference: 65.8 seconds; 95% CI: 35.0-96.5 s, P < .01). Time to BIS 60 and rocuronium onset time were longer in the Group R (P < .01 and P < .01, respectively). The Δheart rate and Δcardiac output values were lower in the Group R (P = .02 and P = .04, respectively). Injection pain was reported by 11 of 28 (39%) in the Group N and in 2 of 28 (7%) in the Group R (difference in proportion: 32%, 95% CI: 10-51%, P = .01).

CONCLUSION

Pre-administration of remifentanil in target-controlled propofol and remifentanil anesthesia prolongs total induction time about 35% compared to co-administration of remifentanil and propofol by decreased CO.

Dose selection of central or peripheral administration of sufentanil affect opioid induced cough?: a prospective, randomized, controlled trial

BACKGROUND

Opioid-induced cough (OIC) is one of the most common complications of opioids during anesthesia induction. This study was designed to assess the incidence of OIC mediated by different intravenous route.

METHODS

A total of 102(ASA I-II) scheduled for elective surgery under general anesthesia were randomly allocated into two groups: central vein group (group CV, n = 51) and peripheral vein group (group PV, n = 51). The incidence, onset time and severity of OIC were evaluated within 1 min just after sufentanil injection during induction. Meanwhile, heart rate (HR) and blood pressure (BP) were also recorded to assess the hemodynamic changes.

RESULTS

The incidence of OIC was 10/51 (20.4%) in group CV and 16/51 (32%) in group PV, patients received central venous administration of sufentanil experienced less OIC compared with those injected by peripheral venous route (P < 0.05), as well as a significantly lower incidence of severe OIC (P < 0.05). Nevertheless, the onset of OIC and hemodynamic data were comparable between two groups (P > 0.05).

CONCLUSION

Our study indicates that sufentanil administration by central venous route reduces the incidence and severity of OIC, but without significant changes in hemodynamic status.

TRIAL REGISTRATION

Chinese Clinical Trial Registry with registration number ChiCTR-IOR-15006075 . Registered 28 February 2015.

Different interventions in preventing opioid-induced cough: a meta-analysis

BACKGROUND

Cough is one of the most common complications of opioids. Many studies have evaluated the effect of various drugs in preventing opioid-induced cough (OIC). However, there is existing controversy about those reports. The present study was performed to assess the efficacy of different interventions on OIC.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase to identify randomized controlled trials on the efficacy of different drugs in the prevention of OIC. Opioids included fentanyl, sufentanil, and remifentanil. We mainly investigated the incidence and severity of OIC after different interventions.

RESULTS

Thirty-four trials including 9906 patients were analyzed in this study. Twenty different drugs were reported, and 10 drugs were indentified in more than 2 articles. These drugs, including lidocaine, ketamine, dexmedetomidine, priming of fentanyl, propofol, dezocine, dexamethasone, dextromethorphan, and magnesium sulfate (MgSO4), showed a significant efficacy compared with controls. There were insufficient numbers of trials for salbutamol, clonidine, tramadol, pentazocine, rocuronium, midazolam, atropine, terbutaline, sodium chromoglycate, beclomethasone, and ephedrine. From these data, we found that salbutamol, tramadol, midazolam, and atropine were ineffective.

CONCLUSIONS

This meta-analysis suggested that the prophylactic administration of lidocaine, ketamine, dexmedetomidine, priming of fentanyl, propofol, and dezocine was effective in preventing OIC.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A comparison of the effect of pretreatment with intravenous dexamethasone, intravenous ketamine, and their combination, for suppression of remifentanil-induced cough: A randomized, double-blind, placebo-controlled clinical trial

Background:

The injection of remifentanil can cause cough during induction of anesthesia. This study was designed to examine the efficacy of ketamine, dexamethasone, and their combination on remifentanil-induced cough (RIC).

Materials and Methods:

One hundred and twenty patients scheduled for elective surgery were randomly assigned into four groups: Group K received 10 mg ketamine; Group D received 10 mg dexamethasone; Group KD received 10 mg ketamine in combination with dexamethasone; and Group S received saline in a similar volume, five minutes prior to the injection of remifentanil. The incidence and severity of the cough was recorded in each person.

Results:

The incidence of RIC was significantly lower in Group KD compared to Group K, Group D, and Group S (3.3 vs. 20%, 20%, and 46.7%, respectively, P < 0.05). The severity of RIC was significantly lower in Group KD compared to Group K, Group D, and Group S (P < 0.05). There was no significant difference between Group K and Group D in this regard (P > 0.05). There was no significant difference in the onset time of coughing among the four groups (19.8 ± 1.3, 20.8 ± 0.9, 19.0 ± 1.1, and 19.9 ± 2.2 in Group K, Group D, Group KD, and Group S, respectively, P > 0.05).

Conclusion:

We found that pretreatment with 10 mg ketamine in combination with 10 mg dexamethasone five minutes prior to the injection of remifentanil could significantly reduce the incidence of RIC, and it was better than using each drug singly.

A target-controlled infusion regimen for reducing remifentanil-induced coughs

BACKGROUND

This study evaluates the effectiveness of the target-controlled infusion (TCI) of remifentanil through stepwise increases in the effect-site concentration (C(eff)) in preventing coughs.

METHODS

In a preliminary study, we randomly selected 140 patients to receive remifentanil through two-step increases in C(eff) (1.0 ng/ml to 4.0 ng/ml: Group R(1-4); 2.0 ng/ml to 4.0 ng/ml: Group R(2-4)). Based on the results of the preliminary study, we employed another sample of 140 patients and implemented a three-step increase in TCI (1.0 ng/ml to 2.0 ng/ml to 4.0 ng/ml: Group R(1-2-4)). We then compared this treatment with direct targeting based on 4.0 ng/ml TCI (Group R(4)). We recorded the episodes of coughs, rating them as mild (1-2), moderate (3-4), or severe (5 or more).

RESULTS

In Group R(1-4), one patient (1.5%) coughed during the first step, and five (7.3%) coughed during the second step. In Group R(2-4), nine (13.2%) coughed during the first step, but none coughed during the next step. Only one patient had a mild cough during the three-step increase in TCI, that is, patients in Group R(1-2-4) were significantly less likely to cough than those in Group R(4) (P < 0.001).

CONCLUSIONS

Stepwise increases in the TCI of remifentanil reduced the incidence of remifentanil-induced coughing, and the three-step increase in TCI nearly eliminated remifentanil-induced coughing.

Drug-administration sequence of target-controlled propofol and remifentanil influences the onset of rocuronium. A double-blind, randomized trial

BACKGROUND

Remifentanil is known to cause bradycardia and hypotension, as well as the decreases of cardiac output (CO). We hypothesized that hemodynamic suppression by remifentanil would affect the onset time of rocuronium. This study investigated whether the onset of rocuronium was influenced by the drug-administration sequence during induction of anesthesia with target-controlled infusion of propofol and remifentanil.

METHODS

Healthy adult patients (n = 126) undergoing elective surgery under general anesthesia were randomized into two groups according to drug-administration sequence. In Remi-Pro-Rocu group (n = 62), remifentanil was infused first, followed by propofol. Then, rocuronium was administered lastly. In Pro-Rocu-Remi group (n = 64), propofol, rocuronium, and remifentanil were given in that order. As a primary outcome, the onset time of rocuronium was measured. Mean arterial pressure (MAP), heart rate (HR), CO, and stroke volume were recorded before anesthesia (T1), at injection of rocuronium (T2), immediately before and after intubation (T3 and T4).

RESULTS

In Remi-Pro-Roc group, the onset of rocuronium was delayed significantly compared with Pro-Rocu-Remi group [median (interquartile range); 130 (105-150) vs. 90 (71-100) s, P < 0.001]. At the time of rocuronium injection (T2), MAP, HR, and CO were significantly lower in Remi-Pro-Rocu group than Pro-Rocu-Remi group (P < 0.001).

CONCLUSION

The onset time of rocuronium is prolonged significantly by early administration of remifentanil during target-controlled infusion of propofol and remifentanil, and it may be due to the decreased CO caused by remifentanil.