Comparison between single-dose suxamethonium and rocuronium after pretreatment with dexmedetomidine in rapid sequence induction

Background Rapid sequence induction is a well-established anesthetic procedure used in patients with a high risk of gastric aspiration. Suxamethonium has been the drug of choice; however, it carries potential risks and sometimes fatal outcomes. The aim of our study was to compare rocuronium after pretreatment with dexmedetomidine, to suxamethonium in providing excellent intubating conditions in rapid sequence induction in adults. Patients were randomly allocated to one of two groups, of 120 each. Control group (SS), patients received pretreatment with 10 ml 0.9% saline over 10 min and suxamethonium 1mg/kg. Experimental group (DR), received pretreatment with dexmedetomidine 1 μg/kg in 10 ml 0.9% saline over 10 min and rocuronium 0.6 mg/kg. Our primary endpoint was the number of patients who scored “excellent” on intubation conditions score, while secondary outcomes were hemodynamics and adverse events. Results The rate of excellent intubating conditions in the DR group 46% was insignificantly less (P value = 0.548) than that of the SS group 49% (relative risk (RR) of DR compared to SS = 1.04, with a confidence interval (CI) of 0.91–1.48. The percentage of patients with adverse events in the SS group was (30%) nearly more than twofold higher than that of the DR group (11%). A significant difference (P value = 0.016) in the incidence of excellent intubating conditions was higher in the female gender 59% compared to the male gender 38% (adjusted RR = 0.98, with a confidence interval of 0.79–1.1). Conclusion A combination of dexmedetomidine 1μg/kg and standard intubating dose of rocuronium 0.6 mg/kg provided comparable endotracheal intubation conditions to suxamethonium 1 mg/kg during RSI and might be used as an alternative to suxamethonium in situations where suxamethonium is contraindicated. Trial registration ClinicalTrials.gov Identifier: NCT04709315

A PROSPECTIVE RANDOMIZED STUDY TO EVALUATE THE ANALGESIC AND SEDATIVE EFFECTS OF FENTANYL AND MIDAZOLAM TO NALBUPHINE AND MIDAZOLAM IN PATIENTS UNDERGOING AWAKE FIBEROPTIC

Background- Awake nasal or oral flexible fiberoptic intubation (AFOI) is technique of choice in known or anticipated difficult airway . The main aim was to have calm and cooperative patient who can follow verbal commands while maintaining adequate oxygenation . In our study, we compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubationmore tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Material and Methods– A prospective, randomized comparison study among patients between the age of 18 and 60yrs of either sex, with anticipated difficult airway . We compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubation. The primary objectives of our study were to observe the level of sedation, intubation score and OAS score after completion of procedure. The secondary objectives included assessment of patient comfort, intubation time, hemodynamic changes and complications. Results – We found that comfort score and intubation time were significant lesser in Group which received fentanyl and midazolam than Group which received nalbuphine and midazolam . (p<0.05). The intubation attempt was similar in both groups (P>0.05). Conclusion– we concluded that both regimens used in this study provided comparable intubating conditions, better sedation and analgesia was observed in group fentanyl for airway procedure events. Our study concluded fentanyl to be the drug of choice for blunting of pressor response in such patients.

Comparison of Two Muscle Relaxants for Tracheal Intubation in Patients Undergoing Surgery at Goa Medical College and Hospital

BACKGROUND Cisatracurium and atracurium are intermediate acting muscle relaxants which do not depend on renal or hepatic metabolism for elimination since they undergo Hofmann elimination. Despite the advantages of cisatracurium such as minimal effects on the cardiovascular system, no accumulative effects, no metabolite toxicity, and metabolic product has no neuromuscular blocking effects, due to slow onset and unsatisfactory intubating conditions, the use of cisatracurium is limited compared with those seen with equipotent doses of other neuromuscular blocking agents. This study was undertaken to find onset time and intubating conditions with 3 × ED95 doses of atracurium versus cisatracurium. METHODS ASA grade 1 or 2 patients, (N = 220) were randomly allocated into 2 groups to receive equipotent doses of either atracurium or cisatracurium. Intubating conditions were assessed using Cooper et al scale and neuromuscular monitoring done using TOF Watch SX. Haemodynamic responses and any adverse effects were noted. RESULTS The onset time was 167.36 ± 75.41 seconds (2.78 ± 1.25 minutes) in atracurium group whereas in cisatracurium group, onset time was 249.26 ± 75.90 seconds (4.15 ± 1.26) and the difference was statistically significant with p value of < 0.001. The difference in intubating conditions between the groups was statistically insignificant. However, atracurium produced a higher incidence of clinically acceptable conditions (excellent in 94.4 %) than cisatracurium (excellent in 87.3 %). The incidence of adverse effects such as erythema, flushing and bronchospasm was greater in Atracurium group though hypotension was observed in both groups. CONCLUSIONS Onset time and intubating conditions are significantly better with equipotent doses of atracurium compared to cisatracurium. But atracurium is associated with higher incidence of adverse effects such as erythema, flushing and bronchospasm, though the potential of cisatracurium to cause anaphylactoid reactions cannot be ignored. KEYWORDS Cisatracurium, Atracurium, Muscle Relaxants, Neuromuscular Blocking Agents, Erythema, Flushing, Bronchospasm, Hypotension, Anaphylactoid Reactions

A Comparative Crossover Randomized Study of Miller and Macintosh Blade for Laryngoscopic View and Ease of Intubating Conditions in Adults

Background: Although several types of laryngoscope blades of different sizes and shapes are present, Miller (MIL) blade is the most preferable blade among paediatric population. However, there is dearth in the literature regarding the use of these blades in the adult population. This study aimed to compare the laryngoscopic view and ease of intubation using MIL and Macintosh (MAC) blade among adults. Methods: A total of 172 patients who were >18 years age, with ASA grades I and II, undergoing elective surgeries with general anaesthesia were included. Patients were distributed in two groups (MAC/MIL and MIL/MAC), where laryngoscopy was first done with MAC blade, followed by MIL blade in the MAC/MIL group and vice-versa in the MIL/MAC group. Grading of laryngoscopic views, number of attempts, ease of intubation and use of backward, upward, rightward pressure (BURP) were noted. R v 3.6.0 was used for statistical analysis and P values≤0.05 were considered as statistically significant. Results: MIL blade showed better laryngoscopic view compared to MAC blade (32.6% vs. 15.1%; P< 0.002). BURP application helped improve the laryngoscopic views with MAC blade. Intubation with MIL blade was easier with regards to ease of intubation and number of attempts 19 (P value<0.05). Conclusion: Glottis visualization is better with the MIL blade as compared to the MAC blade. Therefore, the MIL blade might be helpful in securing the airway among adult patients.

ROCURONIUM VERSUS CISATRACURIUM: INTUBATING CONDITIONS, EFFICACY, AND SAFETY.

Background: Neuromuscular blockers (NMB) are very important adjuvant to general anesthesia,Rocuronium bromide (aminosteroidal NMB) and cisatracurium besylate (benzylisoquinoline NMB) are recently introduced non-depolarizing muscle relaxants.In a prospective randomized study,we had compared both the drugs as regard to the onset of action, intubating conditions,clinical duration,hemodynamic changes,and adverse effects. Method: 80 female patients ASA I&II,18-60 year old underwent elective abdominal surgery under general anesthesia (GA) were randomly assigned into 2 equal groups.ROC group,where 0.9mg/kg rocuronium was given and CIS group, where 0.15mg/kg cisatracurium was given. Standardized GA was given to all patients as follows, fentanyl 1mcg/kg, propofol 2mg/kg,intubation was tried by the same anesthetist who was blind to the given NMB after 60 sec of injection, intubation was done if the intubating condition was acceptable (excellent or good),and it was re-attempted every 30 sec if it was poor or inadequate.Anesthesia was maintained by 60% N2O in O2 and isoflurane to a total MAC 1.5,controlled ventilation was adjusted to normocapnia.Mean arterial blood pressure (MAP),heart rate,and intubating conditions were recorded. Results: Clinically acceptable intubating conditions were achieved after 60 sec more frequently with rocuronium (80%) than with cisatracurium(0%).Rocuronium had advantage of rapid onset of action with good intubating conditions as compared to Cisatracurium and both were found to be potent and safe with excellent cardiovascular stability and also without any apparent histamine release. Conclusion: Rocuronium has a rapid onset of action with good intubating conditions in comparison to cisatracurium both are potent and safe with excellent cardiovascular stability and do not cause apparent histamine release

TO COMPARE THE INTUBATING CONDITIONS WITH DEXMEDETOMIDINE VERSUS MIDAZOLAM-FENTANYL COMBINATION FOR AWAKE FIBREOPTIC INTUBATION

Objectives:To compare the intubating conditions of dexmedetomidine alone versus fentanyl -midazolam combination during AFOI Methodology: Group-I patients (n=30) received dexmedetomidine 1µg/kg bolus infusion over 10 minutes, followed by infusion of 0.1 µg/kg/hr titrated to 0.7 µg/kg/hr whereas Group-II patients (n=30) received i.v fentanyl 2µg/kg bolus followed by midazolam infusion of 0.02-0.1mg/kg/hr until they were adequately sedated i.e. Ramsay Sedation Score (RSS) of 3 .Intraoperatively Total Comfort Score, 5 point FOI score was noted and Questionnaire assessment was done 24 hours after surgery. Results: During preoxygenation, the mean TCS was not statistically signicant different between the two groups but during FOS and during intubation, the mean TCS was lower in group-1than group-2and the difference between the two groups was statistically signicant.(p<0.05). Signicant differences in the patient's reaction to tube were found during FOS and after intubation between the two groups with lower reaction in dexmedetomidine group(p≤0.05). During follow-up assessment 24 hours after the surgical procedure, the dexmedetomidine group patients judged their sedation more positively and were having less pain and discomfort during the procedure than fentanyl plus midazolam patients. Conclusion: The use of dexmedetomidine at 1mcg/kg bolus over 10 minutes, with maintenance rates of 0.1-0.7 μg/kg/hr offer better tolerance, preservation of a patent airway and spontaneous ventilation, while maintaining hemodynamic stability during AFOI.

COMPARISON OF EFFICACY OF ATRACURIUM AND CISATRACURIUM IN PATIENTS UNDERGOING ABDOMINAL SURGERIES UNDER GENERAL ANESTHESIA AT DMCH, LAHERIASARAI, BIHAR

Background: The present study was done to test compare the efcacy of atracurium and cisatracurium regarding onset time, intubating conditions, hemodynamic effects, duration of action, signs histamine release and evaluate whether cisatracurium is more effective than atracurium with regard to the criteria. Materials And Methods: This study was done in the Department of Anaesthesia, Darbhanga Medical College and Hospital, Laheriasarai, Bihar. Study was done for a period from July 2019 to November 2020. An informed consent was taken from all patients. Group A (25 patients) received Atracurium 0.5mg/kg IV and Group B (25 patients) received Cisatracurium 0.3mg/kg IV. Results: Duration of action of Cisatracurium (0.3 mg/kg) is signicantly high compared to Atracurium (0.5mg/kg) with p<0.001. 83% of patients treated with Cisatracurium had excellent intubating conditions as compared to 47% with Atracurium which was signicant. Hemodynamic changes in either of them were clinically insignicant. Signs of histamine release was seen in two patients in Atracurium group whereas none in Cisatracurium group. Conclusion: Cisatracurium at a higher dose of 0.3mg/kg as compared to Atracurium 0.5mg/kg provided more effective and rapid neuromuscular blockade with excellent intubating conditions, longer duration of action, stable hemodynamics and no associated signs of histamine release clinically.