REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
SCIENTIFIC
ARTICLE
Low
dose
propofol
vs.
lidocaine
for
relief
of
resistant
post-extubation
laryngospasm
in
the
obstetric
patient
Ali
M.
Mokhtar
∗,
Ahmed
A.
Badawy
CairoUniversity,DepartmentofAnesthesia,Cairo,Egypt
Received1July2016;accepted31March2017 Availableonline2May2017
KEYWORDS Propofol; Lidocaine; Laryngospasm; Obstetric
Abstract
Background: Post-extubationlaryngospasmisadangerouscomplicationthatshouldbemanaged promptly.Standardmeasuresweredescribedforitsmanagement.Weaimedtocomparethe efficacyofpropofol(0.5mg.kg−1)vs.lidocaine(1.5mg.kg−1)fortreatmentofresistant post-extubationlaryngospasmintheobstetricpatients,afterfailureofthestandardmeasures.
Method: Thisstudywasconductedover2yearsonallobstetricpatientsscheduledforcesarean delivery.Post-extubationlaryngospasmwasinitiallymanagedwithastandardprotocol(removal ofoffendingstimulus,jawthrust,positivepressureventilationwith100%oxygen).Whenthis protocolfailed,thetesteddrugwasthesecondline(lidocaineinthefirstyearandpropofolin thesecondyear).Lastly,succinylcholinewasusedwhenthetesteddrugfailed.
Results:Inlidocainegroup,5%ofparturientsdevelopedpost-extubationlaryngospasm,31.9% ofthemweresuccessfullytreatedviastandardprotocol,and68.1%requiredlidocaine treat-ment.Amongthese,65.6%ofpatientstreatedwithlidocainerespondedsuccessfullyand34.4% requiredsuccinylcholinetorelievelaryngospasm.Inpropofolgroup,4.7%ofparturients devel-oped post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol,and69.9%requiredpropofoltreatment.Amongthese,82.8%ofpatientstreatedwith propofolrespondedsuccessfullyand17.2%requiredsuccinylcholinetorelievelaryngospasm.
Conclusion: Smalldoseofpropofol(0.5mg.kg−1)ismarginallymoreeffectivethanlidocaine (1.5mg.kg−1)forthetreatmentofresistantpost-extubationlaryngospasminobstetricpatients, afterfailureofstandardmeasuresandbeforetheuseofmusclerelaxants.
©2017SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:[email protected](A.M.Mokhtar).
https://doi.org/10.1016/j.bjane.2017.03.003
PALAVRAS-CHAVE Propofol;
Lidocaína; Laringoespasmo; Obstetrícia
Dosebaixadepropofolversuslidocaínaparaalíviodelaringoespasmoresistente
pós-extubac¸ãoempacienteobstétrica
Resumo
Justificativa:O laringoespasmo pós-extubac¸ão é uma complicac¸ão perigosa que deve ser prontamentetratada.Medidaspadrãopara oseumanejoforamdescritas. Onossoobjetivo foicompararaeficáciadepropofol(0,5mg.kg−1)versuslidocaína(1,5mg.kg−1)notratamento delaringoespasmoresistentepós-extubac¸ãoempacientesobstétricasapósfalhadasmedidas padrão.
Método: Esteestudofoiconduzidoaolongodedoisanoscomtodasaspacientesobstétricas programadasparacesariana.Olaringoespasmopós-extubac¸ãofoiinicialmentetratadocomum protocolopadrão(remoc¸ãodoestímuloofensivo,protrusãomandibular,ventilac¸ãocompressão positivacomoxigênioa100%).Aoconstatarafalhadesseprotocolo,ofármacotestadofoia segundaopc¸ão(lidocaínanoprimeiroanoepropofolnosegundoano).Porfim,succinilcolina foiutilizadaquandohouvefalhadofármacotestado.
Resultados: No grupo lidocaína, 5% das parturientes desenvolveram laringoespasmo pós-extubac¸ão,31,9%delasforamtratadascomsucessoviaprotocolopadrãoe68,1%precisaram de tratamentocom lidocaína. Destas, 65,6% responderam comsucesso ao tratamentocom lidocaínae34,4%precisaramdesuccinilcolinaparaalíviodolaringoespasmo.Nogrupo propo-fol,4,7%dasparturientes desenvolveramlaringoespasmo pós-extubac¸ão,30,1%delasforam tratadascomsucesso viaprotocolopadrãoe69,9%precisaramdetratamentocompropofol. Destas,82,8%responderamcomsucessoaotratamentocompropofole17,2%precisaramde succinilcolinaparaalíviodolaringoespasmo.
Conclusão:Umapequenadosedepropofol(0,5mg.kg−1)émarginalmentemaiseficazque lido-caína(1,5mg.kg−1)notratamentodelaringoespasmoresistentepós-extubac¸ãoempacientes obstétricas,apósfalhadasmedidaspadrãoeantesdousoderelaxantesmusculares.
©2017SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Post-extubationlaryngospasmaccountsfor23%ofallcritical postoperativerespiratoryconsequencesinadults.1Itmaybe
causedbysecretions,vomitus,foreignbodyintheairway,
or painat the siteof surgery.2 Itis considered as a
tran-sientperiodofexaggeratedupperairwaydefensivereflex;
duetolaryngealhyperexcitabilityduringtherecoverytime
ofgeneralanesthesia.3Itisadangerouscomplicationthat
mayleadtohypoxiaorNegativePressurePulmonaryEdema
(NPPE).4,5
Somestudieslistedlaryngospasmasananestheticcause
of obstetric mortality.6,7 Fodale et al. described a case
series of three parturients suffered from post-extubation
laryngospasm.8 The anatomical changes associated with
pregnancy,suchaspharyngealedema ornasalcongestion,
couldworsenthesituationduringlaryngospasm,9withmore
riskonthepatient’slife.Therefore,laryngospasmmustbe
treatedimmediately.
Standardmeasures describedformanagementof
laryn-gospasmstartedwithremovaloftheoffendingstimulus,jaw
thrust,andpositiveairway pressureventilationwith100%
oxygenbybagandmask.10Anothertechniquewasdescribed
by applyingfirm pressure at a laryngospasm point, which
liesbehindtheearlobe,betweenthemastoidprocessand
theramusofthemandible.11 Whenthesemeasuresfail,a
smalldose(0.1mg.kg−1)ofintravenous(iv)succinylcholine
isused.12 Somestudiessuggestedtheuseofintramuscular
succinylcholineinabsenceofvenousaccess.13 Other
stud-iesdescribedthe useoftopicalor ivlidocaine14,15;or the
administrationofivnitroglycerine.16
Theuseofsmalldoseofpropofol(0.25---0.8mg.kg−1)have
been suggestedfortreatmentof resistantlaryngospasmin
pediatric patients,17 because of its depressive effect on
laryngeal reflexes.18 Other studies tried a small dose of
propofol(0.5mg.kg−1)forresistantlaryngospasmin
obstet-ricanesthesia.8
Theaimofthiswork wastocomparetheeffectiveness
of a smalldose of propofol(0.5mg.kg−1) versus lidocaine
(1.5mg.kg−1) for treatment of resistant post-extubation
laryngospasm in obstetric patients, after failure of the
standardmeasuresandbeforetheuseofmusclerelaxants.
Methods
After approval of our institutional ethical committee and
informed consents of participants, this prospective study
was conducted over a period of two years starting from
March2014,onallparturientsofASAclassIorII,whowere
scheduled forcesarean deliveryundergeneralanesthesia.
Patientswereallocatedintotwogroupsinasequential
lungdiseases,chronicsmoking,orchronicexposureto smok-ers,dustorfumes.
All patients were anesthetized by the same team of
expert anesthesiologists, and with the same technique
including;premedicationwithintravenousranitidine50mg
with metoclopramide 10mg, airway evaluation for
possi-bledifficultintubation,andpre-oxygenationwith100%O2.
Anesthesia wasthen induced withpropofol 2mg.kg−1 and
suxamethonium1.5mg.kg−1.Sellick’smaneuverwasapplied
until tracheal intubation was achieved. Anesthesia was
maintainedwithisofluranein100%oxygenandatracurium
0.5mg.kg−1aftersuccinylcholineeffectfaded.After
deliv-ery, fentanyl 2g.kg−1 and oxytocin 20 units were given.
Atropine0.02mg.kg−1 andneostigmine 0.05mg.kg−1 were
used for reversal of neuromuscular block under
train-of-fourmonitoring.Extubationweredonewhenthepatientwas
fullyawake,afterpropersuctioningoftheupperairway.
The laryngospasm caseswere treated accordingto the
Anesthesia Department protocol and is not changed from
case tocase. Thus, we studied the cases in a sequential
manner.
All patients who developed post-extubation
laryn-gospasmthroughoutthetwoyearsofourstudywereinitially
managedwithastandardprotocolconsistsof:removalofthe
offendingstimulus(oropharyngealsuctioningofsecretions),
jawthrust,gentlepositiveairwaypressureventilationwith
100% oxygen by bag and mask.10,11 If the spasm was not
relievedbyoneminute (asdenotedonthewallclock),or
oxygensaturationdecreasedbelow93%,oritrecurredagain
afteritwasrelieved,weconsidereditasaresistantcaseand
addedthetesteddrugtothemanagementprotocol.Inthe
firstyear,wegaveadoseofivlidocaine(1.5mg.kg−1)and
consideredthecasesaslidocainegroup(I),whileinthe
sec-ond yearwe gavea dose of iv propofol(0.5mg.kg−1) and
consideredthecasesaspropofolgroup(II).Inbothgroups,
again, if the spasm was not relieved and oxygen
satura-tiondroppedto85%, wegaveadose ofiv succinylcholine
(0.5mg.kg−1)torelievethespasmandrestoreventilation.
Thestudieddrugandsuccinylcholinewereroutinelydrawn
upbeforeextubation,andtheirdoseswerecalculatedbased
onbodyweightinearlypregnancy.
Inbothgroups;thetotalnumberofparturientsenrolled
in the study, the number of cases who developed
laryn-gospasm, those who were successfully treated with the
standardprotocol, otherswhorequiredthetesteddrugto
relievethespasm,andthosewhorequiredsuccinylcholineto
relievethespasm,andtheincidenceofcomplications
(gas-tric distension, aspiration, NPPE, arrhythmias, or cardiac
arrest)wererecorded.
Statisticalanalysis
Theperiodofrecruitingcaseswasbasedontheincidence
oflaryngealspasminourdepartmentdatabase,aimingto
recruitatleast38casesineachstudygroup.Weassumedan objectiveofdoublingtheinitialsuccessratetotreat
laryn-gealspasmfrom35%17 to70%beforeusingsuccinylcholine,
withthe˛valuewas0.05andthepower(1−ˇ)ofthestudy
was0.80.
Data were analyzed using the SPSS statistics program
(Version16,SPSSInc.,Chicago,IL,USA).Accordingtothe
typeofdatatheywererepresentedasmeanandstandard
deviation(mean±SD)orfrequenciesandpercentages.
Com-parisonsof thetwo studied groups were performed using
eitherStudentt-test or Mann---WhitneyUtest.In alltests results were considered statistically significant if p-value waslessthan0.05.
Results
Duringthestudyperiod,1837outof2043pregnantwomen
whounderwent cesarean delivery under general
anesthe-siaacceptedtoparticipateinthestudy,aging18---42years.
942patients were done duringthe first yearof the study
andtheyrepresentedthelidocainegroup(I),and895were
doneduringthesecondyearandrepresentedthepropofol
group(II). A total numberof 89 patients developed
post-extubationlaryngospasmandconsequentlywereenteredin
thetrial:47patientsinthelidocainegroup(I)and42inthe propofolgroup(II),asshowninTable1.
Inlidocainegroup(I),15/47patients(31.9%)were
suc-cessfullytreatedvia standardprotocol,andtheremaining
32 patients required lidocaine treatment. 21/32 patients
(65.6%) responded to lidocaine successfully and 11/32
patients(34.4%) required succinylcholinetorelieve
laryn-gospasm.
Inpropofolgroup(II),13/42patients(30.1%)were
suc-cessfullytreatedvia standardprotocol,andtheremaining
29 patients required propofol treatment. 24/29 patients
(82.8%)respondedtopropofolsuccessfullyand5/29patients
(17.2%)requiredsuccinylcholinetorelievelaryngospasm.
Thenumberofpatientswhodevelopedpost-extubation
laryngospasmwas comparable in the twostudied groups.
Alsothe numberofthosewastreatedsuccessfullyvia the
standard protocol showed no statistically significant
dif-ference between the two groups. Yet, the percentage of
patientssuccessfullytreatedbypropofolwithouttheneed
forsuccinylcholinewasstatisticallysignificanthigherthan
thenumberofthosetreatedbylidocaine.Nocomplications
wererecordedinbothgroups,asshowninTable2.
Discussion
Theresultsofthisstudyshowedthattheincidenceof
laryn-gospasmafterextubationinparturientsunderwentcesarean
sectionunder generalanesthesia waslessthan 5%. These
resultsareinagreementwiththeresultsofthestudydoneby
Afshanetal.,whofoundthattheincidenceoflaryngospasm
was3%outof725pediatric patientsoperatedfor inguinal
hernia,orchidopexyandhydroceleundergeneralanesthesia
usingLaryngealMaskAirway(LMA),17 andtheincidencein
thestudydonebyPaketal.,whichshowedthat8.6%of
pedi-atricpatientssubmittedforstrabismusandinguinalhernia
repairsurgeryundergeneralanesthesiawithendotracheal
intubation developed post-emergence laryngospasm.19 In
contrast,theincidenceoflaryngospasminthepresentstudy
wasmuchlowerthanthatinthestudydonebyLeichtetal.
(22%),20 and in the control group of the study done by
Batraetal.(20%).21Thishigherincidenceofpost-extubation
laryngospasmin these twostudies couldbe explained by
thesiteandthetypeoftheoperation(tonsillectomyinthe
Table1 Patientcharacteristicsandnumberofpatientsdevelopedlaryngospasm.
Group(I)lidocaine (n=942)
Group(II)propofol (n=895)
p-Value
Age(years) 28±8 30±6 0.242
ASAstatusI:II 533:409 498:397 0.253
Numberofpatientsdevelopedlaryngospasm 47(5%) 42(4.7%) 0.371
Datarepresentedasmean±SD,ratio,numberofpatientsandpercentage(%). Nostatisticallysignificantdifferencesbetweenthetwogroups.
Table2 Numberofpatientstreatedsuccessfullyviastandardprotocol,examineddrugandsuccinylcholine.
Group(I)lidocaine (n=942)
Group(II)propofol (n=895)
p-Value
Numberofpatientssuccessfullytreatedviastandardprotocol 15/47(31.9%) 13/42(30.1%) 0.433 Numberofpatientssuccessfullytreatedbyexamineddrug 21/32(65.6%) 24/29(82.8%)a 0.041
Numberofpatientsrequiredsuccinylcholine 11/32(34.4%) 5/29(17.2%)a 0.033
Datarepresentedasnumber&ratioandpercentage(%).
aStatisticallysignificantcomparedtogroup(I),p<0.05.
The results of the present study alsoshowed that the
number of patients successfully treated via the standard
protocol (oropharyngeal suctioning of secretions, jaw
thrust,gentlepositiveairwaypressureventilationwith100%
oxygenbybagandmask,andapplyingoffirmpressureata
laryngospasmpoint)wascomparablebetweenthetwo
stud-iedgroups,(31.9%and31%inlidocaineandpropofolgroups
respectively). These results were in agreement with the
resultsofthestudydonebyAfshanetal.,whichshowedthat 35%ofcasesweresuccessfullytreatedwithpositivepressure ventilationviafacemask,17andalsoinagreementwiththe
standard-practicegroupofthestudydoneAl-Metwallietal. (38.4%).22
Regardingthepatientsnecessitatedtheuseofthe
stud-ied drugs, the number of patients successfully treated
withpropofolwasstatisticallysignificanthigherthanthose successfullytreatedwithlidocaine(82.7%and65.6%
respec-tively). These results are in accordance with the results
of the study done by Afshan et al., which showed that
propofol(0.8mg.kg−1)successfullyrelievedlaryngospasmin
76.9% of cases.17 Again, the results of the present study
were supported by the results of the study done by Pak
etal., whoshowedthat nocase ofpost-extubation
laryn-gospasmreported withthe use of small dose of propofol
(0.25mg.kg−1)onemergencefromanesthesiacomparedto
thecontrolgroup.19
Inthepresentstudy,althoughlidocainesuccessrateto
relievelaryngospasmwassignificantlylowerthanpropofol;
yet,itwasstilleffectivein65.6%ofcases.Thisisincontrast tothestudydonebyPernilleetal.,whichshowedno signif-icantroleof 1%lidocaine(0.15mL.kg−1)intheprevention
ofpost-extubationlaryngospasminchildren.20
Amainlimitationofourstudy wasthelack of
random-ization.Becauselaryngospasmisanemergencysituation,we
hadtofollowafixedprotocoloveraperiodoftime.Another
limitationwasthelackofacontrolgroup,becausewehad
comparedtheefficacyoftwodrugs,oneineachgroup.
How-ever, because theresults of ourstudy was promising, we
recommend todo furtherrandomizedand double-blinded
studies,toensuretheefficacyofthetesteddrugs.
In conclusion, small dose of propofol (0.5mg.kg−1) is
marginallymoreeffective thanlidocaine(1.5mg.kg−1)for
thetreatmentofresistantpost-extubationlaryngospasmin
obstetric patients, afterfailure of thestandard measures
andbeforetheuseofmusclerelaxants.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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