REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
SCIENTIFIC
ARTICLE
Comparison
of
the
effects
of
remifentanil
and
remifentanil
plus
lidocaine
on
intubation
conditions
in
intellectually
disabled
patients
夽
Can
Eyigor,
Esra
Cagiran
∗,
Taner
Balcioglu,
Meltem
Uyar
DepartmentofAnaesthesiology,FacultyofMedicine,EgeUniversity,Izmir,Turkey
Received1March2012;accepted22March2013 Availableonline7November2013
KEYWORDS
Remifentanil; Lidocaine; Endotracheal intubation; Without neuromuscular blockade
Abstract
Backgroundandobjectives: Thisisaprospective,randomized,single-blindstudy.Weaimedto compare thetrachealintubationconditionsandhemodynamicresponseseither remifentanil oracombinationofremifentanilandlidocainewithsevofluraneinduction intheabsenceof neuromuscularblockingagents.
Methods:Fiftyintellectuallydisabled,AmericanSocietyofAnesthesiologistsI---IIpatientswho underwenttoothextractionunderoutpatientgeneralanesthesiawereincludedinthisstudy. Patientswererandomizedtoreceiveeither2gkg−1remifentanil(Group1,n=25)ora
combi-nationof2gkg−1remifentaniland1mgkg−1lidocaine(Group2,n=25).Toevaluateintubation
conditions,Helbo-Hansenscoringsystemwasused.Inpatientswhoscored2pointsorlessin allscorings,intubationconditionswereconsideredacceptable,howeverifanyofthescores wasgreaterthan2,intubationconditionswereregardedunacceptable.Meanarterialpressure, heart rateandperipheraloxygen saturation(SpO2)wererecorded atbaseline,afteropioid
administration,beforeintubation,andat1,3,and5minafterintubation.
Results:Acceptableintubationparameterswereachievedin24patientsinGroup1(96%)and in23patientsinGroup2(92%).Inintra-groupcomparisons,theheartrateandmeanarterial pressurevaluesatall-timepointsinbothgroupsshowedasignificantdecreasecompared to baselinevalues(p=0.000)
Conclusion: Bytheadditionof2g/kgremifentanilduringsevofluraneinduction,successful
trachealintubationcanbeaccomplishedwithoutusingmusclerelaxantsinintellectually dis-abled patientswhoundergooutpatientdentalextraction. Alsoworthnoting, theadditionof 1mg/kglidocaineto2g/kgremifentanildoesnotprovideanyadditionalimprovementinthe
intubationparameters.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
夽 ThestudywasconductedinDepartmentofAnaesthesiology,FacultyofMedicine,EgeUniversity. ∗Correspondingauthor.
E-mail:[email protected](E.Cagiran).
0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE
Remifentanil; Lidocaína; Intubac¸ão endotraqueal; Sembloqueio neuromuscular
Comparac¸ãodosefeitosderemifentanileremifentanil+lidocaínaemintubac¸ãode pacientesintelectualmentedeficientes
Resumo
Justificativaeobjetivos: Esteéumestudoprospectivo,randômicoeduplo-cego.Nosso obje-tivofoicompararascondic¸õesdeintubac¸ãoendotraquealeasrespostashemodinâmicascom ousoderemifentaniloucombinac¸ãoderemifentanilelidocaínaeminduc¸ãoanestésicacom sevofluranosemagentesbloqueadoresneuromusculares.
Métodos: Cinquentapacientesintelectualmente deficientes,estadofísico ASAI---II, submeti-dos àextrac¸ão dentária sob anestesiageral em ambulatório foram incluídos nesteestudo. Os pacientesforam randomizados para receber 2gkg−1 de remifentanil (Grupo 1, n=25)
ouumacombinac¸ãode2gkg−1deremifentanile1mgkg−1delidocaína (Grupo2, n=25).
Paraavaliarascondic¸õesdeintubac¸ão,osistemadepontuac¸ãodeHelbo-Hansen foiusado. Em pacientescom 2ou menos pontos em todasas pontuac¸ões, as condic¸õesde intubac¸ão foramconsideradasaceitáveis,porém,sequalquerumadaspontuac¸õesfossesuperiora2,as condic¸õesdeintubac¸ãoseriamconsideradasinaceitáveis.Pressãoarterialmédia,frequência cardíacaesaturac¸ãoperiféricadeoxigênio(SpO2)foramregistradasnoiníciodoestudo,após
aadministrac¸ãodeopiáceos,antesdaintubac¸ãoenosminutos1,3e5apósaintubac¸ão.
Resultados: Parâmetrosaceitáveis deintubac¸ão foramobtidosem 24pacientesdo Grupo1 (96%)eem23pacientesdoGrupo2(92%).Nascomparac¸õesintragrupo,osvaloresdafrequência cardíacaepressãoarterialmédiaemtodososmomentodemambososgruposmostraramuma reduc¸ãosignificativaemrelac¸ãoaosvaloresbasais(p=0.000).
Conclusão:Comaadic¸ãoderemifentanil(2g/kg)duranteainduc¸ãocomsevoflurano,pode-se
obterintubac¸ãoendotraquealbem-sucedidasemousoderelaxantesmuscularesempacientes intelectualmentedeficientesquesesubmetemàextrac¸ãodentáriaemambulatório.Também édignodenotaqueaadic¸ãodelidocaína(1mg/kg)aremifentanil(2g/kg)não apresenta
qualquermelhoraadicionaldosparâmetrosdeintubac¸ão.
©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Trachealintubationisusuallyfacilitatedwithamuscle relax-ant that is administered following anesthesia induction. During intubation, anesthesia should be deep enough to inhibitthe reflexactivityand complete musclerelaxation shouldbeaccomplished.1Theuseofhypnoticsandopioids
atinductiondosescanbesufficientfortrachealintubation withouttheneedformusclerelaxants,whereuseofa mus-clerelaxantisnotpreferredasisthecasefordaysurgery patients,short surgical procedures,motor neurondisease anddrugallergy.2,3
Trachealintubation withoutmusclerelaxantsmaybea life-savingmeasuretomaintainspontaneousrespirationin patients with difficult airways. According to the previous medicalliterature, intubation can becarried out without theuseofamusclerelaxant.4---6Sevoflurane,anonirritating
inhalationalanestheticagentwithlowblood/gassolubility, has also been used for intubation without neuromuscu-lar blocking agents, either alone or in combination with remifentanil.7,8
In addition,one may improve tracheal intubating con-ditions through the use of additional drugs, such as remifentanilandlidocaine, whichmay potentiate depres-sionofthelaryngealreflexes.4,9
The aim of the present study was to compare the effectsofremifentanilandremifentanilpluslidocaineusing sevofluraneinductionwithoutmusclerelaxantsontracheal
intubating conditions in intellectually disabled patients admittedforoutpatientdentaltreatment.
Materials
and
methods
Thepresent studywasdesignedasaprospective, random-ized, and single-blind study. The study was approved by theethicscommittee,andwritteninformedconsentswere obtainedfromtheparentsandguardiansofthepatients.
Fifty intellectually disabled American Society of Anes-thesiologists(ASA)IandIIpatients,whowerescheduledfor dentalsurgeryrequiringgeneralanesthesia,wereincluded inthestudy.PatientswithASAphysicalstatusIIIorhigher, an expectance of difficult intubation, limited head and neckmovement,reactiveairwaydisease,gastroesophageal reflux, renal or hepatic impairment, allergies to any of thestudydrugswereexcludedfromthestudy.Mallampati classification10ofairwayanatomyhigherthanclassII,mouth
opening<3cm,sternomentaldistance<12.5cm,tiromental distance<6cm,Cormack---Lehaneclassification11higherthan
gradeII,andbodymassindex≥3012wereconsideredasthe
indicatorsofdifficultintubation.
Table1 Intubatingconditionscoresa
1 2 3 4
Jawrelaxation Complete Slighttone Stiff Rigid
Laryngoscopy Easy Fair Difficult Impossible
Vocalcords Open Moving Closing Closed
Coughing None Slight Moderate Severe
Limbmovement None Slight Moderate Severe
a DevisedbyHelbo-HansenRauloandTrap-Andersen.
4% sevoflurane in 100% O2. Then,anesthesia wasinduced using this mask for 2min, where a fresh flow of gas at 5Lmin−1wassuppliedtothecircuit.Onceanadequatelevel of anesthesiawas achieved, an intravenous (IV) line was establishedand0.01mgkg−1atropinewasgiven.After base-line measurements, thepatients wererandomly allocated tooneoftwogroupsonthebasisofacomputer-generated randomtable.PatientsinGroup1(n=25)received2gkg−1 remifentanil+5mLsalinewhereasGroup2(n=25)received 2gkg−1 remifentanil+1mgkg−1 lidocaine. Tracheal intu-bationwasperformed90safterremifentaniladministration by a single, experienced anesthesiologist. Intubation was performed and assessed by an anesthesiologist who was blindedtotheremifentanildoseused.
Thequalityofintubationwasgradedbyanindependent anesthesiologistusingthescoringsystemdevisedby Helbo-HansenRauloandTrap-Andersen13(Table1).
• Easeoflaryngoscopy
• Positionofvocalcords
• Degreeofcoughing
• Jawrelaxation
• Limbmovement
Intubating conditions were deemed acceptable if a patienthad≤2 pointsin allcategories orunacceptable if thepatienthad>2pointsinanysinglecategory.
Mean arterial pressure (MAP), heart rate (HR) and peripheraloxygensaturation(SpO2)wererecordedat base-line, after opioid administration, before intubation, and at 1,3, and5min following intubation.Side effects asso-ciated with remifentanil use including muscle rigidity, hypotension, bradycardia and arterial oxygen desatura-tion below 91% were recorded and treated accordingly. Hypotension (MAP<25% frombaseline) wasmanaged with 5---10mg ephedrine IVand bradycardia (HR<50 beat/min) wastreatedwith0.5mgatropine.
Statistical
analysis
Statistical analysis was performed with the Statistical PackagefortheSocialSciences(SPSS)forWindows(version 13.0;SPSSInc.,Chicago,IL,USA).Descriptivestatisticswere expressedasmean.Variableswithnormaldistributionwere analyzedusingtheStudent’st-testwhilenon-normally dis-tributed variableswere analyzedusing theMann---Whitney rank sum test. Categorical data were analyzed using the Fisher’sexacttest.Hemodynamicresponseswereanalyzed
Table2 Patientcharacteristics.
Group1a Group2a
Age(years) 17.88±7.1 21.20±7.1 Weight(kg) 50.44±18.1 58.76±12.5
Gender(M/F) 13/12 11/14
a Valuesarepresentedasmean±SD.
usingtherepeatedmeasuresanalysisofvariance(ANOVA). Avaluep<0.05wasconsideredstatisticallysignificant.
Results
Each group contained 25 patients. Demographic variables weresimilarinbothgroups(p>0.05)(Table2).
AccordingtotheHelbo-Hansenscoringsystem,therewas nosignificantdifferencebetweenthegroupsintermsofjaw relaxation(p=0.57),easeoflaryngoscope(p=0.31),vocal cordposition(p=0.09), degree of coughing (p=0.14) and limbmovement(p=0.42).OnepatientinGroup1scored3 pointsforjawrelaxation.OnepatientinGroup2scored4 pointsfor jaw relaxation and 3 pointsfor theposition of vocalcords,whileanotherpatientscored3pointsforvocal cordposition.
Intubationwassuccessfulinallpatients,andnofurther interventionwasnecessary.AccordingtotheHelbo-Hansen scoring system, acceptable intubating conditions were achievedin 24 patients in Group 1 (96%) and 23 patients inGroup2(92%)(Fig.1).
25
20
15
10
5
0
Numv
er of patients
Groups
1 2
Unacceptable Acceptable
140
120
100
80
60
40
20
0
Baseline Following opiate administration
Before intubation
1 min following intubation
Group 1
*
*
*
*
*
*
*
*
*
*
Group 2
3 min following intubation
5 min following intubation
Figure2 Mean(SD)changesinheartrate(HR),observations:baseline;followingopiateadministration;beforeintubation;1,3, 5minfollowingintubation.*p=0.000comparedwithbaselinevalue.
ThemeanbasalHRwas107.84±19.2/mininGroup1and 100.72±16.2/mininGroup2,andtherewasnosignificant differencebetweenthegroups(p=0.16).TheMAPat base-linewassignificantly lowerinGroup 2than thatin Group 1(p=0.002).In intra-groupcomparisons, theHRandMAP valuesatall-timepointsinbothgroupsshowedasignificant decreasecomparedtobaselinevalues(p=0.000).
Cardiovascularresponsestoinductionandintubationare showninFigs.2and3.
No patient had clinically significant bradycardia, hypotension, rigidityor hypoxemia.However,1 patientin Group2developedlaryngealspasmforashorttime.
Discussion
In the present study, we found that, when used with sevoflurane, both remifentanil and remifentanil lidocaine combination secured acceptable intubating conditions in mentally retarded patients undergoing outpatient dental treatmentwhenmusclerelaxantswerenotusedduring intu-bation.
The riskof an unexpectedlydifficult intubation is con-siderably higher in mentally retarded patients due to inadequateairwayexamination beforeanesthesiaandthe presenceofpossibleanatomicaldeformities.14Machottaand
100
80
60
40
30
20
10
0
Baseline Following opiate administration
Before intubation
1 min following intubation
Group 1
*
+
*
*
*
*
*
*
*
*
*
Group 2
3 min following intubation
5 min following intubation 50
90
70
Hoeve15 successfullyperformed intubationwithout muscle
relaxants using sevoflurane and remifentanil in mentally retardedchildrenwithMarshall---Smithsyndrome.Similarly, Nakazawaandcoworkers16presentedan11-year-oldpatient
with Down’s syndrome to whom they successfully per-formedtrachealintubationwithoutusingamusclerelaxant despite the risk of a difficult intubation estimated during pre-anesthesia examination. In the present study,we did notencounter difficultintubatingconditionsin anyof our mentallyretardedcasesandallpatientsweresuccessfully intubated.
The improvement in intubating conditions, in case of remifentaniluseincombinationwithsevofluraneinduction without neuromuscularblockingdrugs,maybedue tothe analgesic effectsofthesedrugs.4,6 Crosetal.17 suggested
thatopioidsmight blockafferentnerveimpulsesresulting fromstimulation of the pharynx, larynx and trachea dur-ingintubationandcuffinflation.InastudybyJooetal.,7
theauthorsreportedgoodtooptimalconditionsfortracheal intubationin89%and100%oftheirpatientswhen1gkg−1 and2gkg−1remifentanil,respectively,wasused.Intheir study,whereWeberetal.18 used1
gkg−1 ofremifentanil with4%end-tidalsevofluraneconcentration,allofthe chil-dren included in the study had acceptable (excellent or good)intubatingconditions.Woodsetal.19,20achievedgood
oridealintubatingconditionsin80---90%ofthepatientswith 2gkg−1ofremifentanil.Inagreementwiththeliterature, weachievedacceptable(excellentorgood)intubating con-ditionsin96%ofthepatientsinGroup 1andin92%ofthe patientsinGroup2,whenweused2gkg−1ofremifentanil with4%sevofluranewithout amusclerelaxant for intuba-tion.Intubationwascompletedsuccessfullyinallpatients withouttheneedforanyotherintervention.
The useofremifentanilfortrachealintubationwithout musclerelaxants,hasbeenreportedtocausehypotension, in many studies.16,21 Batra et al.21 observed hypotension
with 2gkg−1 and 3gkg−1 of remifentanil administra-tion. Similar results were reported by Joo et al.7 with
2gkg−1 of remifentanil. However, in both studies low bloodpressurevalueswerewithintheclinicallyacceptable rangeanddidnotrequiretreatment.Inthepresentstudy, in agreement with the literature, hypotension developed after2gkg−1ofremifentanil,butbloodpressure measure-mentswerewithinclinicallyacceptablelimitsandnoneof the patients needed treatment. Lidocaineis known tobe involvedinthesuppressionofairwayreflexes.While numer-ousstudiesreportedimprovementinintubatingconditions withlidocaine,9,22,23 therearealsostudieswithconflicting
results.24,25Munhollandandcolleagues24designeda
double-blind study to compare the intubating conditions with 2.5mgkg−1ofpropofolorasimilarvolumeofisotonicsaline after intravenous lignocaine pretreatment, and found no significantdifferencebetweenthegroups. Similarfindings wereobservedinastudybyGrangeetal.25 whoalsofound
nosignificantdifferencebetweentheeffectsoflignocaine andalfentanilpre-treatmentonorotrachealintubation con-ditions followinginduction withpropofol,but without the useofmusclerelaxants.Severalstudiesalsoexaminedthe effectivenessofintravenouslidocainetosuppressthecough reflex.26,27Inourstudy,lidocaineofferednoadditional
ben-efit on cough reflex. In our study, lidocaine, when given withremifentanil,didnotimprovethetrachealintubating
conditionswhenamusclerelaxantwasnotused.Most plau-sibleexplanationofthefailureoflidocainetoimprovethe intubatingconditionsmaybethefactthatacceptable intu-batingconditions were achievedin ashigh as 96% of the patients,evenwhenonlyremifentanilwasused.
In conclusion, we found that both remifentanil and remifentanil+lidocaine under sevoflurane induction pro-videdacceptableintubatingconditionsinmentallyretarded patientswhohadoutpatientdentalextractionwhena mus-clerelaxantwasnotusedduringintubation.Inourfaculty ofdentistry,therateof mentallyretardedpatients isless thanthat ofthe generalpopulation. Thus,the numberof patientswaslimitedinthepresentstudy.Thepresentstudy mayconstituteanexampleofthedesignoffurtherstudies withhigherpatientnumbers.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Glass PS, Gan TJ, Howell S. A review of the pharmacoki-neticsand pharmacodynamics ofremifentanil.AnesthAnalg. 1999;89:7---14.
2.Stevens JB,Wheatley LD. Tracheal intubation inambulatory surgerypatients:usingremifentanilandpropofolwithout mus-clerelaxants.AnesthAnalg.1998;86:45---9.
3.KavacL.Controllingthehemodynamicresponsetolaryngoscopy andendotrachealintubation.JClinAnesth.1996;8:63---79. 4.Min SK, Kwak YL, Park SY, et al. The optimal dose of
remifentanilforintubationduringsevofluraneinduction with-outneuromuscularblockadeinchildren.Anaesthesia.2007;62: 446---50.
5.IthninF,LimY,Shah M,etal.Trachealintubatingconditions using propofol and remifentanil target-controlled infusion: a comparisonofremifentanilEC50forGlidescopeandMacintosh. EurJAnaesthesiol.2009;26:223---8.
6.He L, Wang X, Zhang XF, et al. Effects of different doses of remifentanil on the end-tidal concentration of sevoflu-ranerequiredfortrachealintubationinchildren.Anaesthesia. 2009;64:850---5.
7.Joo HS, Perks WJ, Belo SE. Sevoflurane with remifentanil allowsrapidtrachealintubationwithoutneuromuscular block-ingagents.CanJAnaesth.2001;48:646---50.
8.SztarkF,ChopinF,BonnetA,etal.Concentrationof remifen-tanilneededfortrachealintubationwithsevofluraneat1MAC inadultpatients.EurJAnaesthesiol.2005;22:919---24. 9.AouadMT,SayyidSS,ZalaketMI,etal.Intravenouslidocaineas
adjuvanttosevofluraneanesthesiaforendotrachealintubation inchildren.AnesthAnalg.2003;96:1325---7.
10.Mallampati SR, Gatt SP, Gugino LD, et al. A clinicalsign to predictdifficulttrachealintubation:aprospectivestudy.Can AnaesthSocJ.1985;32:429---34.
11.Cormack RS. Cormack---Lehane classification revisited. Br J Anaesth.2010;105:867---8.
12.JuvınPH,LavautE,DupontH,etal.Difficulttrachealintubation ismorecommoninobesethaninleanpatients.AnesthAnalg. 2003;97:595---600.
13.Helbo-HansenS, Ravlo O, Trap-AndersenS. The influenceof alfentanilontheintubatingconditionafterprimingwith vecuro-nium.ActaAnaesthesiolScand.1988;32:41---4.
15.Machotta A, Hoeve H. Airway management and fiberop-tic tracheal intubation via the laryngeal mask in a child with Marshall---Smith syndrome. Paediatr Anaesth. 2008;18: 341---2.
16.NakazawaK,IkedaD,IshikawaS,etal.Acaseofdifficultairway duetolingualtonsillarhypertrophyinapatientwithDown’s syndrome.AnesthAnalg.2003;97:704---5.
17.CrosAM,Lopez C,Kandel T,etal. Determinationof sevoflu-rane alveolar concentration for tracheal intubation with remifentanil, and nomuscle relaxant.Anaesthesia. 2000;55: 965---9.
18.WeberF,FüsselU,GruberM,etal.Theuseofremifentanilfor intubationinpaediatricpatientsduringsevoflurane anaesthe-siaguidedbyBispectralIndex (BIS)monitoring.Anaesthesia. 2003;58:749---55.
19.WoodsAW,GrantS,HartenJ,etal.Trachealintubating condi-tionsafterinductionwithpropofol,remifentanilandlignocaine. EurJAnaesthesiol.1998;16:714---8.
20.WoodsA, Grant S,Davidson A. Durationofapnoeawithtwo differentintubatingdosesofremifentanil.EurJAnaesthesiol. 1999;16:634---7.
21.BatraYK,AlQattanAR,AliSS,etal.Assessmentoftracheal intu-batingconditionsinchildrenusingremifentanil and propofol withoutmusclerelaxant.PaediatrAnaesth.2004;14:452---6. 22.Warner LO, Balch DR, Davidson PJ. Is intravenous lidocaine
an effective adjuvant for endotracheal intubation in chil-drenundergoinginductionofanesthesiawithhalothanenitrous oxide?JClinAnesth.1997;9:270---4.
23.DavidsonJAH,GillespieJA.Trachealintubationafterinduction ofanaesthesiawithpropofol,alfentanilandIVlignocaine.BrJ Anaesth.1993;70:163---6.
24.Mulholland D, Carlisle RJ. Intubation with propofol aug-mented with intravenous lignocaine. Anaesthesia. 1991;46: 312---3.
25.GrangeCS,SureshD,MeikleR,etal.Intubationwithpropofol: evaluationofpretreatmentwithalfentanilorlignocaine.EurJ Anaesthesiol.1993;10:9---12.
26.Poulton TJ, James 3rd FM. Cough suppression by lidocaine. Anesthesiology.1979;50:470---2.
