Oral pregabalin premedication for attenuation of haemodynamic pressor response of airway instrumentation during general anaesthesia: A dose response study

Comparison of Different Doses of Pregabalin to Prevent Succinylcholine-Initiated Fasciculations and Myalgia in Patients Under General Anesthesia: A Randomised Controlled Study

Background Succinylcholine (SCh) is the most commonly used muscle relaxant during endotracheal intubation, and it is known to cause fasciculations and postoperative myalgia. Pregabalin is structurally similar to the neurotransmitter gamma-aminobutyric acid (GABA), which is known to reduce SCh-induced fasciculations and myalgia. Materials and methods This study was conducted on patients who underwent surgery under general anesthesia. A total of 201 patients of both genders were assigned to one of the following groups: Group PL (pregabalin low dose) received cap pregabalin 75 mg, Group PH (pregabalin high dose) received cap pregabalin 150 mg, and Group P (placebo) received saccharine pill 10 mg, administered two hours prior to surgery. Results Both the incidence and severity of fasciculations and myalgia were reduced in patients who received pregabalin compared to the placebo group (PH>PL>P). It was observed that as the severity of fasciculations increased, myalgia also increased. The time of the first analgesic dose was longer in the pregabalin group (PH>PL>P). The attenuation of pressor response and hemodynamic stability was greater in the pregabalin group (Group PH>PL>P). Sedation levels were insignificant among groups. The incidence of adverse effects was also insignificant. Conclusion Preoperative prophylactic administration of pregabalin orally in Group PL and PH reduced the incidence and severity of fasciculations and myalgia. Group PH was found to be more effective than PL. Pressor response attenuation was found to be more effective in Group PH.

Effectiveness of Ultrasonography- and Fluoroscopy-Guided Caudal Epidural Injections in the Management of Chronic Lumbar Disc Disease: A Retrospective Comparative Study

INTRODUCTION

Lumbar disc disease is one of the common causes of lower back pain caused by a change in the structure of the normal disc. Most of the time, disc disease happens as a result of aging and the normal breakdown that occurs within the disc. Caudal epidural steroid injections are the popular treatment for patients with chronic low back pain that does not respond to conservative management.

METHOD

A retrospective survey was administered to 160 patients who had received caudal epidural injections for chronic low back pain in the past, but only 74 patients who completed the scheduled follow-ups were included in the study. They were divided into two groups based on the imaging modality used for guiding the caudal epidural steroid injections, either ultrasonography or fluoroscopy, and then assessed for improvement in pain on the Numeric Rating Scale (NRS), for functional improvement on the Oswestry Disability Index (ODI), and for satisfaction on the North American Spine Society Patient Satisfaction Scale (SSPSS).

RESULTS

Mean NRS pain scores improved significantly from baseline at 6.78 and 7.00 in the fluoroscopy and ultrasound groups, respectively, to 2.03 and 2.16 at 12 weeks post-procedure. The difference between the groups was not statistically significant (p > 0.05). The Oswestry Disability Index was completed at baseline and after 12 weeks of follow-up for both groups, and there was no significant difference between the two groups; the fluoroscopy group's mean Oswestry Disability Index scores were 52.4 at baseline and 35.6 at 12 weeks, whereas the scores for the ultrasound group were 50.3 at baseline and 37.9 at 12 weeks. Conversely, patient satisfaction as assessed using the SSPSS rose in both groups up to 12 weeks (p > 0.05).

CONCLUSION

The ultrasound- and fluoroscopy-guided caudal epidural steroid injections proved equally effective in easing the pain, disability, and satisfaction levels of patients with chronic lower back pain.

Assessment of haemodynamic response to tracheal intubation and prone positioning following clonidine and enalaprilat in lumbar spine surgeries: A double blind randomised controlled trial

Background and Aim

This study evaluates the effectiveness of long-acting antihypertensive drugs (clonidine and enalaprilat) in blunting the intubation response. Also, the study seeks to determine how effectively clonidine and enalaprilat can maintain stable haemodynamics during a change in position.

Methods

After ethical committee approval and trial registration, a double-blinded, randomised controlled trial was conducted with 71 consenting patients scheduled for elective spine surgery in a prone position under general anaesthesia. Group C received clonidine 2 μg/kg, and Group E received enalaprilat 1.25 mg diluted in normal saline as an intravenous infusion given over 10 min before induction of anaesthesia. The changes in heart rate (HR) and blood pressure (BP) in response to the infusion of the study drugs, induction, tracheal intubation and change in position were recorded. P value <0.05 was considered significant. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25.

Results

Clonidine infusion caused a significant fall in heart rate post-infusion and post-induction with propofol (p value <0.05). Both clonidine and enalaprilat caused a significant fall in mean arterial pressure (MAP) post-infusion and post-induction (p value <0.05). Clonidine effectively blunted the intubation response with no increase in HR and MAP following intubation. Enalaprilat caused a significant rise in HR in response to intubation. On proning, there was a significant fall in MAP in both groups.

Conclusion

Clonidine is effective in blunting the intubation response. Preoperative infusion of clonidine and enalaprilat causes hypotension during a change of position.

The anxiolytic effects of preoperative administration of pregabalin in comparison to diazepam and placebo

We aimed to evaluate the potential anxiolytic effects of premedication with pregabalin, compared with diazepam and placebo. We conducted this non-inferiority, double-blind, randomized controlled trial in ASA classification I-II patients aged 18-70 years, scheduled for elective surgery under general anesthesia. They were allocated to receive pregabalin (75 mg the night before surgery and 150 mg 2 h before surgery), diazepam (5 and 10 mg in the same manner) or placebo. Preoperative anxiety was evaluated using verbal numerical rating scale (VNRS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS) before and after premedication. Sleep quality, sedation level, and adverse effects were assessed as secondary outcomes. A total of 231 patients were screened and 224 completed the trial. The mean change (95%CI) in anxiety scores from before to after medication in pregabalin, diazepam, and placebo groups for VNRS were - 0.87 (- 1.43, - 0.30), - 1.17 (- 1.74, - 0.60), and - 0.99 (- 1.56, - 0.41), and for APAIS were - 0.38 (- 1.04, 0.28), - 0.83 (- 1.49, - 0.16), and - 0.27 (- 0.95, 0.40). The difference in change for pregabalin versus diazepam was 0.30 (- 0.50, 1.11) for VNRS and 0.45 (- 0.49, 1.38) for APAIS, exceeding the limit of inferiority for APAIS of 1.3. Sleep quality was statistically different between pregabalin and placebo groups (p = 0.048). Sedation in pregabalin and diazepam groups were significantly higher than placebo group (p = 0.008). No significant differences of other side effects, except dry mouth was higher in placebo group compared with diazepam (p = 0.006). The study filed to provide evidence at non-inferiority of pregabalin compared to diazepam. Furthermore, premedication with either pregabalin or diazepam did not significantly reduce the preoperative anxiety in comparison to placebo, despite the fact that both resulted in higher levels of sedation. Clinicians should weigh the benefits and risks of premedication with these 2 drugs.Thai Clinical Trials Registry: TCTR20190424001 (24/04/2019) Registry URL: https://www.thaiclinicaltrials.org/ .

Comparison of pregabalin with magnesium sulfate in the prevention of remifentanil-induced hyperalgesia in patients undergoing rhinoplasty: A randomized clinical trial

Objective

Remifentanil is usually used for controlled hypotension during rhinoplasty under general anesthesia (G/A). One of the complications of the remifentanil is postoperative hyperalgesia. In this study, we compare the effectiveness of pregabalin with that of Mg sulfate in postoperative remifentanil-induced hyperalgesia prevention.

Methods

In this prospective, randomized, double-blinded placebo-controlled trial, 105 patients who candidates rhinoplasty with G/A were enrolled and randomly allocated into three groups. Patients in group A received 300 mg pregabalin before anesthesia. They received physiologic saline infusion during the perioperative period. Those in group B received placebo capsules before anesthesia and intravenous Mg sulfate 30 mg/kg during the perioperative period. Those in group C received a placebo capsule before anesthesia and normal intravenous saline during the operation. Then, pain severity, sedation score, postoperative nausea and vomiting (PONV) were assessed and compared.

Results

In the Mg sulfate and placebo group, the mean numerical rating scale in the postoperative period was higher compared to the pregabalin group (p < .001). The mean total amount of morphine requirement, meanwhile the 24 h post-operation, was significantly decreased in the pregabalin group compared to the other groups (p < .001). Participants in the pregabalin group had less PONV compared to those in the pregabalin and placebo groups (p = .015).

Conclusions

In patients undergoing G/A with remifentanil for rhinoplasty, preoperative 300 mg pregabalin could effectively prevent not only remifentanil-induced hyperalgesia but also PONV.

Level of evidence

1b.

Is there any difference between oral preemptive pregabalin vs. placebo administration on response to EBUS-TBNA under sedation?

Background/aim

The aim of this study is to evaluate the effects of preemptive oral pregabalin on hemodynamic response, anxiety, sedation, and recovery in patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) under sedation with intravenous ketamine-propofol combination.

Materials and methods

Sixty patients were included in this study, and patients were randomly divided into two equal groups to receive the placebo (Group 1) versus pregabalin 150 mg (Group 2) one hour prior to EBUS- TBNA procedure. Patients received 0.25 mg kg^-1 ketamine and 0.25 mg kg^-1 propofol mixture (ketofol) for sedation. Timing of the parameters was defined as follows; T0: in hospital ward before pregabalin or placebo administration, T1: premedication, T2: in operating room, T3: before the procedure, T4: initiation, T5: 3 min after induction, T6: 6 min after induction, T7: 9 min after induction, and T8: 12 min after induction. Hemodynamic parameters, severity of coughing, sedation and anxiety scores, and complications were recorded. The level of satisfaction of the bronchoscopist and the patients were evaluated at the end of the procedure.

Results

The heart rate and mean arterial pressure were significantly higher in Group 1 (P = 0.008, P = 0.04). Total doses of anesthetics, recovery time, and desaturation rate were significantly higher in Group 1 (P = 0.014, P = 0.001, P = 0.045). In Group 2, SpO₂ level was significantly higher at various time periods (T1; P = 0.025, T4; P =0.043, T6; P = 0.001, T7; P = 0.003, T8; P < 0.001). The severity of coughing was found significantly lower in Group 2 (T4; P = 0.011, T5; P = 0.01, T6; P = 0.02, T7; P = 0.03, T8; P < 0.01). Anxiety scores were significantly lower in Group 2 (P < 0.001).

Conclusion

Preemptive oral pregabalin, in addition to sedation with ketamine-propofol combination, was effective in providing limited hemodynamic response, restricted coughing reflex, and lower anxiety during EBUS-TBNA. Besides, with pregabalin usage, decreased anesthetics consumption, lower complication rate, and shorter recovery time might have contributed to safety of the procedure and comfort of the bronchoscopist.

A Randomized Controlled Study to Compare Hemodynamic Effects between Clonidine and Pregabalin in Laparoscopic Cholecystectomy

Background:

Laparoscopic cholecystectomy (LC) is associated with pneumoperitoneum and hemodynamic disturbances. Pregabalin and Clonidine have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated.

Aims:

The study was done to assess and compare the efficacy of preoperative single oral dose of pregabalin and clonidine in maintaining the hemodynamic parameters in the LC.

Settings and Design:

The prospective, interventional, randomized, comparative, single-blinded study was conducted in the department of anesthesia and surgery from January 2015 to September 2016 after taking approval from the institutional ethical committee.

Materials and Methods:

The study included a total of 90 patients, aged between 18 and 56 years of both sexes scheduled for elective LC. Patients were randomized into three groups of 30 each who received oral pregabalin 150 mg, clonidine 200 ug, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse events.

Statistical Analysis:

Quantitative variables were compared using unpaired t-test (when the data sets were not normally distributed) between the two groups. Qualitative variables were compared using Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.

Results:

There was a significant increase in the heart rate (HR) and systolic, diastolic, and mean blood pressure during laryngoscopy and pneumoperitoneum in the control group as compared to both pregabalin and clonidine. HR was significantly lower in clonidine group after extubation and in postoperative period than both control group and pregabalin group. There was no major difference in the incidence of side effects.

Conclusion:

Both pregabalin (150 mg) and clonidine (200 ug) were effective in controlling the hemodynamic parameters during LC, with clonidine providing better hemodynamic stability than Pregabalin.

Preoperative oral pregabalin for anxiety control: a systematic review

OBJECTIVE

The objective of this systematic review was to determine the effectiveness of preoperative oral pregabalin for anxiety control, the most effective dosage regimen, its impact on postoperative pain, and its adverse effects.

MATERIALS AND METHODS

A search was conducted of PubMed/Medline and clinicaltrials.gov (National Library of Medicine, Washington, DC), Scopus, Web of Science, and Cochrane databases for studies published between January 2009 and November 2018, with no language restriction. Based on PRISMA guidelines, the specific question was: is preoperative oral pregabalin effective and safe for anxiety control in patients undergoing surgery? The critical reading of retrieved studies followed questions prepared by the CASPe Network, and their methodological quality was evaluated using the Jadad Scale.

RESULTS

Twelve randomized controlled trials were selected for review. All twelve studies were trials of high quality. A dose of 75 mg preoperative oral pregabalin has been found to reduce anxiety and stabilize intraoperative hemodynamics, although a more significant improvement appears to be achieved with a single dose of 150 mg pregabalin at least 1 h before the surgery. It is not associated with any severe adverse effects.

CONCLUSION

Preoperative administration of oral pregabalin in a single dose of 150 mg appears to be effective to significantly reduce the anxiety of patients, intraoperative hemodynamic changes, and postoperative pain.

CLINICAL RELEVANCE

These findings suggest that pregabalin is useful and safe for preoperative and intraoperative anxiety control in patients undergoing surgery.

Comparison of Nitroglycerin versus Lignocaine Spray to Attenuate Haemodynamic Changes in Elective Surgical Patients Undergoing Direct Laryngoscopy and Endotracheal Intubation: A prospective randomised study

Objectives

This study aimed to compare the effects of nitroglycerin (NTG) versus lignocaine spray in blunting the pressor response during direct laryngoscopy and endotracheal intubation.

Methods

This study was conducted between January and June 2018 in the Department of Anesthesiology, Teerthankar Mahaveer Medical College, Moradabad, India. A total of 90 elective surgical patients of American Society of Anesthesiologists physical status grades I or II were divided into three groups, comprising two treatment groups and one control group. Patients in the treatment groups received either one puff (1.5 mg/kg) of lignocaine 10% spray or one puff (400 μg) of NTG spray in the oropharynx one minute prior to the induction of anaesthesia. Haemodynamic variables and mean rate pressure product at baseline and one, two, three, four and five minutes post-induction were compared.

Results

There was a significant reduction in mean heart rate at 3–5 minutes in both treatment groups compared to the control group (P <0.050), as well as lower increases in mean arterial pressure at 1–3 minutes (P <0.050). However, at 2–4 minutes, there was a significantly greater decrease in mean systolic blood pressure in the NTG group compared to both the lignocaine and control groups (P <0.050). Moreover, a greater decrease in mean rate pressure product response at 1–5 minutes was observed in the NTG group compared to the lignocaine and control groups (P = 0.001).

Conclusion

The NTG spray was more effective than lignocaine in attenuating blood pressure increases and rate pressure product during elective laryngoscopy and intubation.

Comparative Evaluation of Dexmedetomidine and Pregabalin as Premedication Agent to Attenuate Adverse Hemodynamic and Stress Response in Patients Undergoing Laparoscopic Cholecystectomy

Background:

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. The goal of anesthetic management is to minimize stress response and early discharge. Dexmedetomidine, and pregabalin have been used successfully to attenuate laryngoscopy and intubation response in various surgical procedures.

Aim:

To compare efficacy of pregablin and dexmedetomidine in attenuating hemodynamic and stress response.

Setting and Design:

A prospective, double blind randomized trial comprising 130 ASA physical status class I and II patients posted for laparsoscopic cholecystectomy.

Materials and Methods:

Patients were randomized in to Group A and Group B. Group A received intravenous dexmedetomidine in a dose of 1 ug.kg^-1, through an infusion pump 20 min prior to induction of anaesthesia. Group B subjects received oral pregabalin 150 mg. Parameters observed were vitals, discharge time, cortisol level, side effects if any.

Results:

Post intervention heart rate got reduced significantly in Group A and it remained low in comparison to baseline during whole peri-operative period. In Group B, immediate post-pneumoperitoneum heart rate, and post exubation heart rate was higher than baseline. Blood pressure (BP) decreased significantly post intervention in Group A which persisted till pneumoperitoneum. In Group B there was statistically significant rise in systolic, diastolic and mean blood pressure postpneumoperitoneum as compared to baseline blood pressure. Post-operative cortisol level was significantly higher than baseline values and the level is more in Group B.

Conclusion:

Intravenous dexmedetomidine is more effective than oral pregabalin in attenuating perioperative stress response.

Comparative Evaluation of the Effects of Pregabalin, Dexmedetomidine, and Their Combination on the Hemodynamic Response and Anesthetic Requirements in Patients undergoing Laparoscopic Cholecystectomy: A Randomized Double-Blind Prospective Study

Background

In this study, we evaluated the efficacy of premedication with dexmedetomidine, pregabalin, and dexmedetomidine-pregabalin combination for attenuating the haemodynamic stress response to laryngoscopy and intubation and pneumoperitoneum (primary outcome), and for reducing anaesthetic requirement (secondary outcome) in patients undergoing laparoscopic cholecystectomy.

Methods

Ninety ASA physical status classes I-II patients, between 18 to 65 years of age, of either sex, scheduled to undergo laparoscopic cholecystectomy were included in this randomised double blind study. Morbidly obese patients and those with history of hypertension, cardiac, renal, hepatic, endocrine or pulmonary dysfunction were excluded. Patients were randomized to three groups - Group P- received oral pregabalin (150 mg) one hour before induction and 100 mL of i.v normal saline (0.9%) over 10 minutes, 10 minutes before induction; Group D- received i.v dexmedetomidine (1 μg.kg^-1) prepared in 100 mL of 0.9% normal saline and given over 10 minutes, 10 minutes before induction, and an oral placebo tablet one hour before induction; and Group C-received a combination of oral pregabalin 75 mg one hour before induction, and IV dexmedetomidine (0.5 μg.kg^-1) prepared in 100 mL of 0.9% normal saline over 10 minutes, 10 minutes before induction.

Results

Dexmedetomidine significantly attenuated the stress response to laryngoscopy and intubation and pneumoperitoneum and reduced anaesthetic requirement as compared to the other two groups. Dexmedetomidine was associated with significantly lower mean arterial pressures and higher sedation score in the preoperative and postoperative period and significantly lower heart rate and arterial pressures and reduced anaesthetic requirement in the intraoperative period as compared to the other groups.

Conclusion

Dexmedetomidine is a valuable adjunct to the technique of balanced anaesthesia for maintaining haemodynamic stability.

Oral Pregabalin as Premedication on Anxiolysis and Stress Response to Laryngoscopy and Endotracheal Intubation in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Double-Blind Study

Background

Direct laryngoscopy and tracheal intubation lead to increase in heart rate and blood pressure. This can cause serious complications in patients with coronary artery disease, reactive airways, or intracranial neuropathology. Preoperative anxiety is associated with greater level of postoperative pain. Attenuation of anxiety and hemodynamic response to laryngoscopy and intubation are cornerstone of better anesthetic outcome. Gabapentinoids (gabapentin and pregabalin) have been known to possess anxiolytic, analgesic, and anticonvulsant properties.

Aim

The aim of this study is to determine the effects of oral pregabalin on anxiolysis and attenuation of stress response to laryngoscopy and endotracheal intubation.

Study Design

This was a prospective randomized double-blind placebo controlled study.

Materials and Methods

A total of 60 patients ASA physical status Class I and II, undergoing elective laparoscopic cholecystectomy, were randomly allocated into two groups receiving either oral placebo or oral pregabalin 150 mg, 60 min before induction of anesthesia. Visual analog scale (VAS) for anxiety was recorded before, and 60 min after giving the drug. Hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were recorded before, and 60 min after giving drug, during and 2, 4, 6, 8, and 10 min after intubation.

Results

During preinduction, pregabalin showed a decrease in VAS and attenuation of stress response to laryngoscopy and intubation compared to that of placebo. The premedicated patients were hemodynamically stable perioperatively without side effects.

Conclusion

Pregabalin is effective in attenuating preoperative anxiety and stress response to endotracheal intubation.

Preoperative Low-dose and High-dose Pregabalin and Cardiovascular Response to Endotracheal Intubation: A Prospective, Randomized, Single-blind, Controlled Study in China

PURPOSE

A prospective, randomized, single-blind, controlled clinical study was designed to evaluate the efficacy and tolerability of preoperative pregabalin on cardiovascular response to laryngoscopy and endotracheal intubation.

METHODS

Patients aged 18-60 years with an American Society of Anesthesiologists scale score of I or II were recruited and randomly allocated to receive placebo (control), low-dose (150-mg) pregabalin, or high-dose (300-mg) pregabalin. The medications were orally administered 1 hour before general anesthesia. Heart rate, systolic and diastolic blood pressures, and mean arterial blood pressure were measured and recorded prior to the administration of placebo or pregabalin; before endotracheal intubation; and at 0, 1, 3, 5, 7, and 10 minutes after intubation. The sedation score was evaluated 1 hour after the administration of placebo or pregabalin.

FINDINGS

A total of 90 patients were enrolled (n = 30 per group). Pregabalin (150 or 300 mg) was associated with reduced blood pressure fluctuations after intubation, but with no significant differences between the 2 dose groups. Pregabalin was associated with an inhibitory effect on heart rate fluctuations and reduced hemodynamic complications after intubation, in a dose-dependent manner, but no effect on the required perioperative opioid dosage was found. Both doses were effective in reducing preoperative anxiety, but visual analog scale pain scores at 1 hour after surgery were reduced only in limb and spine as well as abdominal surgeries. A pregabalin-related adverse reaction was dizziness, which was observed at 1 hour after surgery in both groups.

IMPLICATIONS

In this study, high-dose (300-mg) pregabalin effectively attenuated cardiovascular response after endotracheal intubation. ClinicalTrials.gov identifier: NCT03456947.

Comparative Study of Oral Gabapentin, Pregabalin, and Clonidine as Premedication for Anxiolysis, Sedation, and Attenuation of Pressor Response to Endotracheal Intubation

Introduction:

The aim of the present study was to evaluate and compare the effect of clonidine 200 μg and gabapentin 900 mg and pregabalin 150 mg in attenuation of the hemodynamic response to laryngoscopy and intubation in normotensive patients undergoing elective surgery.

Methods:

Ninety adult patients between 18 and 60 years are enrolled in the study. Patients with American Society of Anesthesiologists Grade-I and Grade-II are included which are posted for elective surgery under general anesthesia. Patients were divided into three groups: A, B, and C and received oral drugs 90 min before induction of general anesthesia, pregabalin 150, gabapentin 900mg, and clonidine 200 μg, respectively. Hemodynamic parameters such as heart rate and blood pressure were noted just before the (basal) administration of the drug, and in operation room, readings were recorded before intubation (T0) and after intubation at 1, 3, 5, and 10 min. Sedation and anxiety score were noted after 1 h of oral administration of the drug.

Results:

Mean arterial pressure was well attenuated by pregabalin than others, and mean heart rate following laryngoscopy and intubation was attenuated by clonidine group significantly.

Conclusion:

We conclude that oral pregabalin and gabapentin attenuate blood pressure response fairly well and heart rate significantly attenuated by clonidine. All three drugs are very effective for relieving anxiety and improving sedation.

Oral Clonidine vs Oral Pregabalin Premedication to Attenuate Pressor Response to Direct Laryngoscopy in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Double Blind Study

INTRODUCTION

Direct laryngoscopy and tracheal intubation has adverse effects like tachycardia, hypertension, myocardial ischemia and cerebral haemorrhage. There are several studies on various pharmacological agents to attenuate this response.

AIM

This study was designed to compare efficacy and safety of oral clonidine and oral pregabalin premedication to attenuate stress response in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

Total 80 patients of ASA grade I and II, aged between 20-60 years of both sexes scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients were randomized into two groups. Group A received oral clonidine 0.3mg and group B received oral pregabalin 150mg, 60 minutes before surgery. Anaesthesia technique was standardized. Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), mean arterial pressure (MAP) and heart rate were recorded preoperatively, after premedication, immediately after intubation, then at 1 min, 3 min, 5 min, 10 min and 15 min after intubation. Level of sedation, postoperative pain scores and any adverse effects were also noted and compared.

RESULTS

Oral clonidine 0.3mg as well as oral pregabalin 150mg were effective in blunting haemodynamic stress response to laryngoscopy and tracheal intubation. Clonidine was found to be better than pregabalin in lowering of systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate changes associated with laryngoscopy. We also found that bradycardia was common with both the drugs, more so in clonidine group. Post-operative analgesia was better in pregabalin group as compared to clonidine group. Both the drugs cause sedation, but it was more with the use of pregabalin.

CONCLUSION

Both the drugs can be used as an effective premedicant to attenuate the sympathetic response to laryngoscopy and tracheal intubation without much side effects and the added advantage of intraoperative and postoperative analgesia.

Premedication dilemmas, is Pregabalin the answer?

OBJECTIVE

Laryngoscopy and intubation are associated with sympathetic stimulation which can prove deleterious in patients with cardiovascular compromise; so, various methods have been tried to obtund this pressor response. In this study, we have assessed the efficacy of pregabalin in attenuating the pressor response to laryngoscopy and intubation.

METHODS

This prospective randomized study included 80 patients with American Society of Anesthesiologists physical status grades I-II, in the age group of 18-60 years of age. The patients were randomized into two groups of 40 patients each. Group A received the placebo orally, 90 min prior to surgery. Group B received 150 mg of pregabalin orally, 90 min prior to surgery. These patients were assessed in terms of sedation with Ramsay sedation scale (RSS). In the operation theatre, the heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation recorded at baseline and 1, 3, 5, and 10 min after intubation. The rate pressure product (RPP) was calculated for these time intervals. In the postoperative period, patients were assessed for complications like dizziness, nausea, and blurred vision. Statistical analysis was performed using Chi-square and ANOVA tests.

FINDINGS

The group receiving 150 mg of pregabalin as premedication was found to be adequately sedated at 1 h post-premedication with 52% patients having a RSS score of 3 compared to 4% with the same RSS score in the placebo group (P < 0.0001). Hemodynamics was more stable post-intubation with significant stability in the HR (P = 0.002) and RPP (P = 0.004) in the pregabalin group.

CONCLUSION

Pregabalin when given as a premedication provides adequate sedation and obtunds the pressor response seen with intubation.

A comparative study of pre-operative oral clonidine and pregabalin on post-operative analgesia after spinal anesthesia

Objectives:

Pregabalin and clonidine have anti-nociceptive properties. This study assesses their efficacy in prolonging the analgesic effect of spinal anesthesia and post-operative analgesic requirement in patients undergoing vaginal hysterectomy.

Materials and Methods:

A total of 90 females in the age group of 30-60 years were randomly allocated in to three groups of 30 each, to receive either oral clonidine (150 μg) or oral pregabalin (150 mg) or oral multivitamin as placebo 1.5 h before spinal anesthesia with 3ml (15 mg) of 0.5% hyperbaric bupivacaine. Intensity of pain was measured on a visual analog scale (VAS) at the end of operation (0 h) then at 1,2,4,6,12 and 24 h thereafter. Diclofenac sodium intramuscularly 1 mg/kg was provided when the VASscore was >4 in the study period. Sedation was defined by Ramsay sedation scale at 0,6,12 and 24 h. Side-effects such as nausea and vomiting, respiratory depression and dryness of mouth were noted.

Results:

The VAS scores were significantly less in the pregabalin group compared with the clonidine group at 6,12 and 24 h post-operatively with a P < 0.0001. More sedation was seen in the clonidine group than in the pregabalin group (P < 0.05). Analgesic consumption and VAS scores were lower in clonidine and pregabalin group compared with the placebo group (P < 0.05).

Conclusion:

Oral pregabalin (150 mg) prolongs the post-operative pain relief after spinal anesthesia but produces less sedation compared with oral clonidine (150 μg).

Effect of Pregabalin on Cardiovascular Responses to Exercise and Postexercise Pain and Fatigue in Fibromyalgia: A Randomized, Double-Blind, Crossover Pilot Study

Pregabalin, an approved treatment for fibromyalgia (FM), has been shown to decrease sympathetic nervous system (SNS) activity and inhibit sympathetically maintained pain, but its effects on exercise responses have not been reported. Methods. Using a randomized double-blind crossover design, we assessed the effect of 5 weeks of pregabalin (versus placebo) on acute cardiovascular and subjective responses to moderate exercise in 19 FM patients. Blood pressure (BP), heart rate (HR), and ratings of perceived exertion (RPE) during exercise and ratings of pain, physical fatigue, and mental fatigue before, during, and for 48 hours after exercise were compared in patients on pregabalin versus placebo and also versus 18 healthy controls. Results. On placebo, exercise RPE and BP were significantly higher in FM patients than controls (p < 0.04). Pregabalin responders (n = 12, defined by patient satisfaction and symptom changes) had significantly lower exercise BP, HR, and RPE on pregabalin versus placebo (p < 0.03) and no longer differed from controls (p > 0.26). Cardiovascular responses of nonresponders (n = 7) were not altered by pregabalin. In responders, pregabalin improved ratings of fatigue and pain (p < 0.04), but negative effects on pain and fatigue were seen in nonresponders. Conclusions. These preliminary findings suggest that pregabalin may normalize cardiovascular and subjective responses to exercise in many FM patients.

Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation

BACKGROUND

Several drugs have been used in attenuating or obliterating the response associated with laryngoscopy and tracheal intubation. These changes are of little concern in relatively healthy patients but can lead to morbidity and mortality in the high risk patient population.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of pharmacological agents in preventing the morbidity and mortality resulting from the haemodynamic changes in response to laryngoscopy and tracheal intubation in adult patients aged 18 years and above who were undergoing elective surgery in the operating room setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), and the bibliographies of published studies. We reran our search from June 2011 to December 2012 and will deal with these studies when we update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared a drug used as an intervention for preventing or attenuating the haemodynamic response to tracheal intubation to a control group, and that mentioned mortality, major morbidity, arrhythmia or electrocardiogram (ECG) evidence of ischaemia in the methodology, results, or discussion section of the reports.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the outcome data.

MAIN RESULTS

We included 72 RCTs. The included trials studied the effects of 32 drugs belonging to different pharmacological groups. Only two trials mentioned the primary outcome of morbidity and mortality related to the haemodynamic response to tracheal intubation. Of the secondary outcomes, 40 of the included trials observed arrhythmia only, 11 observed myocardial ischaemia only and 20 observed both arrhythmias and myocardial ischaemia. Arrhythmias were observed in 2932 participants and myocardial ischaemia in 1616 participants. Arrhythmias were observed in 134 out of 993 patients in the control group compared to 80 out of 1939 in the intervention group. The risk of arrhythmias was significantly reduced with pharmacological interventions in the pooled data (Peto odds ratio (OR) 0.19, 95% CI 0.14 to 0.26, P < 0.00001, I(2)= 47%). Local anaesthetics, calcium channel blockers, beta blockers and narcotics reduced the risk of arrhythmia in the intervention group compared to the control group. Myocardial ischaemia was observed in 21 out of 604 patients in the control group compared to 10 out of 1012 in the treatment group; the result was statistically significant (Peto OR 0.45, 95% CI 0.22 to 0.92, P = 0.03, I(2) = 19%). However, in subgroup analysis only local anaesthetics significantly reduced the ECG changes indicating ischaemia, but this evidence came from one study. The majority of the studies had a negative outcome. Hypotension and bradycardia were reported with 40 µg kg(-1) intravenous alfentanil, chest rigidity with 75 ug kg(-1) alfentanil, and increased bronchomotor tone with sympathetic blockers.There were 17 studies which included high risk patients. Pharmacological treatment in this group resulted in the reduction of arrhythmias when the data from nine trials looking at arrhythmias were pooled (Peto OR 0.18, 95% CI 0.05 to 0.59, P = 0.005, I(2) = 80%). The analysis from four studies was not included. Three of these trials looked at the effect of sympathetic blockers but arrhythmias or myocardial ischaemia was observed throughout the perioperative period in two studies and some patients had arrhythmias due to atropine premedication in the third study. In the fourth study the authors mentioned myocardial ischaemia in the objectives section but did not report it in the results.

AUTHORS' CONCLUSIONS

The risk of arrhythmias associated with tracheal intubation was significantly reduced with pre-induction administration of local anaesthetics, calcium channel blockers, beta blockers and narcotics compared to placebo. Pharmacological intervention also reduced the risk of ECG evidence of myocardial ischaemia in the pooled data. Lignocaine pretreatment showed a significant effect but evidence came from one study only. The data suggested that there may be a reduction in ECG evidence of myocardial ischaemia with beta blocker pretreatment but this difference was not statistically significant. There is a need to focus on outcomes rather than haemodynamic measurements alone when studying this response in future trials.

Effect of oral pregabalin on opioid-induced hyperalgesia in patients undergoing laparo-endoscopic single-site urologic surgery

Background

Pregabalin is an antiepileptic drug that is effective for treating postoperative pain, neuropathic pain, anxiety, and hemodynamic instability. The aim of this study was to investigate the effect of a single preoperative dose of pregabalin in patients with opioid-induced hyperalgesia (OIH).

Methods

Ninety ASA I-II patients undergoing laparoendoscopic single-site urologic surgery were randomly assigned to one of the following three groups that received either pregabalin or placebo 1 h before anesthesia and an intraoperative remifentanil infusion. Group plL received placebo and 0.05 µg/kg/min remifentanil, group plH received placebo and 0.3 µg/kg/min remifentanil, and group prH received 300 mg pregabalin plus 0.3 µg/kg/min remifentanil. The primary endpoint was pain intensity upon movement 1, 6, 12, and 24 h after surgery. Secondary endpoints were the area of hyperalgesia and mechanical hyperalgesia threshold 24 h after surgery, time to first postoperative analgesic requirement, and cumulative postoperative volume of morphine administered via a patient-controlled analgesia (PCA) pump over 24 h.

Results

The time to first postoperative analgesic requirement in group plH was significantly shorter than that in group plL. The injected PCA volume was significantly greater in group plH than that in the other two groups. Postoperative pain intensity in group plH was significantly greater than that in the other two groups at 6, 12, and 24 h after surgery. The mechanical hyperalgesia threshold and the area of hyperalgesia around the surgical incision 24 h after surgery in group plH differed significantly from those in the other two groups, which were not significantly different. Adverse effects were comparable among groups.

Conclusions

High-dose remifentanil induced hyperalgesia, including increased pain intensity, increased area of hyperalgesia, and decreased mechanical hyperalgesia threshold. These effects were attenuated by oral administration of a single preoperative dose of pregabalin (300 mg) in patients undergoing laparo-endoscopic single-site urologic surgery.