• Article highlight
  • Article tables
  • Article images

Article History

Received : 04-12-2020

Accepted : 14-12-2020

Available online : 01-06-2021



Article Metrics




Downlaod Files

   


Article Access statistics

Viewed: 46

PDF Downloaded: 21

Safneedha and Vishwanath: Dexmedetomidine versus Lignocaine for extubation in patients undergoing craniotomies


Introduction

Endotracheal intubation is an integral part of modern anesthesia techniques for major surgical procedures. Both intubation and extubation are associated with various cardiovascular and airway responses leading to tachycardia, hypertension, arrhythmias, myocardial ischemia, coughing, agitation, bronchospasm, increased bleeding, raised intracranial and intraocular pressure.1 These transitory changes are of little consequences in healthy patients going for general surgical procedures, but could be of major concern for the anesthesiologist in patients especially with intracerebral space occupying lesions (ICSOL), where a sudden hypertension during or in immediate post-extubation phase could lead to raised cerebral blood flow (CBF), intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP) resulting in increased intracranial bleeding, high morbidity and mortality.2

About 76-96% incidence of post-extubation coughing has been reported in the literature.1 Much attention has been paid to attenuate these changes during intubation when compared with extubation. Intratracheal local anaesthetic instillation,3 intracuff lignocaine,4 intravenous 2% lignocaine,5 prostaglandin-E16 and verapamil7 have been used to attenuate these haemodynamic and respiratory responses during extubation in the past but with certain limitations.

Recently dexmedetomidine, a potent α2-adrenoreceptor agonist has been used to facilitate extubation in surgical intensive care unit,8 but its role in the attenuation of hemodynamic and airway reflexes during extubation in general anesthesia is still scarce. A single dose of dexmedetomidine has been found effective in attenuation of the airway and circulatory reflexes during extubation.9 Avoidance of coughing during skull pin removal and during extubation is a desired prerequisite of every neurosurgical anesthetic.

Lignocaine (2%) has long been used to modulate unwanted airway and circulatory reflexes, via intravenous (IV) injection endotracheal cuff inflation, intratracheal (IT) instillation tube lubrication and aerosolized form.10, 11 However, IV 2% lignocaine is short acting.

Hence we decided to compare a bolus dose of dexmedetomidine 0.5mcg/kg/hr to a normal dose of 1.5mg/kg preservative free 2% lignocaine for extubation in patients undergoing craniotomies.

Materials and Methods

This randomized controlled trial was conducted in the department of Anesthesiology at Sri Ramachandra Medical College and Research Institute, Chennai from January 2013 to June 2014. Adult patients aged between 18-60 years belongs to ASA class I and class II undergoing surgeries were included in the study. Ischemic, congestive cardiac disease, renal, hepatic and respiratory dysfunction, hypersensitivity to both drugs, heart block, hypertension with beta blockers, patients on clonidine, methyl dopa, beta blocking drugs, anticonvulsants and psychotropic medications were excluded from the study. Sample size of 25 were determined by power analysis with a standard deviation of systolic blood pressure 6.18 and 6.76 with a power of 80% and alpha error of 5% from a previously published study. Thus a total of fifty cases were included in the study. Primary outcomes measured include heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and Mean arterial pressure (MAP). Secondary outcomes measured emergence time, extubation time, sedation score, pain score and hemodynamic and respiratory complications.

Patients were assigned to one of the two groups by lots (sealed envelope technique), either dexmedetomidine 0.50mcg/kg in 20ml normal saline (group D) administered bolus intravenous over 10 minutes during skin closure using an infusion pump or 2% lignocaine 1.5mg/kg in 20ml normal saline (group L) administered bolus intravenous over 60 seconds before reversal. All study drugs were prepared in identical 20 ml syringes in equal volume by an anesthesiologist who was part of the study but not involved in the anesthetic management of the patient. The attending anesthesiologist recording the data was also blinded to the study drug.

At the end of surgery group D received (syringe X) 0.50 mcg/kg dexmedetomidine with saline dilution in 20ml syringe over 10min during skin closure. Similarly group L received (syringe Y) 1.5mg/kg of preservative free 2% lignocaine over 60 seconds before reversal. Haemodynamic variables were noted before administering study drug (A0), then at one, five, ten and fifteen minutes after the administration of the study drug (A1, A5, A10, A15) and at zero, one, three, five, ten minutes (E0, E1, E3, E5, E10) after extubation respectively. The emergence and extubation time were also noted. Emergence time was defined as time interval between discontinuing of sevoflurane and patient obeying verbal commands post extubation.12 Extubation time was defined as the time interval between cessation of anaesthetics and tracheal extubation.12 Grading of cough was noted as a measure of extubation quality and recovery response.13

Statistical analysis was done using SPSS version 17. Student’s t test and Mann - Whitney U test were used to test the hypothesis, appropriately. Statistical significance was accepted at P<0.05.

Results

Mean age in group D and group L was found to be 40.64 ± 15.81 years and 42.64 ± 12.49 years, respectively (p=0.622). Also in group D there were 56% males and 44% females whereas in group l there were 48% males and 52% females. Mean weight in group D and group L was found to be 59.72 ± 11.67 kgs and 62.52 ± 5.93 kgs, respectively (p=0.290). Comparison of heart rate is shown in Table 1 andFigure 1 1 (SBP), Figure 2 (DBP) and Figure 3 (MAP).

Table 1

Comparison of Heart rate and MAP between groups

Heart rate (beats/min)

Group D

Group L

P value

A -0 minute

80.56 ± 11.90

88.16 ± 12.31

0.002*

A- 1 minute

79.80 ± 11.75

87.60 ± 13.35

0.033*

A-5 minutes

76.76 ± 12.80

86.28 ± 12.39

0.010*

A-10 minutes

72.65 ± 13.47

85.84 ± 12.26

0.001*

A-15 minutes

75.88 ± 23.92

86.50 ± 14.59

0.231

E-0 minute

94.36 ± 12.19

110.48 ± 14.91

0.001*

E-1 minute

94.93 ± 10.31

105.08 ± 11.39

0.002*

E-3 minutes

91.80 ± 11.26

98.88 ± 12.94

0.045*

E-5 minutes

88.88 ± 11.19

91.6 ± 11.99

0.411

E-10 minutes

87.04 ± 9.72

91.28 ± 11.80

0.171

On comparing the SBP at different times, E- 0 minutes, 1 minute, 3 minutes, 5 minutes and 10 minutes were found to have statistically significant difference between groups whereas in DBP A- 15 minutes, E- 0 minutes, 1 minute and 3 minutes were found to have statistically significant difference between groups.

Figure 1

Mean SBP at different time intervals in group G and group L

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/3fd15473-1521-48dc-bba1-271a7dcf7ddb/image/b6f2c4bb-eaf4-4344-a95f-18a6726fe98a-uimage.png

Figure 2

Mean DBP at different time intervals in group G and group L

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/19df09fb-f780-4f1e-b77a-a012b049c350image5.png

Figure 3

Mean MAP at different time intervals in group G and group L

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/19df09fb-f780-4f1e-b77a-a012b049c350image6.png

Comparison of mean grading of cough, sedation score and pain score were significantly low in group D compared to group L. (Table 2)

Table 2

Comparison of mean grading of cough, emergence and extrubation time

Variables

Group D

Group L

P value

Grade of Cough

1.88 ± 0.66

2.60 ± 0.577

0.001*

Emergence time (mins)

19.52 ± 5.29

20.72 ± 4.62

0.397

Extubation time (mins)

14.84 ± 5.44

14.60 ± 4.97

0.871

Sedation score

3.08 ± 0.86

4.72 ± 0.79

0.001*

Pain score

0.84 ± 1.10

2.48 ± 0.82

0.001*

Comparisons of hemodynamic parameters within the groups were shown in Table 3 and all the parameters showed statistically significant difference.

Table 3

Comparison of hemodynamic parameters-intra group

Variables

Group D

P value

Group L

P value

HR-A 0 minute

80.56 ± 11.90

0.001*

88.16 ± 12.31

0.001*

HR-E 0 minute

94.36 ± 12.19

110.46 ± 14.91

SBP-A 0 minute

117.08 ± 12.73

0.001*

113.36 ± 13.48

0.001*

SBP-E 0 minute

128.68 ± 10.23

151.12 ± 8.01

DBP-A 0 minute

75.00 ± 11.31

0.033*

73.24 ± 11.31

0.001*

DBP-E 0 minute

80.44 ± 7.62

96.68 ± 7.62

MAP-A 0 minute

90.24 ± 11.01

0.004*

85.92 ± 11.01

0.001*

MAP-E 0 minute

97.88 ± 4.634

115.32 ± 4.63

Discussion

Dexmedetomidine is useful in blunting hemodynamic responses in perioperative period. It is successfully used in intravenous doses varying from 0.25 to 1 mcg/kg for attenuating intubation response.14 Optimal dose for attenuating pressor response seems to be 1 mcg/kg with lesser doses not being effective.14 Doses in the range of 0.5 mcg/kg not only blunted the extubation response but also reduced the emergence reaction and analgesic requirement post extubation in neurosurgical procedures. There was no delay in recovery or prolonged sedation when boluses were administered before induction or before extubation. Similar was the observation when duration of infusion was within 2 hours.15 Bradycardia and hypotensions are the major side effects observed following dexmedetomidine infusion.16

Dexmedetomidine and preservative free 2% lignocaine have been found to be quite effective in attenuating the hemodynamic response to extubation as shown by previous studies.12, 13 In patients undergoing vascular surgery, dexmedetomidine (plasma concentrations in the range of 0.18 to 0.35 ng/ml) attenuated the increase in HR and plasma norepinephrine concentrations during emergence from anaesthesia.17 An infusion of dexmedetomidine started 20 minutes before anesthesia and continued until the start of skin closure in patients undergoing supratentorial brain tumor surgery was found to blunt tachycardic response to intubation and the hypertensive response to extubation.18 Dexmedetomidine 0.5 mcg/kg administered 10 minutes before the end of surgery has been shown to stabilize hemodynamic, allow easy extubation, provide a more comfortable recovery and allow early neurological examination following intracranial operations.19

There are many studies showing the attenuation of hemodynamic in neurosurgical patients.16, 17, 18, 19 Although both drugs – dexmedetomidine and preservative free 2% lignocaine prove themselves superior to other treatment modalities / placebo, data on the comparison between these two techniques is less as yet compared. Hence we designed this study with the aim to compare the attenuating effects of single dose dexmedetomidine and 2% lignocaine on hemodynamic and the airway responses during extubation in patients undergoing craniotomy for ICSOL.20, 21

The variation in heart rate noted in this study was comparable with the previous study by Dilip Kothari et al.16 which also showed a significant attenuation of HR in group D when compared to group L, suggesting that dexmedetomidine was superior to lignocaine in obtundation of HR.

In the present study, the increase in SBP and DBP as response to extubation seems to be significantly higher in group L as compared to group D, but in both the groups the increase in SBP did not exceed the 20% of baseline value and it did not last for more than 5 minutes. These results of SBP and DBP when analyzed with previous study, significant difference were seen upto 15min post extubation. The probable reason for the prolongation of attenuation was due to late administration of study drugs along with reversal drug.16

The maximum MAP variations during extubation between the groups were comparable with the results of previous study conducted by Vivek et al.,15 which stated that MAP initially increased during the first 2 minutes followed by decrease from 3rd minute, suggesting that slow infusions are better than rapid bolus doses of dexmedetomidine.

The baseline Mean arterial blood pressure (MAP) is comparable between the two groups. However, after drug administration MAP tends to decrease to about 20% below the baseline in both groups producing comparable values before extubation. The MAP at 1, 3and 5 minutes after extubation is significantly higher in group L as compared to group D (p<0.05).

None of the patients in both the groups had haemodynamic perturbation as per defined criteria. This is consistent with the hemodynamic profile of dexmedetomidine as demonstrated by Uyar et al.22 and Bekker et al.23 No patients had breath holding / laryngospasm / bronchospasm / respiratory depression during or after extubation in both the study groups which shows dexmedetomidine is safer to use with lesser adverse outcomes.

Conclusion

We conclude that a single dose of 0.5 mcg/kg dexmedetomidine given 10minutes before extubation significantly attenuated the hemodynamic and airway response following extubation as compared to 1.5 mg/kg intravenous preservative free 2% lignocaine given before reversal in patients undergoing craniotomy for intracranial space occupying lesions.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest.

References

1 

SC Minogue J Ralph MJ Lampa Laryngotracheal Topicalization with Lidocaine Before Intubation Decreases the Incidence of Coughing on Emergence from General AnesthesiaAnesth Analg20049941253710.1213/01.ane.0000132779.27085.52

2 

M Hartley RS Vaughan Problems associated with tracheal extubationBr J Anaesth1993714561810.1093/bja/71.4.561

3 

D Jee SY Park Lignocaine sprayed down the endotracheal tube attenuates the airway-circulatory reflexes by local anaesthesia during emergence and extubationAnaesth Analg2003962937

4 

C Fagan HP Frizelle J Laffey V Hannon M Carey The effects of intracuff lignocaine on endotracheal-tube-induced emergence phenomena after general anaesthesiaAnaesth Analg2000912015

5 

K Gefke LW Andersen E Friesel Lignocaine given intravenously as a suppressant of cough and laryngospasm in connection with extubation after tonsillectomyActa Anaesthesiol Scand1983271112

6 

K Nishina K Mikawa M Shiga N Maekawa H Obara Prostaglandin E1 attenuates the hypertensive response to tracheal extubationCan J Anaesth19964376788310.1007/bf03017950

7 

K Mikawa K Nishina N Maekawa H Obara Attenuation of cardiovascular responses to tracheal extubation: Verapamil versus diltiazemAnaesth Analg199682120510

8 

MS Siobal RH Kallet VA Kivett JF Tang Use of dexmedetomidine to facilitate extubation in surgical intensive-care-unit patients who failed previous weaning attempts following prolonged mechanical ventilation: A pilot studyRespir Care2006514926

9 

G Turan A Ozgultekin C Turan E Dincer G Yuksel Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgeryEur J Anaesthesiol200825108162010.1017/s0265021508004201

10 

HA Soltani O Aghadavoudi The effect of different lidocaine application methods on postoperative cough and sore throatJ Clin Anesth200214115810.1016/s0952-8180(01)00344-0

11 

UM Kautto J Heinonen Attenuation of Circulatory Response to Laryngoscopy and Tracheal Intubation: A Comparison of Two Methods of Topical AnaesthesiaActa Anaesthesiol Scand198226659960210.1111/j.1399-6576.1982.tb01823.x

12 

V Sharma H Prabhakar G Rath P Bithal Comparison of dexmedetomidine and lignocaine on attenuation of airway and pressor responses during tracheal extubationJ Neuroanaesthesiol Crit Care2014010150510.4103/2348-0548.124850

13 

D Kothari N Tandon M Singh A Kumar Attenuation of circulatory and airway responses to endotracheal extubation in craniotomies for intracerebral space occupying lesions: Dexmedetomidine versus lignocaineAnesth Essays Res201481788210.4103/0259-1162.128916

14 

A E Sağıroğlu M Celik Z Orhon S Yüzer B Sen Dıfferent doses of dexmedetomidine on controlling haemodynamic responses to tracheal intubationInt J Anaesthesiol2010272

15 

G Turan A Ozgultekin C Turan E Dincer G Yuksel Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgeryEur J Anaesthesiol200825108162010.1017/s0265021508004201

16 

R Aksu A Akin C Biçer A Esmaoğlu Z Tosun A Boyaci Comparison of the effects of dexmedetomidine versus fentanyl on airway reflexes and hemodynamic responses to tracheal extubation during rhinoplasty: A double-blind, randomized, controlled studyCurr Ther Res20097032092010.1016/j.curtheres.2009.06.003

17 

P Talke R Chen B Thomas A Aggarwall AGottlieb P Thorborg The Hemodynamic and Adrenergic Effects of Perioperative Dexmedetomidine Infusion after Vascular SurgeryAnesth Analg2000904834910.1213/00000539-200004000-00011

18 

PE Tanskanen JV Kyttä TT Randell RE Aantaa Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: a double-blind, randomized and placebo-controlled study †Br J Anaesth20069756586510.1093/bja/ael220

19 

G Turan A Ozgultekin C Turan E Dincer G Yuksel Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgeryEur J Anaesthesiol200825108162010.1017/s0265021508004201

20 

N Bhana KL Goa KJ McClellan DexmedetomidineDrugs2000592263810.2165/00003495-200059020-00012

21 

PE Tanskanen JV Kyttä TT Randell RE Aantaa Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: a double-blind, randomized and placebo-controlled study †Br J Anaesth20069756586510.1093/bja/ael220

22 

AS Uyar H Yagmurdur Y Fidan C Topkaya H Basar Dexmedetomidine Attenuates the Hemodynamic and Neuroendocrinal Responses to Skull-pin Head-holder Application During CraniotomyJ Neurosurg Anesthesiol2008203174910.1097/ana.0b013e318177e5eb

23 

A Bekker M Sturaitis M Bloom M Moric J Golfinos E Parker The Effect of Dexmedetomidine on Perioperative Hemodynamics in Patients Undergoing CraniotomyAnesth Analg200810741340710.1213/ane.0b013e3181804298



jats-html.xsl

© This is an open access article distributed under the terms of the Creative Commons Attribution License - Attribution 4.0 International (CC BY 4.0). which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.