Comparative Evaluation of Bolus Administration of Dexmedetomidine and Fentanyl for Stress Attenuation During Laryngoscopy and Endotracheal Intubation

Comparison of Fentanyl and Dexmedetomidine in Preventing an Increase in Heart Rate During Intubation Among Patients Undergoing General Anesthesia: A Meta-Analysis

General anesthesia induction, tracheal intubation, extubation, and laryngoscopy are associated with specific hemodynamic changes. Tracheal intubation and laryngoscopy are related to sympathetic stimulation and lead to hypertension and tachycardia. Recent studies have shown that dexmedetomidine is safe and effective as it does not depress respiratory function. This meta-analysis aims to compare the efficacy of dexmedetomidine and fentanyl in preventing an increase in heart rate (HR) during intubation among patients undergoing general anesthesia. A systematic literature search was done using PubMed, Cochrane Library, and Embase to assess studies comparing the efficacy of dexmedetomidine and fentanyl in preventing an increase in HR during intubation. A meta-analysis was done utilizing a random-effects model, and mean differences of HR were determined between fentanyl and dexmedetomidine at baseline, one minute, five minutes, and 10 minutes of intubation. In this meta-analysis, eight randomized control trials were included, involving 548 patients (274 in the fentanyl group and 274 in the dexmedetomidine group). The findings showed that significant difference of HR was significantly lower in the dexmedetomidine group than the fentanyl group at one minute of intubation (mean difference = -8.46; P-value = 0.003), at five minutes of intubation (mean difference = -7.51; P-value = 0.001), and at 10 minutes of intubation (mean difference = -5.15; P-value = 0.030). In the current meta-analysis, dexmedetomidine was better than fentanyl in preventing tachycardia following endotracheal intubation. HR was significantly lower at one minute, five minutes, and 10 minutes after intubation in the dexmedetomidine group compared to the fentanyl group.

Comparison of Hemodynamic Response to Laryngoscopy Using Miller and McCoy Blade

Background: The most commonly used equipment to aid endotracheal intubation is a laryngoscope, and the procedure performed is known as laryngoscopy, which leads to profound cardiovascular effects. The process of laryngoscopy causes the release of catecholamines, thereby leading to marked pressor responses and tachycardia. The process of laryngoscopy can be made easier by the use of various types of laryngoscopic blades. The McCoy blade is a modification of the standard Macintosh blade that incorporates a hinged tip blade. It allows elevation of the epiglottis while decreasing overall laryngeal movement. A Miller blade is a straight blade with a slight upward curve near the tip. It is found that the force exerted, head extension, and cervical spine movement are less with the Miller blade. This study was undertaken to compare changes in haemodynamic parameters before, during, and after laryngoscopy using these two blades.

Materials and methods: Following institutional ethical committee approval and obtaining informed written consent, 100 patients of American Society of Anesthesiologists (ASA) grades I and II in the age group of 18-45 years of either sex undergoing elective surgeries under general anaesthesia were included in the study. The patients were randomly allocated into two groups of 50 patients each. Group Mc - laryngoscopy was performed using a no. 3 McCoy blade. Group Ml - laryngoscopy was performed using a no. 2 Miller blade. The laryngoscopic view was compared using Cormack and Lehane grading. Haemodynamic parameters before, during, and after laryngoscopy were recorded.

Results: Hemodynamic parameters including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were increased in both the groups but were statistically and clinically significant in the Miller group with p≤0.001.

Conclusion: McCoy blade is associated with a significantly more stable hemodynamic response to laryngoscopy in comparison with the Miller blade.

Comparison of the hemodynamic response of dexmedetomidine versus additional intravenous lidocaine with propofol during tracheal intubation: a randomized controlled study

Background

Laryngoscopy and tracheal intubation are strong stimuli that cause a reflex increase in blood pressure (BP), heart rate (HR), and serum catecholamine level. These can lead to myocardial infarction or cerebrovascular accidents. The purpose of this study is to compare the efficacy of dexmedetomidine and lidocaine combined with propofol in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation.

Methods

This study was a randomized controlled study and adhered to the CONSORT guidelines. One-hundred and six patients undergoing elective general anesthesia with endotracheal intubation were divided randomly into two groups. Group D received dexmedetomidine (1 μg kg^− 1) before induction. Group LP received lidocaine (1.5 mg kg^− 1) before induction with additional propofol (0.5 mg kg^− 1) before laryngoscopy. The primary endpoint was hemodynamic including systolic (S) BP, diastolic (D) BP, mean arterial blood pressure (MAP) and HR measured before and after induction and ≤ 10 min after intubation. Secondary outcome was complications/adverse effects.

Results

After induction, the mean SBP, DBP, MAP and HR decreased significantly from baseline in both groups except for mean HR in group LP at 1 min. Differences in mean values of SBP, DBP, and MAP were significantly lower in group D after intubation at 4–10 min (P <  0.05). Group LP had a non-inferior effect in blunting BP at all time points except 1 and 2 min after induction, and 2 min after intubation. The mean difference in HR in group D was significantly lower than that in group LP at all time points (P <  0.001). Group D had significantly more episodes of bradycardia (18.87% vs. 0%, P = 0.001) and hypotension (52.83% vs. 15.09%, P < 0.001) than did group LP.

Conclusion

Lidocaine (1.5 mg kg^− 1) with additional propofol (0.5 mg kg^− 1) had a non-inferior effect compared with dexmedetomidine (1 μg kg^− 1) in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation, and had fewer adverse effects.

Trial registration

Thai Clinical Trial Registry, (TRTC20190206002). Retrospectively registered 4 February 2019.

Comparative Evaluation of Nalbuphine and Fentanyl for Attenuation of Pressor Response to Laryngoscopy and Tracheal Intubation in Laparoscopic Cholecystectomy

Background

In this study, our primary aim was to compare the efficacy of fentanyl and nalbuphine in attenuating the pressor response to laryngoscopy and tracheal intubation in patients undergoing laparoscopic cholecystectomy under general anesthesia. The secondary aim was to observe hemodynamic response to pneumoperitoneum and to study the level of sedation using the Richmond Agitation-Sedation Scale (RASS).

Methodology

A total of 180 patients belonging to the American Society of Anesthesiologist Physical Status class I/II scheduled to undergo elective laparoscopic cholecystectomy under general anesthesia were divided into two groups of 90 each. group A received intravenous nalbuphine 0.2 mg/kg and group B received intravenous fentanyl 2 μg/kg, five minutes before induction of anesthesia. Technique of anesthesia was standardized for all patients in the study. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded before giving the study drug; before induction; immediately after intubation; at one, three, and five minutes after intubation; before creating pneumoperitoneum; 15 minutes after creating pneumoperitoneum; and five minutes after release of pneumoperitoneum. Preoperative and postoperative sedation scoring was done using RASS.

Results

Immediately after intubation, HR was significantly higher in group A (p = 0.016). Both groups showed a rise in SBP immediately after intubation. Group A showed a significantly higher SBP in comparison to group B (135.97 ± 13.02 vs. 130.04 ± 13.33; p = 0.003). The DBP and MAP showed a similar trend. At one, three, and five minutes after intubation, HR, SBP, DBP, and MAP were similar between the groups. Post-extubation sedation score was significantly higher in group A (p < 0.0001).

Conclusions

We found that fentanyl was more effective than nalbuphine in attenuating the pressor response to laryngoscopy and tracheal intubation in patients undergoing laparoscopic cholecystectomy under general anesthesia. There was no significant difference observed between nalbuphine and fentanyl in the hemodynamic response to pneumoperitoneum. The depth of sedation post-extubation was significantly greater with nalbuphine.

Comparison of morphine, dexmedetomidine and dexamethasone as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus block for postoperative analgesia-a randomized controlled trial

Background and Aims:

An ideal adjuvant to local anesthetic in a nerve block should prolong the duration of analgesia, and hasten the onset of sensory and motor blockade without significant adverse effects. The aim of this study was to compare morphine, dexmedetomidine, and dexamethasone as an additive to ropivacaine in ultrasound-guided supraclavicular brachial plexus block (SBPB) for postoperative analgesia.

Material and Methods:

In this randomized, double-blinded study, 150 patients undergoing upper extremity surgery were randomly divided into three groups: group A (morphine 5 mg), group B (dexmedetomidine 50 μg), and group C (dexamethasone 8 mg). The additives were added to 30 ml of 0.5% ropivacaine solution and administered in SBPB. The duration of postoperative analgesia, onset of sensory and motor blockade, sedation, and adverse effects were observed. The pain was assessed by visual analog scale (VAS) and sedation by Ramsay sedation score. The duration of postoperative analgesia was taken as time consumed from block completion to administration of rescue analgesia (VAS >3).

Results:

The demographic profile was similar in both groups. The duration of analgesia was significantly longer in dexamethasone (867.2 ± 217.6 min) than morphine (739. 2 ± 162.5 min) and dexmedetomidine (654.2 ± 179.9 min) (P < 0.001). The onset of sensory and motor blockade was quicker with dexmedetomidine than dexamethasone and morphine. Three cases of block failure were reported with morphine. No major adverse effects were reported.

Conclusion:

Dexamethasone is an ideal adjuvant to ropivacaine in brachial plexus block to prolong postoperative analgesia and devoid of adverse effects. Dexmedetomidine has a quicker onset of sensory and motor blockade.

Comparison of Dexmedetomidine, Lidocaine, and Fentanyl in Attenuation Hemodynamic Response of Laryngoscopy and Intubation in Patients Undergoing Cardiac Surgery

Materials and Methods

This clinical trial was conducted on 90 patients, aged 30–70 years, who had heart surgery. The participants were categorized into three groups. Group D received 1 µg/kg intravenous dexmedetomidine in 10 minutes, group L received 1.5 mg/kg lidocaine (1%) 90 seconds before intubation, and group F received 2 µg/kg fentanyl. The vital signs (HR, SBP, DBP, and MAP) were measured before intubation and 1st, 3rd, 5th, and 10th minutes after intubation. Data were analyzed with SPSS 19 software (chi-square, one-way ANOVA, or Kruskal–Wallis).

Results

The age (P=0.389) and gender distributions of patients were similar in all three groups. Dexmedetomidine significantly attenuated HR in the 3^rd (P=0.001), 5^th (P=0.001), and 10^th (P=0.003) minutes after intervention. It also reduced the systolic blood pressure in the 5^th (P=0.024) and 10^th (P=0.006) minutes. This reduction was significantly higher in the dexmedetomidine group than that in the two other groups. In addition, dexmedetomidine caused a greater reduction in MAP in the 1^st (P=0.048), 5^th (P=0.0001), and 10^th (P=0.0001) minutes. Discussion. All three medications were effective in controlling HR; however, dexmedetomidine caused bradycardia in the 3^rd, 5^th, and 10^th minutes. Lidocaine resulted in an increase in MAP in the 1^st minute after intubation; whereas, dexmedetomidine reduced MAP at the 5^th and 10^th minutes after intubation. Changes in blood pressure and mean arterial pressure in the fentanyl group was lower than the two other groups.

Conclusion

As a result, dexmedetomidine was not suitable for hemodynamic control and led to hypotension and bradycardia; on the other hand, fentanyl was more effective than two other medications in patients undergoing cardiac surgery. This trial is registered with IRCT2017013132320N1.

The Benefits of Opioid Free Anesthesia and the Precautions Necessary When Employing It

The use of opioids in the perioperative period is associated with respiratory depression, impaired gastrointestinal function, post-operative nausea and vomiting (PONV), pruritus, urinary retention, delirium and the potential for developing opioid addiction. Currently the United States is experiencing an epidemic of prescription opioid abuse and deaths from overdose. Many addicts develop their addiction during a routine surgical admission to hospital. More people now die from overdose of synthetic prescription opioids than from heroin and other street drugs. Public education campaigns teaching family members of addicts to reverse opioid induced respiratory depression with naloxone are currently underway. Preventing the development of addiction in the first place during and after the surgical admission however will be more successful at saving lives. Primary prevention of opioid addiction is possible when non-opioid analgesic drugs are used. Employing alternative analgesic drugs in the peri-operative period that have a lower addiction potential and less respiratory depression has therefore become a matter of great national importance. Many powerful non-opioid analgesics are currently available that have more favorable side effect profiles and a lower potential for developing addiction. However, these medications are currently not used as often in routine clinical practice as they should be. Replacing opioids with other analgesics will not only reduce the development of opioid addiction but will also lead to better perioperative outcomes and enhanced patient recovery. This article briefly reviews the opioid alternatives that can significantly reduce or even entirely eliminate the perioperative use of opioids in the majority of surgical procedures.

Is It Time for an Expanded Role of Dexmedetomidine in Contemporary Anesthesia Practice? - A Clinician's Perspective

Since its approval by US Food and Drug Administration in 1999 the clinical use of dexmedetomidine has been gaining in popularity. The indications and clinical applications of this drug have been expanded significantly. In this paper we reviewed its pharmacokinetics, pharmacodynamics, mechanisms of action and mainly focused on its clinical uses and outcomes. Common clinical uses of dexmedetomidine include pre-operative anxiolysis, heart rate control during intubation, treatment of bronchospasm, prevention of laryngospasm and avoiding opioid-induced post-operative respiratory depression and nausea and vomiting. Avoiding opioid induced respiratory depression has been especially beneficial in patients with sleep apnea syndrome. Other problems that can be prevented with dexmedetomidine are tachydysrhythmias, myocardial ischemia, delirium and acute kidney injury. Dexmedetomidine is an excellent sedative drug for intubated patients and it greatly facilitates neurological evaluation. It has been used successfully as a patient-controlled anesthesia drug and to prevent shivering. It is also used as an adjuvant to local anesthetics. It has been suggested that dexmedetomidine is a drug that has many beneficial effects and should be used more frequently by anesthesia care providers to prevent common problems in the peri-operative period. With judicious titration to effect during the intravenous administration of this drug the occurrence of side effects can be minimized. It is very likely that this drug will ascend to take a much more prominent role in future anesthesia practice.

Target-controlled infusion of propofol and remifentanil combined with dexmedetomidine reduces functional endoscopic sinus surgery bleeding

The aim of the present study was to investigate the effects of target-controlled infusion (TCI) of propofol and remifentanil combined with dexmedetomidine on functional endoscopic sinus surgery (FESS) bleeding and surgical field. 62 patients scheduled to undergo FESS were randomly divided into experimental group (intravenous 0.5 µg kg^-1 h^-1 dexmedetomidine after 0.5 µg kg^-1 bolus within 15 min until the end of surgery) or control group (intravenous saline administration at the same dose). All patients underwent endotracheal intubation under general anesthesia with TCI of propofol and remifentanil for anesthesia induction and maintenance. During anesthesia, arterial pressure (MAP), heart rate (HR), intraoperative propofol and remifentanil dosage and intraoperative blood loss were recorded. Surgeons rated their satisfaction with the surgical field using the Numeric Rating Scale (NRS). Following surgery, visual analog scale (VAS) was assessed. During tracheal intubation and extubation, HR and MAP in the experimental group were significantly lower compared with the control group (P<0.05); HR was also significantly lower compared with the control group throughout surgery (P<0.05). The mean infusion rate of propofol and remifentanil was significantly lower in the experimental group compared with the control group (P=0.001 and P=0.045, respectively). Blood loss in the experimental group was significantly lower compared with the control group (P=0.007). NRS and VAS scores in the experimental group were significantly improved compared with control group (P<0.01). In conclusion, TCI of propofol and remifentanil for FESS combined with dexmedetomidine reduced intraoperative bleeding and improved the quality of surgical field compared with the same procedure without dexmedetomidine. Dexmedetomidine also reduced the increase in MAP and HR during tracheal intubation and extubation, and improved postoperative analgesia quality.

Dexmedetomidine in Attenuation of Haemodynamic Response and Dose Sparing Effect on Opioid and Anaesthetic Agents in Patients undergoing Laparoscopic Cholecystectomy- A Randomized Study

INTRODUCTION

Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period.

AIM

To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc-Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant.

RESULTS

Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The Minimum Alveolar Concentration (MAC) requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective.

CONCLUSION

Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.

Pheniramine Maleate is more effective than Lidocaine on Fentanyl Induced Cough

OBJECTIVE

Fentanyl is frequently used during anesthesia induction. The use of fentanyl can cause cough through different mechanisms. Here, we aimed to investigate effects of pheniramine maleate (PM), an antihistaminic agent, and compare it with lidocaine on fentanyl induced cough.

METHODS

This is a randomized double-blind prospective clinical study of ASA I-II, 120 patients scheduled for elective abdominal surgery. Patients were administered drugs intravenously and randomly allocated into three groups: Group C (2 ml 0.9 % normal saline), Group L (1mg/kg lidocaine), and Group F (PM 45.5 mg). 90 seconds after administration, 2µ/kg fentanyl was applied in three seconds to all patients. Severity of cough (mild: 1-2, moderate: 3-5, severe> 5), time of the cough and vital parameters were recorded 90 seconds after fentanyl injection.

RESULTS

Eight patients (25%) in Group C had fentanyl induced cough whereas three patients (7.5%) in Group L and one patient (2.5%) in Group F experienced this phenomenon. There was statistically significant difference between Group F and Group C (p<0.05); however, differences between Group L and Group C or Group F and Group L were not statistically significant (p>0.05).

CONCLUSIONS

Pheniramine Maleate 45.5 mg is better that placebo and as effective as lidocaine to prevent fentanyl induced cough.