stress response during laryngoscopy and endotracheal

8
Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019 Sai Sudha L 1 , Krishna Chaitanya K 2 * 1 Postgraduate Student, 2 Professor Department of Anaesthesiology & Critical Care, Narayana Medical College, Nellore (AP), India. ORIGINAL AR TICLE * Corresponding author Email ID: [email protected] http://dx.doi.org/105455/nmj/00000169 ABSTRACT Objective: To compare the anaesthetic effects of a 3-drug mixture - IV Magnesium sulphate, IV Dexamethasone, IV Loxicard ; and IV Dexmedetomidine in suppressing the hemodynamic stress response to laryngoscopy and endotracheal intubation. Materials and Methods: 60 patients were divided into two equal groups of 30 in each group were enrolled in this study. GROUP M - received 1g MgSO4, 8mg dexamethasone, 1.5mg/kg Loxicard in 100ml NS given over 10mins (n=30) GROUP D - received 1mcg/kg dexmedetomidine in 100ml NS given over 10 mins (n=30) ; prior to induction of anaesthesia. Both the groups were observed for changes in hemodynamic parameters like HR, SBP, DBP at 0, 1, 3, 5, 10 minutes after laryngoscopy and intubation. Results: Comparison of both the groups reveals that HR response post intubation was better attenuated with dexmedetomidine with statistically significant p values at all time intervals. Attenuation of blood pressure with dexmedetomidine at 0,1 min post intubation had statistically significant p values (SBP at 0min(p-0.003) ,1 min(p-0.01) and DBP at 0min(p- 0.04), 1min(p-0.04) , whereas there was no statistically significant difference in blood pressure at 3,5,10 minutes post intubation between both the groups. Conclusion: The increase in heart rate was better attenuated with dexmedetomidine and blood pressure was as effectively attenuated with the 3-drug mixture when compared to dexmedetomidine. Hence, this mixture can be used as an effective and safe alternative to dexmedetomidine. Keywords: Stress response, Dexmedetomidine, 3-drug mixture, heart rate, blood pressure, laryngoscopy, intubation. Stress Response During Laryngoscopy and Endotracheal Intubation 64

Upload: others

Post on 05-Apr-2022

3 views

Category:

Documents


0 download

TRANSCRIPT

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

Sai Sudha L1, Krishna Chaitanya K2*

1Postgraduate Student, 2 Professor

Department of Anaesthesiology & Critical Care, Narayana Medical College, Nellore (AP), India.

ORIGINAL ARTICLE

* Corresponding author

Email ID: [email protected]

http://dx.doi.org/105455/nmj/00000169

ABSTRACT

Objective: To compare the anaesthetic effects of a 3-drug mixture - IV Magnesium sulphate, IV Dexamethasone,

IV Loxicard ; and IV Dexmedetomidine in suppressing the hemodynamic stress response to laryngoscopy and endotracheal

intubation.

Materials and Methods: 60 patients were divided into two equal groups of 30 in each group were enrolled in

this study. GROUP M - received 1g MgSO4, 8mg dexamethasone, 1.5mg/kg Loxicard in 100ml NS given over 10mins

(n=30) GROUP D - received 1mcg/kg dexmedetomidine in 100ml NS given over 10 mins (n=30) ; prior to induction of

anaesthesia. Both the groups were observed for changes in hemodynamic parameters like HR, SBP, DBP at 0, 1, 3, 5, 10

minutes after laryngoscopy and intubation.

Results: Comparison of both the groups reveals that HR response post intubation was better attenuated with

dexmedetomidine with statistically significant p values at all time intervals. Attenuation of blood pressure with dexmedetomidine

at 0,1 min post intubation had statistically significant p values (SBP at 0min(p-0.003) ,1 min(p-0.01) and DBP at 0min(p-

0.04), 1min(p-0.04) , whereas there was no statistically significant difference in blood pressure at 3,5,10 minutes post intubation

between both the groups.

Conclusion: The increase in heart rate was better attenuated with dexmedetomidine and blood pressure was as

effectively attenuated with the 3-drug mixture when compared to dexmedetomidine. Hence, this mixture can be used as an

effective and safe alternative to dexmedetomidine.

Keywords: Stress response, Dexmedetomidine, 3-drug mixture, heart rate, blood pressure, laryngoscopy, intubation.

Stress Response During Laryngoscopy

and Endotracheal Intubation

64

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

Introduction

Laryngoscopy and endotracheal intubation provokes

sympathetic stimulation which can result in tachycardia and

hypertension, due to an increase in the plasma concentration

of catecholamines(1). The longer the duration and number

of failed attempts , severe is the haemodynamic stress

response. The elevation in arterial blood pressure generally

starts within seconds of laryngoscopy, peaks in 1-2 min and

returns to baseline levels within 5 to 10 mins. This

cardiovascular response could be hazarduous in patients with

hypertension, myocardial ischemia and cerebrovascular

disease (2).

Common factors precipitating this pressor response are

lighter planes of anaesthesia, anatomically difficult view,

greater force used to displace the tongue, prolonged time

and multiple attempts during laryngoscopy and intubation

and additional stimulation caused by endotracheal tube

placement alongwith cuff inflation(3).

Several strategies have been tried to obtund the stress

response following laryngoscopy and endotracheal

Intubation like local anaesthetics, intravenous opioids, ?

blockers, ?2 adrenergic agonists, vasodilators, magnesium

or by increasing volatile anaesthetic concentrations(4). No

single agent has been established as the most appropriate

for this purpose.

Lignocaine is a synthetic amide (-NHCO-) local anaesthetic.

It blocks the sodium channels in the cell membranes of the

heart. Intravenous lignocaine blunts the rise in heart rate

and blood pressure; the possible mechanism being a direct

myocardial depressant effect(5), a peripheral vasodilating

effect and an effect on synaptic transmission.

Magnesium sulfate plays a role in attenuating the stress

reponse because of its inhibitory action on the release of

catecholamines. Its anesthetic and analgesic effects are due

to its actions as an antagonist of N-methyl-D- aspartate

(NMDA) receptors(6) in the central nervous system.

Dexamethasone, a synthetic glucocorticoid decreases basal

and stress-elevated levels of the pituitary hormone ACTH.

Dexamethasone inhibits the release of ACTH via an action

on HPA axis.It also has anti inflammatory and antiemetic

effects.

Dexmedetomidine, a highly selective 2 adreno-receptor

agonist decreases the sympathetic outflow(7) and

noradrenergic activity thereby counteracting haemodynamic

fluctuations associated with sympathetic stimulation

occurring at the time of intubation(8).

This study was undertaken to compare the anaesthetic effects

of a 3-drug mixture - Magnesium sulphate, Dexamethasone

and Loxicard to Dexmedetomidine in suppressing the

hemodynamic stress response to laryngoscopy and

endotracheal intubation.

Materials and Methods

This prospective randomized, double blinded control study

was conducted in sixty patients undergoing elective surgical

procedures under general anaesthesia with endotracheal

intubation. After getting institutional ethical committee

approval, the patients were informed of the study and written

consent was obtained.

Inclusion Criteria

Patients in the age group of 18 to 60 years

65

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

ASA Physical status I, II and III

Weight between 50 to 80 kgs

Modified Mallampati Grade III and IV were included in

the study.

Exclusion Criteria

The patients with ischemic heart disease, cerebrovascular

disease, asthma, pregnancy, full stomach and emergency

surgery were excluded from the study.

All the patients were assessed preoperatively and

Premedicated with Tab. Alprazolam 0.5mg orally on the

night before surgery. In preoperative room, baseline

parameters were recorded. Intravenous access was secured

and all patients were hydrated with 500ml of Ringer's lactate.

60 patients were randomly divided by computer generated

randomization into two groups of 30 patients in each group.

Group M - received 1g MgSO4, 8mg dexamethasone,

1.5mg/kg Loxicard in 100ml NS given over 10mins (n=30)

Group D - received 1mcg/kg dexmedetomidine in 100ml

NS given over 10 mins (n=30) ; prior to induction of

anaesthesia.

The anaesthesiologist, who was not aware of the groups,

administered the study drug and recorded the vital

parameters HR,SBP and DBP. After preoxygenation with

100% oxygen for 3 minutes, patients were induced with

Inj. Midazolam 1mg IV, Inj Fentanyl 2mcg/kg IV, Inj

Propofol 2 mg/kg IV, followed by Inj. Atracurium 0.5mg/

kg IV, after confirming a lack of response to voice and a

loss of the eyelash reflex. Laryngoscopy and intubation was

performed by another anaesthesiologist who was also

blinded to the drug given. After 3 minutes of ventilation

with 100% oxygen, endotracheal intubation was performed

with an appropriate size cuffed endotracheal tube. No

surgical stimulation was allowed for 10 minutes after

intubation.HR, SBP, DBP were noted at 0,1,3,5 and 10

minutes after intubation. Anaesthesia was maintained with

50% oxygen, 50% air, Sevoflurane 2% and Inj. Atracurium

0.1mg/kg. At the end of the surgery, patients were reversed

with Inj. Neostigmine 0.05mg/kg and Glycopyrrolate

0.01mg/kg.

Statistical Analysis

Statistical analysis was performed using SPSS version 20.

Continuous variables were expressed as Mean and Standard

Deviation. Categorical variables were expressed as numbers

and percentages. Intergroup comparison was done using

Student's T test and Chi-square test. P value <0.05 was

considered as statistically significant.

Results

There was no statistically significant difference in the

demographic parameters in both the groups (Table 1).

Group D Group M

Age ( in years) 36.18±8.56 34.27±8.43

Gender (M/F) M-11, F-19 M-9, F-21

Table 1:Demographic parameters in the both groups.

66

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

Baseline parameters were comparable in both the groups

with statistically no significant difference.

Both the groups controlled the heart rate and blood pressure

to laryngoscopy and endotracheal intubation effectively.

Comparison of Heart Rate between both the groups reveals

that; the decrease in heart rate was more with Group D when

compared to Group M. Heart rate values were statistically

significant at all time intervals in Group D as compared to

Group M (p<0.05).

At pre induction, the mean value for HR in Group D was

97.6 and in Group M was 94.8. At 0 minute that is

immediately after intubation, mean HR in Group D was 80.6

and in Group M were 84.13. At 1 minute, HR in Group D is

78.7 and in group-M is 86. At 3 minutes, HR in Group D

was 77.06 and in Group M was 85. At 5 minutes, HR in

Group D was 74.08 and in Group M was 84. At 10 minutes,

HR in Group D was 74.8 and in Group M was 83.

Table 2: Heart rate recordings in both the groups

Fig 1. Heart Rate

Comparison of Systolic blood pressure response between

both the groups reveals that there was a statistically

significant difference at 0 and 1 minute after intubation in

Group D (SBP at 0min(p-0.003) ,1 min(p-0.01) ) when

compared to Group M. At other time intervals; 3,5,10

minutes after intubation, the systolic blood pressure was

comparable between both the groups with no statistically

significant difference.

At Pre induction, the mean value for SBP in Group D was

117 and in Group M was 132.9. At 0 minute that is

immediately after intubation, mean SBP in Group D was

99 and in Group M was 110.4. At 1 minute, SBP in Group

D is 105 and in Group M is 111.7. At 3 minutes, SBP in

Group D was 110.5 and in Group M was 113. At 5minutes,

SBP in Group D was 115 and in Group M was 111. At 10

minutes, SBP in Group D was 115.3 and in Group M was

113.

67

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

Table 3: Systolic blood pressure recordings in both the

groups.

Fig 2. Systolic Blood pressure

Comparison of Diastolic blood pressure between both the

groups reveals that there was a statistically significant

difference at 0 and 1 minute after intubation in Group D

(DBP at 0min(p-0.04), 1min(p-0.04) ) when compared to

Group M. At other time intervals; 3,5,10 minutes after

intubation, the diastolic blood pressure was comparable

between both the groups with no statistically significant

difference.

At Pre induction, the mean value for DBP in Group D was

84.2 and in Group M was 83.3. At 0 minute that is

immediately after intubation, mean DBP in Group D was

78.06 and in Group M was 85.26. At 1 minute, DBP in

Group D is 70.7 and in Group M is 76.2. At 3 minutes,

DBP in Group D was 77 and in Group M was 75.5. At

5minutes, DBP in Group D was 77.4 and in Group M was

73.8. At 10 minutes, DBP in Group D was 72.4 and in Group

M was 74.8.

Table 4: Diastolic blood pressure in both the groups.

Fig 3. Diastolic Blood pressure

Discussion

Laryngoscopy and endotracheal intubation during general

anaesthesia results in a marked sympathetic response with

a transient increase in Heart Rate and arterial blood pressure

probably as a result of intense sympathetic nervous system

stimulation(9) . In patients who are at risk of developing

increased intracranial pressure, arterial hypertension and

myocardial ischemia, these changes may be life threatening.

68

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

They may lead to cerebral haemorrhage, left ventricular

failure and life threatening cardiac arrhythmias (10). If no

specific measures are taken to prevent hemodynamic

response, reflex changes in the cardiovascular system lead

to an average increase in blood pressure by 40-50% and

20% increase in heart rate.

Commonly used drugs are Beta blockers, alpha-2 agonists,

opioids, Magnesium Sulphate and Lignocaine attenuate

these potentially harmful cardiovascular reactions during

laryngoscopy and intubation.Various other techniques were

also tried to attenuate the cardiovascular response , one of

them being deep inhalational anaesthesia, which may cause

intracranial hypertension. Potent vasodilator drugs need

larger doses to attenuate arterial blood pressure but they

may cause reflex tachycardia which is not desirable while

others depress the myocardium in patients with preexisting

left ventricular dysfunction or those receiving beta

adrenergic antagonist. These effects are not desirable and

limit their usefulness.

Various studies have shown that intravenous lignocaine is

effective in attenuating the arterial hypertension and

tachycardia in response to endotracheal intubation.

Splinter & Cervenko (11) demonstrated that 1.5mg/kg of

I.V. Lignocaine could attenuate the increase in systolic blood

pressure, mean arterial pressure and rate pressure product

associated with endotracheal intubation.

Calcium exerts a major role in stimulus-response

relationship, including the release of catecholamines from

the adrenal gland and adrenergic nerve terminals in response

to sympathetic stimulation. Because Magnesium competes

with calcium for membrane channels, it has been described

as the physiological calcium antagonist (12) and can modify

many calcium mediated responses.

The ability of magnesium ion in inhibiting the release of

catecholamines has long been recognized, hence Magnesium

Sulphate is considered for use in laryngoscopy and

intubation to minimize unwanted cardiovascular responses

(13).

Dexamethasone, a synthetic glucocorticoid decreases basal

and stress-elevated levels of the pituitary hormone ACTH.

Dexamethasone inhibits the release of ACTH via an action

on HPA axis (14). It also has anti inflammatory and

antiemetic effects. It is usually used prior to induction of

anaesthesia. It has been used for many purposes like intra-

op and post-op shivering, to reduce the airway edema after

a difficult intubation, for prevention of PONV, used in

peripheral nerve blocks to prolong the duration of blockade

and to potentiate the effect. Razavizadeh et.al has advocated

the use of dexamethasone in epidural anaesthesia for post

operative analgesia (15).

Hence, in this study, we have compared the additive

anaesthetic effects of 3 drugs viz. Magnesium Sulphate,

Lignocaine and Dexamethasone, and to assess the usefulness

of dexamethasone in potentiating the effect of the other two

drugs for attenuation of the stress response during

endotracheal intubation.

Dexmedetomidine, a highly selective alpha 2-

adrenoreceptor agonist offers a unique pharmacological

profile with sedation, sympatholysis, analgesia,

cardiovascular stability and with great advantage of

respiratory depression sparing effect.

69

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

Dexmedetomidine by activating pre and post-synaptic alpha

2 receptors of sympathetic system produces vasodilatation;

and also by acting on post-synaptic alpha 2 receptors of

vascular smooth muscle cells it produces vasoconstriction.

Thus it shows a biphasic, dose dependent response on blood

pressure and heart rate, characterized by an initial short term

increase in BP followed by a longer lasting reduction in BP

and HR. It produces sympatholysis by stimulating alpha 2

adrenergic inhibitory neurons in medullary vasomotor centre

(16) which is manifested as peripheral vasodilatation and

decrease in blood pressure, heart rate and cardiac output.

Smitha et al observed that dexmedetomidine 1 ?g/kg was

more effective in controlling haemodynamic responses to

tracheal intubation (17).

Few authors (18) have observed increased sedation levels

and need for oxygen supplementation with

dexmedetomidine at a dose of 1mcg/kg.

It has been shown to cause irregular breathing with episodes

of apnoea, especially at a dose of 2.0 ?g/kg (19).Increased

incidence of adverse effects such as bradycardia and

hypotension (20) have also been reported.

Dexmedetomidine is better avoided in elderly patients,

patients with pre-existing bradycardia or heart blocks. In

such cases, the combination of the 3-drug mixture can be

used safely for all patients and for any kind of surgery.

Conclusion

The increase in heart rate was better attenuated with

dexmedetomidine and blood pressure was as effectively

attenuated with the 3-drug mixture when compared to

dexmedetomidine. Hence, this mixture can be used as an

effective and safe alternative to dexmedetomidine.

References

1. Hakim AA, Hassan S, Bahgat A. Dexmedetomidine

vs. Magnesium sulphate vs. Lidocaine for blunting the

stress response to direct laryngoscopy in abdominal

surgeries. Zagazig University Medical Journal

2018;26(6):503-06.

2. Mahajan L, Kaur M, Gupta R. Attenuation of the

pressor responses to laryngoscopy and endotracheal

intubation with intravenous dexmedetomidine versus

magnesium sulphate under bispectral index-controlled

anaesthesia: A placebo-controlled prospective

randomised trial. Indian J Anaesth 2018;62:337-43.

3. Stoelting RK. Circulatory response to laryngoscopy

and tracheal intubation with or without prior

oropharyngeal viscous lidocaine. Anesth Analg 1977;

56:618-21.

4. Joffe AM, Deem SA. Physiologic and pathophysiologic

responses to intubation. In: Benumof J,Hagberg CA,

editors. Benumof and Hagberg's Airway Management.

3rd ed. Philadelphia: Elsevier Saunders; 2012. p. 184-

95.

5. Prasad SR, Maheshwar U, Priya G. Comparison of IV

Lignocaine and IV Dexmedetomidine for attenuation

of hemodynamic stress response to laryngoscopy and

intubation. Journal of Dr.NTR Univ of Health Sciences.

2015;4(2):86.

6. Khan A, Mahtalath B, Sirajuddin MD. Attenuation of

cardiovascular responses to laryngoscopy and

intubation dexmedetomidine vs. magnesium sulfate.

Journal of Evidence Based Medicine and Healthcare.

2017;(4):495-98.

70

Narayana Medical Journal Volume-8 | Issue-2 | July - December 2019

7. Jain D, Khan R, Maroof M. Effect of dexmedetomidine

on stress response to extubation. Internet J Anesthesiol.

2008; 21:1.

8. Chaitanya K, Vaddineni J, Reddy PN. A comparative

study between IV 50%MgS04 and Dexmed for

attenuation of stress response during laryngoscopy and

intubation- jemds/2014/3116.

9. King BD, Harris LC, Greifenstein FE, Elder JD, Dripps

RD. Reflex circulatory responses to direct

laryngoscopy and tracheal intubation performed during

general anaesthesia. Anesthesiol 1951;12:556-66.

10. Fox EJ, Sklar GS, Hill CH, et al. Complications related

to pressor response to endotracheal intubation.

Anaesthesiology 1977; 47: 524-25.

11. Splinter WM, Cervenko F. Haemodynamic responses

to laryngoscopy and tracheal intubation in geriatric

patients: Effects of fentanyl, lidocaine and thiopentone.

Can J Anaesth. 1989;36:370-6.

12. lseri LT, French JH. Magnesium: Nature's physiologic

calcium blocker. Am Heart J 1984; 108: 18 & 93.

13. James MF, Beer RE, Esser JD. Intravenous magnesium

sulfate inhibits catecholamine release associated with

tracheal intubation. Anesth Analg.1989; 68:772- 6.

14. Singh R, Analgesic effect of pre-op dexamethasone in

gynecological laprotomies- a dose ranging study-

women's medical college, Toronto, Canada (Personal

communication).

15. Razavizadeh, Fazel, Heydarian, Atoof F. Epidural

Dexamethasone for postoperative analgesia in patients

undergoing unilateral inguinal herniorraphy. Pain Res

Manag.2017;2017:7649458.

16. Aantaa R, Kanto J, Scheinin M. Dexmedetomidine,

an alpha 2-adrenoceptor agonist, reduces anesthetic

requirements for patients undergoing minor

gynecologic surgery. Anesthesiology 1990; 73: 230-

35.

17. Smitha KS, Shukla D, Sathesha M, Rao R, Nethra S,

Sudhhesh K, et al. Comparison of two different doses

of dexmedetomidine in attenuating hemodynamic

changes during laryngoscopy. J Evol Med Dent Sci.

2014;3:13501-8

18. Sulhyan SR, Vagarali AT, Patil SS, Dixit MD. A

comparative clinical study of dexmedetomidine versus

placebo to attenuate hemodynamic response to

endotracheal intubation in patients undergoing off

pump coronary arterial bypass grafting. J Sci Soc.

2014;41:151-5.

19. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of

intravenous dexmedetomidine in humans. I. Sedation,

ventilation, and metabolic rate. Anesthesiology.

1992;77:1125-33.

20. Keniya VM, Ladi S, Naphade R. Dexmedetomidine

attenuates sympathoadrenal response to tracheal

intubation and reduces perioperative anaesthetic

requirement. Indian J Anaesth. 2011;55:352-7.

71