Comparison of effects of fentanyl and remifentanil on hemodynamic response to endotracheal intubation and myoclonus in elderly patients with etomidate induction

Remimazolam vs Etomidate: Haemodynamic Effects in Hypertensive Elderly Patients Undergoing Non-Cardiac Surgery

Background

Remimazolam tosilate (RT) is a novel ultrashort-acting γ-aminobutyric acid subtype A (GABAA) agonist, with several advantages including rapid induction and recovery, stable haemodynamics, and mild respiratory inhibition. However, studies have not been conducted to explore the haemodynamic effects of RT in elderly hypertensive subjects undergoing non-cardiac surgery. Therefore, we sought to compare the effects of anaesthesia induction using different doses of RT and etomidate on the haemodynamics of this group of patients.

Methods

Patients were recruited into this single-center, prospective, randomized, double-blind trial from October 2022 to June 2023. A total of 150 hypertensive elderly undergoing non-cardiac surgery were randomly assigned into 0.2 mg/kg RT group (Group RL), 0.3 mg/kg RT group (Group RH) and 0.3 mg/kg etomidate group (Group E). The primary outcome of the study was haemodynamic changes (mean arterial pressure fluctuation value -∆MAP and heart rate fluctuation value -∆HR) observed during anaesthesia induction. Secondary outcomes included incidence of adverse cardiovascular events and adverse drug reactions (injection pain and myoclonus), cumulative doses of vasoactive drugs and vital signs at different time points.

Results

Patients in Group E and Group RL had significantly lower haemodynamic fluctuations (∆MAP), lower incidence of hypotension and cumulative dose of ephedrine than subjects in Group RH. Patients in groups RL and RH had significantly lower incidence of injection pain and myoclonus compared with patients in group E. The results showed no statistically significant differences in ∆HR, hypertension, bradycardia, tachycardia, and time to loss of eye-opening reflex and start of intubation, and vital signs at different time points among the three groups.

Conclusion

Use of low-dose RT (0.2 mg/kg) for induction of non-cardiac surgical anaesthesia in elderly hypertensive patients is more effective in maintaining haemodynamic stability and has fewer adverse effects compared with etomidate.

Efficacy of Granisetron versus Sufentanil on Reducing Myoclonic Movements Following Etomidate: Double-blind, randomised clinical trial

Objectives

This study aimed to reduce the intensity of myoclonus movements by comparing the effectiveness of granisetron and sufentanil in reducing the intensity of etomidate-induced myoclonic movements. Etomidate-induced myoclonus occurs in up to 85% of patients under general anaesthesia. This type of myoclonus can induce significant clinical and economic problems in patients with special conditions.

Methods

This double-blind randomised clinical trial study consisted of 96 adult patients recruited between January and July 2021 from Mashhad University of Medical Sciences, Mashhad, Iran. Using block randomisation, subjects were divided into three groups of 32 patients: the group receiving granisetron 40 μg/kg (group G), the group receiving sufentanil 0.2 μg/kg (group S) and the control group who did not receive the pretreatment (group C). Patients received these medications as pretreatments 120 seconds before induction with etomidate. After the injection of etomidate with a dose of 0.3 mg/kg, the incidence of myoclonus was evaluated. After evaluating the myoclonus, the full dose of narcotics (fentanyl 1 μg/kg) and muscle relaxants (atracurium 0.5 mg/kg) were administered to patients and a suitable airway was established for them.

Results

The findings indicated that granisetron reduced the intensity and incidence of myoclonic movements more than sufentanil. In addition, myoclonic movements were observed at a significantly higher intensity in the control group (P = 0.001).

Conclusion

The results obtained from the current study indicate that granisetron and sufentanil as pretreatments are effective for reducing myoclonus in patients.

Effects of Fentanyl Versus Remifentanil Pretreatment on the QTc Interval in Patients Undergoing Rapid Sequence Intubation: A Randomized Clinical Trial

Background

One of the complications of laryngoscopy is cardiac dysrhythmia due to an increased QT interval.

Objectives

This study aimed to compare the effect of fentanyl and remifentanil on QTc interval in patients undergoing intubation by the rapid method in 2020.

Methods

In this study, 50 patients without a history of heart disease and without a history of drug use who were candidates for rapid intubation in the emergency department were selected and divided into two groups. Before the injection of intubation drugs, a baseline ECG was obtained from the patient and then randomly assigned to one group of patients with 2 μg/kg fentanyl and the other group with 1 μg/kg remifentanil. Other intubation drugs, including lidocaine, etomidate, and succinylcholine, were fixed in both groups. Immediately after drug injection and immediately after laryngoscopy, ECG was prepared from patients, and the QT interval was calculated.

Results

In group comparison, changes in QT values during the studied time were statistically significant (P = 0.004). However, in the comparison between groups, there was no statistically significant difference between the two groups receiving fentanyl and remifentanil (P = 0.235). The results showed that the rate of QT interval changes during three different measurements increased in both groups of patients receiving fentanyl and remifentanil.

Conclusions

In the present study, in comparing the QT interval, there was a statistically significant difference between the two groups receiving fentanyl and remifentanil at any of the studied times. Therefore, fentanyl and remifentanil during endotracheal intubation did not have a statistically and clinically significant effect on the QT distance of patients' ECG, and the administration of the above two drugs during intubation was safe.

Comparison of the Effectiveness of Various Drug Interventions to Prevent Etomidate-Induced Myoclonus: A Bayesian Network Meta-Analysis

Background

Myoclonic movement is a very common but undesirable phenomenon during the induction of general anesthesia using etomidate. Such movement may cause unnecessary problems. Currently, there is an increasing number of drugs for preventing etomidate-induced myoclonus (EM). However, direct comparisons of various drugs are lacking, and this interferes with clinical decision-making. Our network meta-analysis (NMA) aimed to compare the efficacy of different drugs for the prevention of moderate-to-severe general myoclonus.

Methods

Using several biomedical databases, randomized controlled trials (RCTs) published in English from inception to August 22, 2021 were searched. Among the various interventions, we selected nine types of intervention drugs (dexmedetomidine, etomidate, lidocaine, NMDA receptor antagonist, κ opioid receptor agonist, μ opioid receptor agonist, muscle relaxant, gabapentin, and midazolam) for comparison, according to the number of studies. Bayesian NMA was performed using STATA16 and R softwares. The relative risk of EM was assessed using risk ratios (RRs) and the corresponding 95% confidence intervals (CI).

Results

A total of 31 RCTs (3209 patients) were included. NMA results showed that, compared with a placebo, etomidate (RR 4.0, 95%CI 2.1–7.8), κ opioid receptor agonist (RR 2.9, 95%CI 1.9–4.6), μ opioid receptor agonist (RR 3.1, 95%CI 2.3–4.3), NMDA receptor antagonist (RR 1.7, 95%CI 1.0–2.8), dexmedetomidine (RR 2.4, 95%CI 1.5–3.9), lidocaine (RR 2.1, 95%CI 1.2–3.9), and midazolam (RR 2.2, 95%CI 1.5–3.2) can significantly reduce the risk of EM. In contrast, the effects of muscle relaxants (RR 2.1, 95%CI 0.81–5.3) and gabapentin (RR 2.8, 95%CI 0.92–9.3) were inconclusive. Further subgroup analyses showed that preoperative low-dose etomidate, μ-opioid receptor agonist, and κ-opioid receptor agonist were significantly better than other interventions in the prevention of moderate to severe EM.

Conclusion

Preoperative use of small doses of etomidate or opioids may be the most effective way to avoid EM, especially moderate and severe EM, which makes anesthesia induction safer, more stable, and aligns better with the requirements of comfortable medicine.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/], [CRD4202127706].

Effectiveness of lidocaine/prilocaine cream on cardiovascular reactions from endotracheal intubation and cough events during recovery period of older patients under general anesthesia: prospective, randomized placebo-controlled study

BACKGROUND

Endotracheal intubation is known to pose significant physiological, pharmacokinetic, and dynamic changes and postoperative respiratory complications in patients under general anesthesia.

METHOD

An RCT trial was organized by the Third Affiliated Hospital at Sun Yat-sen University, China. Patients were eligible for inclusion in the trial if they were over 60 years old and had upper-abdominal surgery during the induction of anesthesia and had enrolled in endotracheal intubations. The primary end point included cardiovascular reactions during the induction of anesthesia and endotracheal intubations and cough events during the recovery period. In the test group, 2 g of lidocaine/prilocaine cream (and in the control group, 2 g of Vaseline) were laid over the surface of the tracheal tube cuff.

RESULTS

The systolic blood pressure (F value = 62.271, p < 0.001), diastolic blood pressure (F value = 150.875, p < 0.001), and heart rate (F value = 75.627, p < 0.001) of the test group were significantly lower than the control group. Cough events during the recovery period in the test group were better (spontaneous cough, χ² value = 10.591, p < 0.001; induced cough, χ² value =10.806, p < 0.001).

CONCLUSION

In older patients, coughing and cardiovascular reactions under anesthesia and endotracheal intubations were reduced, as a result of using lidocaine/prilocaine cream on the surface of the tracheal tube cuff.

TRIAL REGISTRATION

International Clinical Trials Network NCT02017392, 2013-12-16.

Comparison of the efficacy and safety of remifentanil versus different pharmacological approaches on prevention of etomidate-induced myoclonus: a meta-analysis of randomized controlled trials

Objective: Myoclonus was considered as one conundrum in etomidate induction, which led to multiple risks during clinical anesthesia. The present study was conducted to compare the efficacy of pretreatment with remifentanil to different pharmacological approaches on reducing etomidate-induced myoclonus.

Methods: We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure from the inception to October 2018. Randomized controlled trials comparing remifentanil versus other pharmacological approaches in reducing etomidate-induced myoclonus were eligible to be analyzed.

Results: Overall, 13 trials with 1,392 patients met with the inclusion criteria. 1) Pretreatment with remifentanil could reduce the incidence of etomidate-induced myoclonus compared to placebo and fentanyl; few differences were found between the use of remifentanil and the use of midazolam: (incidence of myoclonus: 5.56% with remifentanil vs 71.65% with saline, RR=0.08, with 95% CI [0.05, 0.12], P<0.0001; 3.80% with remifentanil vs 13.33% with fentanyl, RR with 95% 0.31 [0.11, 0.86], P=0.02; 46.00% with remifentanil vs 55.45% with midazolam, RR=0.82, with 95% CI [0.64, 1.06], P=0.13). 2) Compared with placebo, pretreatment with remifentanil could reduce the incidence of mild, moderate, and severe myoclonus; compared with midazolam, patients receiving remifentanil experienced lower occurrence of severe myoclonus; compared with fentanyl, pretreatment with remifentanil associated with significant low occurrence of moderate and severe myoclonus. 3) The outcomes also indicated that pretreatment with remifentanil could prevent excessive hemodynamic changes after endotracheal intubation compared to fentanyl.

Conclusions: Pretreatment with remifentanil could be considered as one operative option to reduce both incidence and severity of etomidate-induced myoclonus. Compared with fentanyl, it also provides efficacy in preventing excessive hemodynamic changes after endotracheal intubation. However, the best treatment and the proper prophylactic dosage calls for more high quality evidence with large sample size.

Effect of Fentanyl and Nalbuphine for Prevention of Etomidate-Induced Myoclonus

BACKGROUND

Etomidate is a potent intravenous inducing agent with known undesirable side effects such as myoclonus and pain on injection in nonpremedicated patients.

AIMS

The aim of this study is to compare the effect of fentanyl and nalbuphine in the prevention of etomidate-induced myoclonus.

SETTINGS AND DESIGN

Randomized double-blind, placebo-controlled, and prospective comparative study.

MATERIALS AND METHODS

A total of 120 patients were randomly allocated to one of the three groups containing 40 patients each for intravenous administration of fentanyl 2 μg/kg diluted in 10 mL normal saline (NS) (Group 1), nalbuphine 0.3 mg/kg diluted in 10 mL NS (Group 2), and only 10 mL NS (Group 3) over 10 min. All groups subsequently received 0.3 mg/kg etomidate by intravenous bolus injection over 15-20 s and were assessed for the severity of pain using Grade IV pain scale and observed for myoclonus for 2 min and graded according to clinical severity. Serum creatinine phosphokinase (CPK) levels were obtained prior and postetomidate injection.

STATISTICAL ANALYSIS

Statistical analysis was performed by the SPSS program version 17.0 for Windows. Tests used are Shaipro-Wilk test, ANOVA, Tukey's multiple comparison test, Tamhane's T2, and the Chi-square test. For all statistical tests, P < 0.05 was considered statistically significant with 5% level of significance (α).

RESULTS

The incidence of myoclonus in Group 1 and 2 was 52.5% and 17.5%, respectively, whereas it was 92.45% in Group 3. There was no pain observed in 70%, 92.5%, and 50% of patients in Group 1, 2, and 3, respectively. There was a statistically significant difference in mean CPK level after induction among three groups (P < 0.001).

CONCLUSION

Nalbuphine is more effective than fentanyl in the prevention of etomidate-induced myoclonus and pain with the minimum rise in CPK levels.

Efficacy of dexmedetomidine versus remifentanil to blunt the hemodynamic response to laryngoscopy and orotracheal intubation: a randomized clinical trial

The study aims to compare the efficacy of dexmedetomidine (DEX) vs. remifentanil (REM) to blunt the hemodynamic response to laryngoscopy and orotracheal intubation. Enrolled in a double-blind clinical trial, 124 patients undergoing elective surgery under general anesthesia at Amirkabir Hospital (Arak, Iran), were assigned into four groups equally (31 patients in each group), DEX, REM, DEX-REM, and normal saline (NS), who received intravenous DEX (1 µg/kg), REM (1 µg/kg), their equal mixture (each 0.5 µg/kg, 1 minute before tracheal intubation), and NS, respectively. Then, blood pressure (BP), heart rate (HR), and arterial oxygen saturation (SaO₂) were measured on arrival to the operating room, 1 minute before laryngoscopy and tracheal intubation, immediately after intubation, and afterwards every 5 to 15 minutes, and finally the data were analyzed using SPSS 18.0. The groups were same regarding to age, sex and baseline hemodynamic variables including mean of BP (P = 0.157), HR (P = 0.105) and SaO₂ (P = 0.366). Tukey post-hoc test showed that there DEX, REM, and a DEX + REM groups was same regarding to MBP and HR, but these hemodynamic responses were higher in NS group than other groups at all time after laryngoscopy and intubation (P < 0.05). Moreover, repeated measure test showed a decreasing trend in MBP and HR in three intervention groups at all time after intubation (P > 0.05). A DEX/REM mixture had the lowest BP and three intervention groups had lower HR than the NS group. A mixture of the drugs used seems to lead to not only a prevented increase in HR and BP during laryngoscopy but also a decreased BP and HR. This study was registered in Iranian Registry Clinical Center with the registration No. IRCT2016092722254N1.

Oxycodone for prevention of etomidate-induced myoclonus: a randomized double-blind controlled trial

Objective

This study was performed compare the effectiveness of oxycodone and fentanyl in reducing the incidence and severity of etomidate-induced myoclonus.

Methods

In total, 162 patients with an American Society of Anesthesiologists physical status of I or II were assigned at random to three groups. Patients assigned to Group O received 0.1 mg/kg of oxycodone (n = 54), those assigned to Group F were given 1 µg/kg of fentanyl (n = 54), and those assigned to Group S were given an equal volume of saline intravenously 2 minutes prior to administration of 0.3 mg/kg of etomidate (n = 54). The incidence and severity of myoclonus was evaluated 2 minutes after etomidate administration. The patients’ vital signs, coughing, nausea, dizziness, and other related adverse reactions were also recorded.

Results

The incidence of myoclonus was significantly lower in Group O (0.0%) than in Group F (31.5%) and Group S (72.2%); the intensity was also lowest in Group O. All patients in each group had stable cardiovascular profiles.

Conclusions

Intravenous injection of 0.1 mg/kg of oxycodone 2 minutes prior to etomidate is more effective in preventing etomidate-induced myoclonus during general anesthesia than is 1 µg/kg of fentanyl.

Induction of anaesthesia with remifentanil after bolus midazolam administration in Landrace/Large White swine

OBJECTIVE

To investigate an alternative combination for anaesthesia induction in swine.

STUDY DESIGN

Randomized, 'blinded' experimental study.

ANIMALS

Forty-five Landrace/Large White swine weighing 20.0±1.5 kg.

METHODS

Pulse oximetry, heart rate (HR) and blood pressure were measured after premedication with ketamine, midazolam and atropine as well as after intubation following induction with a fixed dose of 0.2 mg kg^-1 midazolam combined with 1, 2, 3, 4 or 5 μg kg^-1 remifentanil (groups R1, R2, R3, R4 and R5, respectively). Intubation was evaluated using a numerical scoring system assessing jaw relaxation, resistance to the laryngoscope, vocal cord position, vocal cord movement and response to intubation. The time required to intubate and necessity for an additional midazolam dose were recorded. Baseline and post-intubation variables were compared with paired t tests, whereas for differences between the remifentanil groups the Spearman's rank correlation coefficient was estimated. Multivariate regression analysis was performed to disentangle the effect of remifentanil dose and the additional midazolam.

RESULTS

Higher dose of remifentanil was associated with better vocal cord position (p<0.001), better response to intubation (p<0.001), shorter time required for intubation (p=0.030) and less frequent necessity for additional administration of midazolam (p=0.004). In total, 39.5% of the animals required additional midazolam. In groups R1, R4 and R5, there were decreases in HRs (p=0.009, p=0.008 and p=0.032, respectively) between baseline and post-intubation phase; in groups R3 and R4, there were decreases in systolic blood pressure (p=0.040 and p=0.019, respectively). In the multivariate analysis, remifentanil dose was not associated with the observed changes in haemodynamic variables. One animal developed apnoea and four electrocardiographic anomalies; all resolved without pharmaceutical interventions.

CONCLUSIONS AND CLINICAL RELEVANCE

A combination of 0.2 mg kg^-1 midazolam with 4 or 5 μg kg^-1 remifentanil may provide an alternative method of anaesthesia induction for swine.

Propofol decreases etomidate-related myoclonus in gastroscopy

OBJECTIVE

Myoclonus, a common complication during intravenous induction with etomidate, is bothersome to both anesthesiologists and patients. This study explored the preventive effect of pretreatment with propofol on etomidate-related myoclonus.

METHODS

This was a prospective, double-blind, clinical, randomized controlled study. Totally, 363 patients who were scheduled for a short-duration, painless gastrointestinal endoscopy were divided into 5 groups. Four groups received 0 mg/kg (E group), 0.25 mg/kg (LPE group), 0.50 mg/kg (MPE group), or 0.75 mg/kg (HPE group) propofol pretreatment before etomidate anesthesia. Another group only received 1 to 2 mg/kg of propofol (P group) as anesthesia. The incidence and severity of myoclonus, patient circulation and respiratory status, and intraoperative and postoperative complications were recorded.

RESULTS

The incidence of myoclonus in the LPE group (26.8%), MPE group (16.4%), HPE group (14.9%), and P group (0) was lower than the E group (48.6%, P < .05). The incidence of grade 1, 2, and 3 of myoclonus in the LPE group, MPE group, HPE group, and P group was significantly lower than the E group, and that in the P group was lower than the LPE group (P < .05). The incidence of hypoxemia in the P group was higher than the E group, and the incidence of adverse events in the HPE group and P group was lower than the E group (P < .05).

DISCUSSION

Pretreatment with propofol was feasible for preventing etomidate-related myoclonus. Furthermore, as propofol dosage increased, its effect on reducing the incidence and severity of myoclonic movements induced by etomidate increased.

Comparison of ketamine/propofol (ketofol) and etomidate/fentanyl (etofen) combinations for procedural sedation and analgesia in the emergency department: An observational study

OBJECTIVES

The primary aim of this study was to report the vital signs, hemodynamic parameters and pain scores of the patients who have received procedural sedation and analgesia (PSA) with either ketofol (combination of ketamine and propofol) or etofen (combination of etomidate and fentanyl) and compare the proportion of patients with airway or respiratory adverse events (AEs) requiring an intervention and calculate the relative risk of AEs with each combination.

METHODS

This study is a prospective observational study with survey analysis. All patients received procedural sedation and analgesia (PSA) with either ketofol (combination of ketamine and propofol) or etofen (combination of etomidate and fentanyl) were prospectively observed. Vital and hemodynamic parameters and pain scores of the patients were recorded by automated equipment and visual analog scale (VAS) charts.

RESULTS

112 patients were enrolled, 55 received ketofol and 57 received etofen. All patients with a respiratory AE (n = 27) observed to receive a respiratory intervention. Respiratory AE rate and proportion of patient who required a respiratory intervention were significantly higher with ketofol (p = 0.0029). Overall AE rate, and rates of desaturation, emergence reaction were also significantly higher in ketofol group.

CONCLUSION

Etofen is a promising combination for the PSA of adult patients with lower respiratory AE and intervention rates and with better hemodynamic profile.

Effects of preanesthetic dexmedetomidine on hemodynamic responses to endotracheal intubation in elderly patients undergoing treatment for hypertension: a randomized, double-blinded trial

Background

Dexmedetomidine is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic properties. This study was designed to evaluate the inhibitory effects of preoperative administration of 0.5 µg/kg dexmedetomidine on hemodynamic responses caused by endotracheal intubation in elderly patients undergoing treatment for hypertension.

Methods

Forty elderly (≥ 65 years old) patients who had been receiving hypertension treatment, had American Society of Anesthesiologists physical status II, and were scheduled to undergo elective noncardiac surgery were randomly selected and assigned to 2 groups. Group C received normal saline and group D received 0.5 µg/kg dexmedetomidine intravenously over 10 min just before endotracheal intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded preoperatively in the ward, immediately after study drug administration, and at 1, 3, and 5 min after endotracheal intubation.

Results

Compared to group C, group D showed significantly lower SBP and MAP at 1, 3, and 5 min as well as significantly lower DBP and HR at 3 and 5 min after endotracheal intubation.

Conclusions

In elderly patients receiving hypertension treatment, a single preanesthetic dose of dexmedetomidine (0.5 µg/kg) effectively suppressed the hemodynamic responses to endotracheal intubation.

Comparison of the Effects of Low-Dose Midazolam, Magnesium Sulfate, Remifentanil and Low-Dose Etomidate on Prevention of Etomidate-Induced Myoclonus in Orthopedic Surgeries

BACKGROUND

Etomidate is a potent hypnotic agent with several desirable advantages such as providing a stable cardiovascular profile with minimal respiratory adverse effects and better hemodynamic stability compared with other induction agents. This drug is associated, however, with myoclonic movements which is characterized by a sudden, brief muscle contractions as a disturbing side-effect.

OBJECTIVES

The present study was designed to compare the effectiveness of low- dose midazolam, magnesium sulfate, remifentanil and low-dose etomidate to suppress etomidate-induced myoclonus in orthopedic surgery.

PATIENTS AND METHODS

A double-blind clinical trial study was conducted in an academic hospital from September 2014 to August 2015. Two hundred and eighty-four eligible patients, American society of anesthesiologists class I - II, scheduled for elective orthopedic surgery were randomly allocated into four equal groups (n = 71). They received premedication with intravenous low-dose midazolam 0.015 mg/kg, magnesium sulfate 30 mg/kg, remifentanil 1 μg/kg and low-dose etomidate 0.03 mg/kg two minutes before induction of anesthesia with 0.3 mg/kg intravenous etomidate. Then the incidence and intensity of myoclonus were evaluated on a scale of 0 - 3; 0 = no myoclonus; 1 = mild (movement at wrist); 2 = moderate (movement at arm only, elbow or shoulder); and 3 = severe, generalized response or movement in more than one extremity, within ninety seconds. Any adverse effect due to these premedication agents was recorded.

RESULTS

The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group. The incidence rates of myoclonus were 51 (71.85%), 61 (85.9%), 30 (42.3%) and 41 (57.7%), and the percentages of patients who experienced grade III of myoclonus were 30 (58.8%), 32 (52.5%), 9 (30%) and 14 (34.1%) in the midazolam, magnesium sulfate, etomidate and remifentanil groups, respectively. The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group (P = 0.0001). No notable adverse effect was detected in our patients during the study period.

CONCLUSIONS

Intravenous etomidate 0.03 mg/kg prior to induction can effectively reduce the incidence and severity of myoclonus linked to etomidate.

Comparative evaluation of esmolol and dexmedetomidine for attenuation of sympathomimetic response to laryngoscopy and intubation in neurosurgical patients

Background and Aims:

The present study compared the efficacy of esmolol and dexmedetomidine for attenuation of the sympathomimetic response to laryngoscopy and intubation in elective neurosurgical patients.

Material and Methods:

A total of 90 patients aged 20-60 years, American Society of Anesthesiologists physical status I or II, either sex, scheduled for elective neurosurgical procedures were included in this study. Patients were randomly allocated to three equal groups of 30 each comprising of Control group (group C) 20 ml 0.9% saline intravenous (IV), group dexmedetomidine (group D) 1 μg/kg diluted with 0.9% saline to 20 ml IV and group esmolol (group E) 1.5 mg/kg diluted with 0.9% saline to 20 ml IV. All the drugs were infused over a period of 10 min and after 2 min induction of anesthesia done. Heart rate (HR), systolic blood pressure, diastolic blood pressure, and mean arterial pressure were recorded baseline, after study drug administration, after induction and 1, 2, 3, 5, 10, and 15 min after orotracheal intubation.

Results:

In group D, there was no statistically significant increase in HR and blood pressure after intubation at any time intervals, whereas in group E, there was a statistical significant increase in blood pressure after intubation at 1, 2, and 3 min only and HR up to 5 min.

Conclusion:

Dexmedetomidine 1 μg/kg is more effective than esmolol for attenuating the hemodynamic response to laryngoscopy and intubation in elective neurosurgical patients.

Sedation and analgesia with fentanyl and etomidate for intrathecal injection in childhood leukemia patients

In this study, we tried to find a safe as well as fast effective treatment for sedation and analgesia for intrathecal injection in childhood leukemia patients, relieving treatment difficulties and pain, increasing the success rate of single intrathecal injection.The patients were divided into the experimental group (fentanyl combined with etomidate) and the control group (lidocaine only) randomly. The experimental group was given fentanyl 1 to 2 μg/kg intravenously first, then etomidate 0.1 to 0.3 mg/kg intravenously after the pipe washed. The patients younger than 1.5 years or who did not achieve satisfied sedative and analgesic situation received an additional time of etomidate (0.1-0.3 mg/kg). The patients were given oxygen at the rate of 4-5 L/min during the whole operation, and the finger pulse oximeter was used simultaneously to detect the changes in heart rate (HR) and blood oxygen saturation (SpO2). The doctors who performed the procedures assessed the quality of sedation and analgesia.In the experimental group, the patients' HR increased slightly after given fentanyl combined with etomidate. The patients' SpO2 was stable. Most patients achieved a good sedative and analgesic state within 1 to 2 minutes, and no case of respiration depression or cardiac arrhythmias occurred during the whole operation. The wake-up time was 55.42 ± 20.62 min. In the control group, the patients were not very cooperative during the intrathecal injection, which made the procedures very difficult.During intrathecal injection, pain obviously reduced and the success rate of single lumbar puncture increased. It is safe and effective to apply fentanyl combined with etomidate for sedation and analgesia.

Comparison between the effects of alfentanil, fentanyl and sufentanil on hemodynamic indices during rapid sequence intubation in the emergency department

Background:

Laryngoscopy and tracheal intubation lead to the alteration of hemodynamic parameters, including blood pressure and heart rate, in traumatic patients who sustain rapid sequence intubation (RSI). Various drugs such as fentanyl, alfentanil and sufentanil have been used to modify these hemodynamic responses.

Objectives:

The aim of the present study is to compare the effects of fentanyl, sufentanil and alfentanil in trauma patients who require RSI in the emergency department (ED).

Patients and Methods:

This was a randomized double-blinded study conducted on 90 patients (18-65 years old, ASA I, II), who needed intubation following trauma. The patients were randomly divided into three groups, Group I, Group II and Group III, who have received alfentanil, fentanyl and sufentanil, respectively. Heart rate, blood pressure, saturation of peripheral oxygen and end-tidal carbon dioxide were measured 5 minutes before and 3, 5 and 10 minutes after intubation, respectively. The changes of the hemodynamic parameters were compared in between groups. Data were analyzed by One-way ANOVA, General Linear Model Repeated Measure and Mauchly’s Sphericity Test. A P < 0.05 was considered statistically significant.

Results:

There was no significant statistical difference among groups with respect to hemodynamic parameters.

Conclusions:

Alfentanil, fentanyl and sufentanil can be used safely as premedication drugs for trauma patients who need intubation.