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Table of Content - Volume 12 Issue 2 -November 2019


 

Comparative study of intravenous dexmedetomidine and intravenous fentanyl for attenuation of sympathoadrenal response for laryngoscopy and tracheal intubation

 

Shweta Patel1*, Sheetal M Shah2

 

1Assistant Professor, Department of Anaesthesiology, New Civil Hospital, Surat, Gujarat, INDIA.

2Assistant Professor, Department of Anaesthesiology, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, INDIA.

Email: shwtpatel730@gmail.com

Abstract               Background: Endotracheal intubation is a noxious stimulus, which can be sympathetic and parasympathetic. A basic need is continuously felt among the anesthesiologist for the desired availability of a drug that effectively suppresses all the hazardous responses to obnoxious stimuli with a maximum safety margin. Aim: To evaluate and compare the efficacy of Dexmedetomidine and Fentanyl in attenuating the sympathoadrenal response. Material and Methods: This study was conducted on 60 patients undergoing elective surgical procedures under general anaesthesia. Patients were divided into two groups with 30 patients in each group as Group D received intravenous Dexmedetomidine 1µg/kg and Group F received intravenous Fentanyl 2µg/kg. Patients were monitored for pulse rate, systolic and diastolic blood pressure and mean arterial pressure. Results: In group D mean HR was increased only by 2.9 bpm and in group F it was 22.2 bpm after intubation. Mean MAP was increased by 5.9 mmHg in group D and by 16.93 mmHg in group F. Patients in dexmedetomidine group exhibit more hemodynamic stability than in fentanyl group. Conclusion: Both inj. dexmedetomidine 1µg/kg and inj. Fentanyl 2µg/kg, given 10 minutes before intubation attenuate the stress responses to laryngoscopy and intubation but inj. Dexmedetomidine was far superior to fentanyl in blunting the stress responses and it can safely be administered in the dose of 1µg/kg without any side effects.

Key Words: laryngoscopy and tracheal intubation, Dexmedetomidine, Fentanyl, sympathoadrenal response

 

INTRODUCTION

Endotracheal intubation is the translaryngeal placement of a tube into trachea via nose or mouth. Endotracheal intubation includes laryngoscopy and intubation, which often evokes cardiovascular responses, characterized by increases in arterial pressure, change in heart rate and disturbance in cardiac rhythm,1 which are transient, variable and unpredictable. Endotracheal intubation is a noxious stimulus, which can be sympathetic and parasympathetic. Parasympathetic response is seen in pediatric population while in adults, sympathetic response predominant, which may be the result of increase in catecholamine activity. Though these changes are well tolerated by healthy individuals. In patients with cardiovascular and cerebrovascular disease, they can produce deleterious effects in the form of myocardial ischemia, pulmonary edema and cerebral hemorrhage.2 A basic need is continuously felt among the anesthesiologist for the desired availability of a drug that effectively suppresses all the hazardous responses to obnoxious stimuli with a maximum safety margin. Newer α2-adrenergic agonist, Dexmedetomidine has multidimensional features. It has partial agonistic activity and is known to decrease the plasma catecholamines level and suppress the release of catecholamines. It possesses anxiolytic, sedative, analgesic and sympatholytic properties.3 Fentanyl is an opioid µ-receptor agonist and is widely used in clinical practice as sedative/analgesic.4 Dexmedetomidine and Fentanyl both have sympatholytic, analgesic and sedative properties but unlike Fentanyl, Dexmedetomidine has been reported to induce sedation without respiratory depression. The present study was conducted to evaluate and compare the efficacy of Dexmedetomidine and Fentanyl in attenuating the sympathoadrenal response i.e., heart rate and arterial blood pressure changes during tracheal intubation.

 

MATERIAL AND METHODS

In this prospective study, a total of 60 patients undergoing elective surgical procedures during the study period of two years were selected. Approval from Institutional Ethical Committee was obtained prior to the commencement of the study. Written informed consent was taken from all patients.

Inclusion criteria

  • Age 16-60 years
  • Either sex
  • ASA I and II
  • undergoing elective surgical procedures under general anaesthesia

Exclusion criteria

  • Severe systemic disease
  • history of allergy of any study drugs
  • difficult airway and obese patient (BMI>30)
  • patient coming for emergency surgery
  • pregnant female
  • basal heart rate <55/min and SBP<90 mm of Hg.

All patients were assessed a day before surgery and screened for past medical, surgical history, any drug allergy and any anaesthesia exposure. Detailed systemic examinations were done. Routine investigations like complete blood count, random blood sugar, renal function tests, Chest X-ray and ECG were carried out. Airway assessment was done by Mallampatti gradation and Grade I and II were selected for the study. The patients were randomized into two groups, each group comprises thirty patients.

Group D: Inj. Dexmedetomidine 1 µg/kg i.v.

Group F: Inj. Fentanyl 2 µg/kg i.v.

All patients were kept nil by mouth for 8 hours before surgery. On arrival to operation theatre, patients were monitored with 3 lead ECG, pulse oximetry (SpO2) and noninvasive blood pressure was instituted and baseline vitals such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded. All patients were premedicated with inj. Ondansetrone 4 mg/kg i.v. 10min before surgery. Group D patients were given inj. Dexmedetomidine 1µg/kg diluted in 50 ml NS infused over 10 min with infusion pump. Group F patients were given bolus inj. Fentanyl 2 µg/kg diluted in 10 ml in NS slowly 10 min before induction. All the patients were pre-oxygenated with100% O2 by mask for 3 min. Sedation score was recorded at the end of the 10 min according to Ramsaysedation scale. Induction was achieved with inj. Thiopentone sodium 6 mg/kg i.v. slowly and inj. Succinylcholine 2mg/kg i.v. In both groups intubation and laryngoscopy was performed using Macintosh curved blade within a periods of 15 seconds and intubated with appropriate size portex cuffed endotracheal tube. After confirming the position of endotracheal tube in situ, bilateral equal airentry was checked and tube was fixed. Observation period started after 10 min following administration of both study drug and before induction. Then patients pulse rate, SBP, DBP, MAP and SPO2 were recorded immediately after laryngoscopy and at 2, 3, 5, 7,10min intervals. We decided to give inj. Atropine 0.01 mg/kg i.v. if pulse rate goes below 55 bpm. General anesthesia was maintained with O2+N2O+sevoflurane and non-depolarizing muscle relaxant inj. Atracurium. Intermittent positive pressure ventilation was given by anesthesia ventilator. At the end of surgery, patients were reversed with Inj. Neostigmine0.05mg/kg and Inj. Glycopyrolate 0.008mg/kg. Patients were extubated when they were fully conscious with normal muscle tone and power, presence of spontaneous respiration and all reflexes. Patients were shifted to postoperative room; observed for complications like hypotension, hypertension, bradycardia, tachycardia, arrhythmias, hypoxemia, bronchospam, vomiting and shivering.

Statistical analysis

Statistical Package for the Social Sciences (SPSS) 17.0 software was used for the statistical analysis of the compiled data by applying Chi-square test and the One-Way Analysis of Variance (ANOVA) with post hoc Tukey HSD tests. Means and standard deviations represented the average and typical spread of values. P<0.001 was considered a highly significant difference and P<0.05 was significant.


 

 

 

RESULTS

The minimum age in group D and F were 16 and 19 years respectively. The maximum age in groups D and F was 60 and 56 years respectively. Male to female ratio in group D was 10:20 and in group F was 14:16. No significant difference among the groups as regards the age, weight and sex.

Table 1: Demographic characteristics of patients in two groups

Characteristics

Group D

Group F

p-value

Age

41.1±11.92

33.57±11.22

>0.05

Weight

52.87±10.64

53.97±10.04

>0.05

Sex (male/female)

10/20

14/16

 

Table 2 shows the statistical evaluation of changes in meanpulse rate between two groups. Preoperatively it was not significant (p=0.1333). While 10 min after premedication with Dexmedetomidine, there was more decrease in pulse rate. Comparison was done using the unpaired t-test, which was statistically significant. Lowest pulse rate noted in one patient was 56bpm in dexmedetomidine group. The increase in mean pulse rate in Group F was statistically significant as compared to group D(p<0.05), immediately after intubation and at 2, 3, 5, 7, 10 minutes.

 

Table 2: Comparison of mean pulse rate between two groups

Mean PR

Group D

Group F

P value

Pre-op

89.5±12.2

84.76±13.74

0.1333

10 min after study drug

69.9±9.7

79.87±13.41

0.0016

Immediately after intubation

92.4±9.1

107.43±15.6

0.001

At 2 min

90.6±9.2

101.1±13.4

0.0009

At 3 min

87.5±9.1

96.9±12.8

0.0018

At 5 min

83.8±8.9

93.5±12.5

0.0010

At 7 min

80.5±8.7

90±11.9

<0.008

At 10 min

77.5±8.5

86.4±11.6

<0.0013

Table 3 shows that the basal mean SBP was comparable in both groups (p=0.8173). Statistical evaluation between two groups showed highly significant fall in SBP in group D when compared to group F, after 10 minutes of injection of drug (before induction), which was statistically significant (p=0.0001). The increase in SBP in both group was statistically significant immediate after intubation and at 2, 3, 5, 7, 10 min.(p<0.05).

 

Table 3: Comparison of SBP changes between two groups

SBP

Group D

Group F

P value

Pre-op

136.3±13.74

135.6±9.18

0.8173

10 min after study drug

117.9±14.61

131.9±9.9

0.0001

Immediate after intubation

142.9±12.98

154.4±8.8

0.0002

At 2 min

140.9±13.36

150.1±7.71

0.0018

At 3 min

137±12.80

146.1±7.47

0.0014

At 5 min

133.8±12.75

142±7.46

0.0035

At 7 min

130.3±13.07

137±7.52

0.0073

At 10 min

127±13.27

134.1±8.05

0.0147

Regarding diastolic BP, after 10 min of study drug administration, in group D there was significant fall in DBP as compared to group F, which was statistically significant (p=0.0001). The increase in DBP in group F was statistically significant compared to group D immediately after intubation and at 2, 3, 5, 7, 10 min.(p<0.05).

                                                                Table 4: Comparison of DBP changes between two groups

DBP

Group D

Group F

P value

Pre-op

84.34±7.27

83.3±7.45

0.5509

10 min after study drug

71.06±7.55

79.7±7.51

0.0001

Immediate after intubation

89.97±6.46

99.23±8.33

0.0001

At 2 min

88.3±6.20

95.86±7.59

0.0001

At 3 min

85.3±5.93

92.3±7.09

0.0001

At 5 min

82.1±5.51

89.43±7.48

0.0001

At 7 min

79.03±5.73

86.87±7.47

0.0001

At 10 min

76.26±05.2

84.1±9.83

0.0003

There was no significant difference between MAP between both the groups (p value >0.05) pre-operatively. While after 10 min of Dexmedetomidine administration, there was more decrease in MAP than preoperatively, which is statistically significant.There was significant difference of MAP in group D and group F immediate after intubation and at 2, 3, 5, 7 and 10 minutes. After intubation p value of MAP between two groups was 0.0024 which was significant.

Table 5: Comparison of MAP changes between two groups

MAP

Group D

Group F

P value

Pre-op

101.7±8.46

100.69±7.37

0.6238

10 min after study drug

86.67±8.89

97.1±7.24

0.0001

Immediate after intubation

107.6±7.8

117.62±7.7

0.0024

At 2 min

105.8±7.65

113.94±6.89

0.0001

At 3 min

102.5±7.38

110.23±6.51

0.0001

At 5 min

99.33±7.13

106.97±6.7

0.0001

At 7 min

96.11±7.32

103.88±6.76

0.0001

At 10 min

93.17±7.11

100.76±6.72

0.0001

The patient in dexmedetomidine group were more sedated (2.73±0.58) than the patients in fentanyl group (2.40±0.56)which was statistically significant(p=0.0288). There was no spo2 changes observed in both the groups throughout study period. No side effects were noted in any groups of patients in our study.

DISCUSSION

Peri-intubation period is one of the most stressing moments of general anesthesia. The pressure response to laryngoscopy and endotracheal intubation in the form of tachycardia, hypertension and arrhythmias may be potentially dangerous. Wide variety of pharmacological agents were used to overcome this problem but most of them were partially effective. So, search for ideal agents for attenuation of hemodynamic changes still continuous. We used Inj. fentanyl 2µg/kg i.v. before induction and observed fall in HR(5.8%) and MAP(3.6%) 10 min. after fentanyl administration from baseline. After intubation rise in pulse rate with fentanyl is 107.43±15.6bpm(26.7%) Our study has similar finding with Malde and Sarode.5 They found that significantly lesser rise in HR and MAP after intubation in group F as compared to group L and group C. In our study fentanyl also reduced pressure response to laryngoscopy and intubation which supports this study. We noted pulse rate immediately after intubation (92.4±9.1), at 2 min(90.6±9.1), at 3 min (87.5±9.1) in group D. This reading is near to baseline(89.5±12.2). we also noted MAP immediately after intubation (107.6±7.8), at 2 min(105.8±7.65), at 3 min(102.5±7.38), which is also near to baseline(101.7±8.46). Our result is similar with Laha et al.6 They found significant fall in mean HR and MAP after 10 min of dexmedetomidine ingestion, which was increased after intubation and came to baseline after 3 min of intubation. We also found similar increase in HR and MAP after intubation which came to near baseline at 3 min of intubation. In this way our study supports this study. In our study, there was decrease in parameters from baseline but increase in HR 26.1%, SBP 13.26%, DBP 19% with group F than HR 3.2%, SBP 4.84%, DBP 6.67% in group D after intubation. Our finding is similar with study of Bajwa et al,7they compared the effect of dexmedetomidine (1µg/kg) and fentanyl (2µg/kg) in modifying the hemodynamic response following laryngoscopy and tracheal intubation. They noted that the mean HR(P=0.02) and MAP(P=0.015) were significantly lower in group D approximately 10-15% from baseline, 20min after infusion as compared to group F. Similarly, in our study HR (P=0.0016) and MAP (P=0.0001), 10 min after study drug ingestion significantly lower in group D than Group F. They showed 2µg/kg fentanyl was not sufficient to attenuate stress response to laryngoscopy and tracheal intubation as they recorded 15-25% increase in HR and Blood pressure. Our study supports this, as increase in HR 26.1% and MAP 16.8% with fentanyl after intubation as compared to HR 3.2% and MAP 5.8% in group D. We also found similar results like Sulaiman et al8 that in Dexmedetomidine (0.5µg/kg) group significantly lower in HR (62.37±8.6 vs 73.23±10), SBP(121.10±13 vs 131.87±21), DBP(61.10±13 vs 71.50±7.9) and MAP (83.67±10 vs 93.12±12) after 10 min of drug administration (compared with baseline). In our study after 10 min of drug administration, significantly fall in HR (69.9±9.7 vs 89.5±12.2), SBP(117.9±14.61 vs 136.3±13.74), DBP (71.06±7.55 vs 84.34±7.27) and MAP(86.67±8.89 vs 101.7±8.46) in Group D. In this way our study supports this study. Our finding with Dexmedetomidine (1µg/kg) is almost similar with this. In present study, immediately after intubation, we noticed increased in HR (92.4±9 vs 107.43±15.6), SBP (142.9±12.98 vs154.4±8.8), DBP (89.97±6.46 vs 99.23±8.33) and MAP(107.6±7.8 vs 117.62±7.7). This data shows that dexmedetomidine effectively attenuate pressure response compared to fentanyl. This results follows the results of Kharwar et al,9 They concluded that inj. Dexmedetomidine was more effective in attenuating hemodynamic response than fentanyl, similarly in our study, dexmedetomidine also more effective than fentanyl. In our study, we noted sedation according to Ramsay sedation scale after 10 min of infusion of study drug but before induction, it was more in dexmedetomidine groups(2.73±0.58) than in fentanyl group (2.40±0.56) which is statistically significant(p<0.05). Spo2 was also not affected. Our study supports this study of Sagiroglu et al10 in this way.

 

CONCLUSION

Both inj. dexmedetomidine 1µg/kg and inj. Fentanyl 2µg/kg, given 10 minutes before intubation attenuate the stress responses to laryngoscopy and intubation but inj. Dexmedetomidine was far superior to fentanyl in blunting the stress responses and it can safely be administered in the dose of 1µg/kg without any side effects.

 

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