Inhalational anesthetic technique in microlaryngeal surgery: a comparison between sevoflurane-remifentanil and sevoflurane-alfentanil anesthesia

Topical larynx lidocaine Spraying reduces cardiovascular stress response caused by suspension laryngoscopic surgery

OBJECTIVE

This study aimed to investigate the potential reduction of cardiovascular stress response caused by suspension laryngoscopic surgery through the application of lidocaine spray on the larynx and trachea.

METHODS

A total of 68 patients scheduled for elective suspension laryngoscopic surgery were randomly assigned to either the lidocaine group (Group L, n = 34) or the control group (Group C, n = 33). In Group L, patients received a sprayed lidocaine dose of 2 mg/kg on the larynx and trachea after anesthesia induction, prior to intubation. In Group C, equal volumes of saline solution were administered. MAP and HR were recorded at various time points: before anesthesia (T0), 1-minute after intubation (T1), 1 and 3 min after suspension laryngoscopy (T2 and T3), at the end of the operation (T4), and at 1, 5, and 30 min after extubation (T5, T6, and T7). Arterial blood glucose, epinephrine, and norepinephrine levels were measured at T0, T2, T5, and T7. The occurrence of severe cough and sore throat at T6 and T7 after extubation was compared between the two groups.

RESULTS

At T0 and T1, there were no statistically significant differences in mean arterial pressures, heart rate, and blood catecholamine levels between the two groups. However, from T2 to T7, the blood pressure and heart rate in Group L were lower compared to Group C, with significant differences observed at T2‒T6 (p < 0.05). Group L also showed less elevation in blood glucose at T2, T5, and T7 (p < 0.05). The changes in epinephrine and norepinephrine levels between the two groups were statistically significant at T2 and T5 (p < 0.05).

CONCLUSIONS

Administering lidocaine spray on the larynx and trachea during intubation for suspension laryngoscopic surgery can effectively alleviate the stress response. LEVEL 1 EVIDENCE: Patients in this study are randomly assigned to the treatment or control group and are followed prospectively.

Comparison of nebulized ropivacaine (0.75%) with nebulized dexmedetomidine on the hemodynamic response on intubation in patients undergoing surgery under general anesthesia: A comparative randomized double-blind placebo-controlled study

Background

Laryngoscopy and tracheal intubation lead to sympathetic stimulation resulting in hemodynamic fluctuations. We compared local anesthetic ropivacaine 0.75% with alpha agonist dexmedetomidine through ultrasonic nebulization for direct local action of the drug in the airway.

Methods

In our randomized study, 180 patients were prospectively assigned to three groups of 60 each: group R (0.75%), group D (1 microgram/kg), and group C (control). The primary objective was to determine whether nebulized ropivacaine or nebulized dexmedetomidine can cause a reduction in stress response to laryngoscopy and intubation. The secondary objectives were to compare the hemodynamic parameters at extubation, cough response at extubation, and postoperative sore throat.

Results

A total of 165 patients were analyzed. Demographically, all the groups were similar. Group R and group D were found to significantly attenuate the heart rate (HR) at intubation and extubation when compared to group C (P < 0.05). A significant reduction in mean arterial pressure (MAP) was seen (P < 0.05; group D: 90 ± 18.4 mmHg, group C: 99.5 ± 15.9 mmHg, group R: 92.4 ± 16.1 mmHg). There was a significant reduction in cough response in both groups in comparison with group C at 0 minutes (P value; group C vs group D: <.0001; group C vs group R:.01) and 5 minutes (P value; group C vs group D: <.0001; group C vs group R: <.0001).

Conclusion

Preinduction topical use of ropivacaine or dexmedetomidine, through the nebulization route, effectively attenuated the pressor responses when compared to placebo.

Real-Time Monitoring of Blood Pressure Using Digitalized Pulse Arrival Time Calculation Technology for Prompt Detection of Sudden Hypertensive Episodes During Laryngeal Microsurgery: Retrospective Observational Study

Background

Laryngeal microsurgery (LMS) is often accompanied by a sudden increase in blood pressure (BP) during surgery because of stimulation around the larynx. This sudden change in the hemodynamic status is not immediately reflected in a casual cuff-type measurement that takes intermittent readings every 3 to 5 min.

Objective

This study aimed to investigate the potential of pulse arrival time (PAT) as a marker for a BP surge, which usually occurs in patients undergoing LMS.

Methods

Intermittent measurements of BP and electrocardiogram (ECG) and photoplethysmogram (PPG) signals were recorded during LMS. PAT was defined as the interval between the R-peak on the ECG and the maximum slope on the PPG. Mean PAT values before and after BP increase were compared. PPG-related parameters and the correlations between changes in these variables were calculated.

Results

BP surged because of laryngoscopic manipulation (mean systolic BP [SBP] from 115.3, SD 21.4 mmHg, to 159.9, SD 25.2 mmHg; P<.001), whereas PAT decreased significantly (from mean 460.6, SD 51.9 ms, to 405.8, SD 50.1 ms; P<.001) in most of the cases. The change in SBP showed a significant correlation with the inverse of the PAT (r=0.582; P<.001). Receiver-operating characteristic curve analysis indicated that an increase of 11.5% in the inverse of the PAT could detect a 40% increase in SBP, and the area under the curve was 0.814.

Conclusions

During LMS, where invasive arterial catheterization is not always possible, PAT shows good correlation with SBP and may, therefore, have the potential to identify abrupt BP surges during laryngoscopic manipulations in a noninvasive manner.

Comparison of Effect of Airway Nebulization with Lignocaine 2% versus Ropivacaine 0.25% on Intubation and Extubation Response in Patients Undergoing Surgery under General Anesthesia: A Randomized Double-Blind Clinical Trial

Context:

Both intubation and extubation are associated with pressor response.

Aims:

We aimed to evaluate if ropivacaine 0.25% nebulization would prevent hemodynamic and cough responses to intubation and extubation and compared it with lignocaine 2% and saline group.

Settings and Design:

This was a randomized double-blind clinical trial.

Materials and Methods:

A total of 75 patients classified as the American Society of Anaesthesiologists physical status Classes I and II belonging to 18–60 years were included in the randomized double-blind trial and divided into three groups; Group 1: received 5 ml of normal saline, Group 2: received 5 ml of 0.25% ropivacaine, Group 3: received 5 ml of 2% lignocaine through nebulization before the induction. Patients were then administered general anesthesia. Mean arterial pressure (MAP), heart rate (HR), and saturation were recorded at baseline (T1), at intubation (T2), upon anesthetic withdrawal (T3), upon eye opening (T4), upon extubation (T5), and 2 min after extubation (T6). Cough response was recorded at emergence and extubation.

Statistical Analysis Used:

Repeated measures analysis of variance were used to compare hemodynamic variables and Chi-square test to compare the grades of cough between the two groups.

Results:

The drug ropivacaine was found to be effective in reducing the hemodynamic responses to both intubation and extubation when compared to saline (P < 0.05). At extubation, though the mean values of HR and MAP were lower in ropivacaine compared to lignocaine group, the difference did not achieve statistical significance (P = 0.103 and 0.153 respectively). Only 40% of patients who received ropivacaine had cough at extubation (P < 0.001).

Conclusion:

Ropivacaine when used through nebulization preinduction effectively reduced both intubation and extubation responses when compared to saline. However, there was no significant difference between the ropivacaine and lignocaine on extubation response.

Effects of lignocaine on pressor response to laryngoscopy and endotracheal intubation during general anaesthesia in rigid suspension laryngoscopy

OBJECTIVE

This study aimed to compare the effects of topical and systemic lignocaine on the circulatory response to direct laryngoscopy performed under general anaesthesia.

METHODS

Ninety-nine patients over 20 years of age, with a physical status of I-II (classified according to the American Society of Anesthesiologists), were randomly allocated to 3 groups. One group received 5 ml of 0.9 per cent physiological saline intravenously, one group received 1.5 mg/kg lignocaine intravenously, and another group received seven puffs of 10 per cent lignocaine aerosol applied topically to the airway. Mean arterial pressures, heart rates and peripheral oxygen saturations were recorded, and changes in mean arterial pressure and heart rate ratios were calculated.

RESULTS

Changes in the ratios of mean arterial pressure and heart rate were greater in the saline physiological group than the other groups at 1 minute after intubation. Changes in the ratios of mean arterial pressure (at the same time point) were greater in the topical lignocaine group than in the intravenous lignocaine group, but this finding was not statistically significant.

CONCLUSION

Lignocaine limited the haemodynamic responses to laryngoscopy and endotracheal intubation during general anaesthesia in rigid suspension laryngoscopy.

Local airway anesthesia attenuates hemodynamic responses to intubation and extubation in hypertensive surgical patients

BACKGROUND

The aim of this study was to evaluate the effects of topical ropivacaine anesthesia on hemodynamic responses during intubation and extubation of hypertensive patients.

MATERIAL AND METHODS

One hundred fifty patients with hypertension ASA II-III were scheduled for noncardiac operations. Patients were divided into 3 groups: a control group receiving 5 ml saline, and 2 groups receiving topical anesthesia with 100 mg lidocaine or 37.5 mg ropivacaine. Hemodynamic responses, including blood pressure and heart rate (HR), were recorded at baseline (T0), before intubation (T1), during tracheal intubation (T2), 2 min after intubation (T3), upon eye opening on verbal commands (T4), during tracheal extubation (T5), and 2 min after extubation (T6). Patients were injected with urapidil 5 mg during intubation and extubation if their systolic blood pressure (SBP) was ≥160 mmHg or diastolic blood pressure (DBP) was ³90 mmHg, and esmolol 10 mg when HR was ≥90 bpm.

RESULTS

During extubation, the total dosages of urapidil and esmolol were significantly higher in the saline than in the lidocaine or ropivacaine groups, and were significantly lower in the ropivacaine than in the lidocaine group. At T2, SBP, SBP, MAP, and HR were lower in the lidocaine and ropivacaine groups than in the saline group, but the differences were not significant. From T4 to T6, SBP, DBP, MAP, and HR were significantly lower in the ropivacaine group than in the other 2 groups (P<0.05 each).

CONCLUSIONS

Topical lidocaine and ropivacaine anesthesia can effectively reduce hemodynamic responses during intubation, with ropivacaine better at inhibiting hemodynamic changes at emergence in hypertensive patients.

Prevention of perioperative and anesthesia-related complications in facial cosmetic surgery

Although office-based anesthesia for facial cosmetic surgery remains remarkably safe, no anesthesia or sedation performed outside the operating room should be considered minor. Proper organization, preparation, and patient selection, close collaboration with the surgeon, and expert and effective anesthesia care will increase patient safety and improve perioperative outcomes and patient satisfaction. This article presents a comprehensive overview of anesthesia in terms of facial plastic surgery procedures, beginning with a broad review of essentials and pitfalls of anesthesia, followed by details of specific anesthetic agents, their administration, mechanism of action, and complications.

Effect of sevoflurane versus propofol-based anesthesia on the hemodynamic response and recovery characteristics in patients undergoing microlaryngeal surgery

Background:

This randomized study was conducted to compare the hemodynamic changes and emergence characteristics of sevoflurane versus propofol anesthesia for microlaryngeal surgery.

Methods:

Forty adult patients undergoing microlaryngoscopy were randomly allocated into two groups. In propofol group, anesthesia was induced with 2-3 mg/kg propofol and maintained with propofol infusion 50-200 μg/kg/h. In sevoflurane group induction was carried out with 5-8% sevoflurane and maintained with sevoflurane in nitrous oxide and oxygen. The propofol and sevoflurane concentrations were adjusted to maintain the bispectral index of 40-60. All patients received fentanyl 2 μg/kg before induction and succinylcholine 2 mg/kg to facilitate tracheal intubation. The hemodynamic changes during induction and suspension laryngoscopy were compared. In addition, the emergence time, time to extubation, and recovery were assessed.

Results:

The changes in heart rate were comparable. The mean arterial pressure was significantly lower after induction and higher at insertion of operating laryngoscope in propofol group as compared to sevoflurane group. More patients in propofol group had episodes of hypotension and hypertension than sevoflurane group. The emergence time, extubation times, and recovery time were similar in both groups.

Conclusion:

We found that sevoflurane showed advantage over propofol in respect of intraoperative cardiovascular stability without increasing recovery time.

Effects of 10% lidocaine spray on arterial pressure increase due to suspension laryngoscopy and cough during extubation

Background

It is well known that suspension laryngoscopy (SL) produces marked hemodynamic changes. Coughing during extubation sometimes causes adverse clinical problems. We investigated whether 10% lidocaine spray could attenuate hemodynamic stress responses due to SL and reduce coughing incidence during extubation.

Methods

Sixty patients undergoing SL were randomly divided into two groups and intubated without 10% lidocaine spray (control group) or given 1.5 mg/kg of 10% lidocaine, sprayed onto laryngeal and intratracheal sites 2 min prior to intubation (10% lidocaine group). Mean arterial pressure (MAP) and heart rates (HR) during SL and coughing incidence during extubation were recorded.

Results

MAP at 2.5 and 5 min (P < 0.05) and HR at 2.5 min after SL (P < 0.01) were greater in the control group than in the 10% lidocaine group. The number of coughs decreased in the 10% lidocaine group compared to the control group during pre- (6.8 ± 3.2 vs 10.3 ± 4.4, P < 0.01) and post-extubation period of 5 min (4.0 ± 2.3 vs 6.2 ± 4.2, P < 0.05) and during the entire study period (10.8 ± 3.9 vs 16.5 ± 5.6, P < 0.001).

Conclusions

Preoperative laryngeal and intratracheal spraying with 1.5 mg/kg of 10% lidocaine spray is effective for attenuation of arterial pressure increase to SL and suppression of coughing during extubation.

Remifentanil for general anaesthesia: a systematic review

We performed a quantitative systematic review of randomised, controlled trials that compared remifentanil to short-acting opioids (fentanyl, alfentanil, or sufentanil) for general anaesthesia. Eighty-five trials were identified and these included a total of 13 057 patients. Intra-operatively, remifentanil was associated with clinical signs of deeper analgesia and anaesthesia, such as fewer responses to noxious stimuli (relative risk 0.65, 95% CI 0.48-0.87), more frequent episodes of bradycardia (1.46, 1.04-2.05), more hypotension (1.68, 1.36-2.07) and less hypertension (0.60, 0.46-0.78). Postoperatively, remifentanil was associated with faster recovery (difference in extubation time of -2.03, 9.5% CI, -2.92 to -1.14 min), more frequent postoperative analgesic requirements (1.36, 1.21-1.53) and fewer respiratory events requiring naloxone (0.25, 0.14-0.47). Remifentanil had no overall impact on postoperative nausea (1.03, 0.97-1.09) or vomiting (1.06, 0.96-1.17), but was associated with twice as much shivering (2.15, 1.73-2.69). Remifentanil does not seem to offer any advantage for lengthy, major interventions, but may be useful for selected patients, e.g. when postoperative respiratory depression is a concern.