Comparison of hemodynamic response to tracheal intubation and postoperative pain in patients undergoing closed reduction of nasal bone fracture under general anesthesia: a randomized controlled trial comparing fentanyl and oxycodone

The effect of magnesium sulfate on emergence agitation in surgical adult patients undergoing general anesthesia: A systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVE

Investigating the effect of magnesium sulfate (MS) on emergence agitation (EA) in adult surgical patients following general anesthesia (GA).

DESIGN

Systematic literature review and meta-analysis (PROSPERO number: CRD42023461988).

SETTING

Review of published literature.

PATIENTS

Adults undergoing GA.

INTERVENTIONS

Intravenous administration of MS.

MEASUREMENTS

We searched PubMed/MEDLINE, EMBASE, the Cochrane Library, Scopus, and Web of Science for publications until September 14, 2023. The primary outcome was the incidence of EA, while the secondary outcomes included the impact of MS on postoperative agitation score (PAS), emergence variables and adverse events. Relative risk (RR) with 95% confidence interval (CI) measured dichotomous outcome, while standardized mean difference (SMD) or mean difference (MD) with 95% CI measured continuous outcomes.

MAIN RESULTS

Meta-analysis of five randomized controlled trials (RCTs) indicated that MS was associated with a lower incidence of EA at various time points (0 min: RR = 0.62, 95% CI [0.41, 0.95]; p = 0.183, I2 = 43.6%; 5 min: RR = 0.29, 95% CI [0.16, 0.52]; p = 0.211, I2 = 36%; 10 min: RR = 0.14, 95% CI [0.06, 0.32]; p = 0.449, I2 = 0%; 15 min: RR = 0.11, 95% CI [0.02, 0.55]; p = 0.265, I2 = 19.5%; 30 min: RR = 0.05, 95% CI [0.00, 0.91]; the postoperative period: RR = 0.21, 95% CI [0.09, 0.49]; p = 0.724, I2 = 0%;). Additionally, MS was associated with a reduced PAS at various time points except for 0 min. However, no significant differences were observed in extubation time, the length of stay in the post-anesthesia care unit, postoperative nausea and vomiting or total complications.

CONCLUSIONS

Limited available evidence suggests that MS was associated with a lower incidence of EA. Nevertheless, further high-quality studies are warranted to strengthen and validate the effect of MS in preventing EA in adult surgical patients.

The effects of intraoperative magnesium sulfate administration on emergence agitation and delirium in pediatric patients: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The role of intraoperative magnesium for the prevention of emergence agitation or delirium is unclear as there have been conflicting results reported by several randomized controlled trials.

AIMS

The aim of this study was to investigate the effect of magnesium sulfate on emergence agitation or emergence delirium in pediatric patients.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science, were searched to identify studies which evaluated the effects of magnesium on postoperative emergence agitation or emergence delirium. The primary outcome was the incidence of emergence agitation or emergence delirium during the post-anesthesia stay. The secondary outcome was the agitation or delirium score upon admission to the post-anesthesia care unit. We estimated the odds ratio and standardized mean difference using a random-effect model.

RESULTS

A total of 712 pediatric patients from 10 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 29.7% in the magnesium group and 50.5% in the control group. The pooled effect size revealed that the administration of magnesium sulfate significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery with general anesthesia (Odds ratio, 0.31; 95% confidence interval, 0.15 to 0.64; p = .002). Additionally, children in the magnesium group reported significantly lower agitation or delirium scores than those in the control group (standardized mean difference, -0.70; 95% confidence interval, -1.15 to -0.24; p = .003).

CONCLUSION

The administration of magnesium sulfate reduced the incidence and severity of emergence agitation or emergence delirium in pediatric patients after the use of general anesthesia during surgery.

Effect of intravenous oxycodone on the physiologic responses to extubation following general anesthesia

BACKGROUND

Endotracheal intubation and extubation may cause undesirable hemodynamic changes. Intravenous oxycodone has recently been introduced and used for relieving hemodynamic alterations in response to intubation, but there is insufficient information regarding its application in stabilizing hemodynamics during extubation in the patients emerging from general anesthesia.

METHODS

One hundred patients, who had undergone assorted laparoscopic surgeries under general anesthesia, were randomly assigned to Control group (saline injection, 50 cases) and Study group (intravenous injection of 0.08 mg/kg oxycodone immediately after completion of the surgical procedure, 50 cases). Blood pressure, heart rate, blood oxygen saturation (SpO₂) as well as blood concentrations of epinephrine, norepinephrine, and cortisol were recorded or measured immediately before extubation (T₀), during extubation (T₁), as well as one minute (T₂), 5 min (T₃), and 10 min after extubation (T₄). In addition, coughing and restlessness, time of eye-opening, and duration from completing surgery to extubation as well as Ramsay Sedation Scale were analyzed.

RESULTS

Blood pressure and heart rate as well as blood concentrations of epinephrine, norepinephrine, and cortisol were significantly higher in the Control group compared with the Study group at the time of extubation as well as 1, 5, and 10 min after extubation (P < 0.05). When the patients emerged from general anesthesia, 70 % of the Control group had cough, which was significantly higher than that of Study group (40 %, P < 0.05). Significantly higher number of patients manifested restlessness in the Control group before (40 %) and after extubation (20 %) compared with that in the Study group (20 and 2 %, respectively, P < 0.05). In addition, patients of Control group had lower Ramsay score at extubation (1.7 ± 0.7) as well as 30 min after extubation (2.4 ± 0.9) compared to that of the patients of Study group (2.2 ± 0.9, and 3.0 ± 0.8, respectively, P = 0.003 and 0.001).

CONCLUSIONS

Intravenous oxycodone attenuated alterations of hemodynamics and blood hormones associated with extubation during emergence from general anesthesia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000040370 (registration date: 11-28-2020) "'retrospectively registered".

Feasibility of using oxycodone as the sole opioid for induction and maintenance of general anaesthesia in minor/moderate surgery: a prospective, observational, descriptive study

Objectives

This study presented the feasibility of oxycodone as the sole opioid for general anaesthesia in minor/moderate surgery.

Methods

In this prospective, observational, descriptive study, 62 patients were enrolled and received intravenous oxycodone as the sole opioid for the induction and maintenance of general anaesthesia. We observed all of these patients to determine whether oxycodone alone could provide sufficient intraoperative and postoperative analgesia, as well as to record the extubation times and adverse events.

Results

A total oxycodone dose of 0.316 ± 0.05 mg/kg was used for induction and maintenance of general anaesthesia. The dose could maintain haemodynamic stability during surgery and good postoperative analgesia. Oxycodone caused deep sedation (nine patients had Ramsey sedation scores ≥4), leading to respiratory depression and long stays in the post-anaesthesia care unit (PACU). The extubation time (16.9 ± 6.4 minutes) increased with increasing oxycodone doses.

Conclusion

Oxycodone can be used as the sole opioid for general anaesthesia in minor/moderate surgery. However, care should be taken because of its deep sedation effect.

Trial registration: This study is registered at the Chinese Clinical Trial Registry (www.chictr.org.cn): ChiCTR-opc-16009175

Effective dose of intravenous oxycodone depending on sex and age for attenuation of intubation-related hemodynamic responses

Background/aim

Preoperative intravenous oxycodone may help to prevent or attenuate intubation-related hemodynamic responses (IRHRs), but its pharmacokinetics differs according to age and sex. Therefore, we investigated the 95% effective dose (ED₉₅) of intravenous oxycodone for attenuating all IRHRs, depending on the age and sex of the study population.

Materials and methods

All patients were allocated to one of 6 groups: 1) 20–40 year old males, 2) 41–65yearold males, 3) 66–80 year old males, 4) 20–40 year old females, 5) 41–65yearold females, and 6) 66–80 year old females (groups YM, OM, EM, YF, OF, and EF, respectively). Using Dixon’s up-and-down method, the first patient in each group was slowly injected with intravenous oxycodone (0.1 mg kg^-1) 20 min before intubation. The subsequent patient received the next oxycodone dose, which was decreased or increased by 0.01 mg kg^-1, depending on the “success” or “failure” of attenuation of all IRHRs to within 20% of the baseline values at 1 min after intubation in the previous patient. After obtaining 8 crossover points, predictive ED₉₅ was estimated with probit regression analysis.

Results

ED₉₅ varied greatly according to age and sex. ED₉₅was 0.133 mg kg^-1, 0.181 mg kg^-1, 0.332 mg kg^-1, 0.183 mg kg^-1, 0.108 mg kg^-1, and 0.147 mg kg^-1in groups YM, OM, EM, YF, OF, and EF, respectively.

Conclusion

ED₉₅ is higher in males with increasing age but is ambiguous for females. ED₉₅ is higher in males than in females over 40 years of age but is higher in females than in males under 41 years of age. However, after considering the age and sex of the study population, these results can be used as reference doses for further studies to verify the clinical effects of oxycodone for attenuating all IRHRs.

Emergence agitation: current knowledge and unresolved questions

Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.

Comparison of emergence agitation between succinylcholine and rocuronium-sugammadex in adults following closed reduction of a nasal bone fracture: a prospective randomized controlled trial

BACKGROUND

Sugammadex allows rapid recovery from rocuronium-induced neuromuscular blockade. Succinylcholine is often used for brief surgeries but is associated with myalgia, headache, histamine release, and increased lactate levels. Thus, we hypothesized that succinylcholine may affect emergence agitation (EA) and compared the effects of succinylcholine and rocuronium-sugammadex on EA in patients undergoing closed reduction of a nasal bone fracture under general anesthesia.

METHODS

Forty-two patients were prospectively enrolled and allocated randomly to the succinylcholine group (group SC) or the rocuronium-sugammadex group (group RS; each n = 21). Neuromuscular block and its reversal were achieved with succinylcholine and normal saline in group SC, whereas rocuronium and sugammadex were administered in group RS. After surgery, the incidence of EA as a primary outcome, the incidence of dangerous EA, and duration of EA as secondary outcomes were compared.

RESULTS

The incidence of EA was higher in group SC than in group RS (90.5% vs. 47.6%, respectively; relative risk [RR] 4.3; 95% confidence interval [CI] 1.2 to 15.7; P = .006). The incidence of dangerous EA increased in group SC compared to group RS (33.3% vs. 4.8%, respectively; RR 2.1; 95% CI 1.3 to 3.4; P = .045). The duration of agitation was longer in group SC than in group RS [106.5 (65.1) vs. 40.4 (26.0) sec; mean difference 66.1 s; 95% CI 31.0 to 101.1; effect size 1.3; P = .001).

CONCLUSION

Succinylcholine increases the incidence, severity, and duration of EA compared to rocuronium-sugammadex in patients undergoing closed reduction of a nasal bone fracture.

TRIAL REGISTRATION

CRiS Registration number KCT0002673. Initial registration date was 31 January 2018 (Retrospectively registered).

Effect of different doses of intravenous oxycodone and fentanyl on intubation-related hemodynamic responses: A prospective double-blind randomized controlled trial (CONSORT)

BACKGROUND

Intubation using direct laryngoscopy is a risky and painful procedure that is associated with undesirable hemodynamic changes such as tachycardia, hypertension, and arrhythmia. Recently, intravenous oxycodone was introduced and used for the control of acute postoperative pain and to attenuate intubation-related hemodynamic responses (IRHRs), but there is insufficient information regarding its proper dosage. We investigated the attenuating effects of different doses of oxycodone and fentanyl on IRHRs.

METHODS

For calculating oxycodone effective dose (ED95), which attenuated all IRHR changes to less than 20% over baseline values in 95% of male patients at 1 minute after intubation, oxycodone 0.1 mg/kg was injected for the first patient 1 hour before intubation, and the next dose for each subsequent patient was determined by the response of the previous patient using Dixon up-and-down method with an interval of 0.01 mg/kg. After obtaining the predictive oxycodone ED95, 148 patients were randomly allocated to groups receiving normal saline (group C), oxycodone ED95 (group O1), oxycodone 2 × ED95 (group O2), or fentanyl 2 μg/kg (group F). We recorded the incidence of "success" as a less than 20% change from baseline values in all IRHRs 1 minute after intubation.

RESULTS

The predictive oxycodone ED95 was 0.091 (0.081-0.149) mg/kg. The incidence of "success" was highest in group O2 (75.7%), followed by group O1 (62.2%) and group F (45.9%) with significant differences between the groups (P < .001). The systolic, diastolic, mean arterial pressure, and heart rate were not significantly different among groups after administration of either oxycodone or fentanyl. The percentage hemodynamic changes of the group O2 were significantly lower than those of groups F and O1, but the absolute percentage hemodynamic changes were not significantly different among groups F, O1, and O2. The recalculated oxycodone ED95 with probit analysis (0.269 mg/kg) was needed to prevent any arterial pressure and heart rate changes.

CONCLUSIONS

Oxycodone 0.182 mg/kg is more effective in attenuating all IRHRs than fentanyl 2 μg/kg with safe hemodynamic changes. Further research is required to determine if the recalculated oxycodone ED95 (0.269 mg/kg) is also effective and hemodynamically safe for preventing all IRHRs.

Gender Affects the Median Effective Dose and 95% Effective Dose of Oxycodone for Blunting the Hemodynamic Response to Tracheal Intubation in Narcotic-Naïve Adult Patients

Background

Intravenous (IV) oxycodone has been used at induction to prevent an intubation reaction. The aims of the current study were to calculate the median effective dose (ED₅₀) and the 95% effective dose (ED₉₅) of an IV bolus of oxycodone that blunts the hemodynamic response to tracheal intubation with propofol according to gender and to observe the adverse events of induction-dose oxycodone.

Methods

Adult patients who required general anesthesia and tracheal intubation were enrolled. Tracheal intubation was performed using unified TD-C-IV video laryngoscopy and an ordinary common endotracheal tube. Dixon's up-and-down method was used to obtain ED₅₀data for women and men separately. The initial dose of oxycodone was 0.2 mg/kg for women and 0.3 mg/kg for men (step size was 0.01 mg/kg). Next, a dose-response curve from the probit analysis was generated to determine the ED₅₀and ED₉₅to blunt the intubation reaction in female and male patients. Adverse events following oxycodone injection were observed for 5 min before propofol injection.

Results

Sixty-three patients were analyzed, including 29 females and 34 males. According to the probit analysis, the ED₅₀ and ED₉₅of oxycodone required to blunt the intubation reaction in women were 0.254 mg/kg (95% confidence interval [CI], 0.220-0.328 mg/kg) and 0.357 mg/kg (95% CI, 0.297-2.563 mg/kg), respectively. In men, the ED₅₀ and ED₉₅were 0.324 mg/kg (95% CI, 0.274-0.381 mg/kg) and 0.454 mg/kg (95% CI, 0.384-2.862 mg/kg), respectively. Men required 28% more oxycodone than women for induction (P < 0.01). The most common adverse events were dizziness (87.3%), vertigo (66.7%), sedation (74.6%), and respiratory depression (66.7%).

Conclusions

Oxycodone can be used for induction to prevent intubation reactions. Gender affected the ED₅₀and ED₉₅of oxycodone for blunting the tracheal intubation reaction.

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.