Comparative Study of Safety and Efficacy of Three Different Doses of Fentanyl on Hemodynamic Response to Laryngoscopy and Tracheal Intubation in Patients under General Anaesthesia

Aim of Study: Laryngoscopy and endotracheal intubation are the commonest method for securing a definitive airway for general anaesthesia. It is one of the most invasive and painful stimuli in anaesthesia producing clinically relevant changes in the hemodynamic variables. This study has been designed to compare the safety and efficacy of three different doses of fentanyl (2µg/kg, 3µg/kg and 4µg/kg) in attenuating hemodynamic response, following laryngoscopy and endotracheal intubation. Materials and Methods: In this observational study, three groups of 90 patients belonging to ASA grade I and II, aged between 18 to 65 years, including either gender, posted for elective surgery under GA with informed consent. Baseline vital hemodynamic parameters and the serial heart rate, arterial pressures, SpO2 and respiratory rate were noted at five minutes after intravenous fentanyl administration, during laryngoscopy & intubation and at 1-, 3-, 5-, 10- and 20-minutes after laryngoscopy. Ramsay sedation scores were also noted at five minutes after intravenous fentanyl administration, during extubation and at 10-, 20- and 30-minutes after extubation. Results: There was substantial difference in mean HR, SBP, DBP & MAP values post 5 minutes after intravenous fentanyl administration, during laryngoscopy, at 1, 3-, 5-, 10- and 20-minutes following laryngoscopy and intubation between the three groups. Patients’ behaviour belonging to group C (IV fentanyl 4µg/kg), followed by the patients of group B (IV fentanyl 3µg/kg) presented considerable amount of attenuation of all the hemodynamic stress parameters effectively, with statistically significant results when compared to group A (IV fentanyl 2µg/kg). Conclusion: Intravenous fentanyl 4µg/kg and 3µg/kg are better at attenuating the laryngo-tracheal stress response, in comparison to intravenous fentanyl 2µg/kg.

EFEKTIVITAS PREEMTIF KETAMIN SUB DOSIS DALAM MENGURANGI KEBUTUHAN OPIOID INTRAOPERATIF DAN LAMA WAKTU EKSTUBASI

Surgical perioperative management undergoes updates to support postoperative patient outcomes. The concept of longer preoperative fasting times, cleansing ofthe gastrointestinal tract, and re-feeding after 3-5 days after surgery has begun to be abandoned which is then formulated into a new protocol called ERAS(Enhanced Recovery After Surgery) including preoperative counseling, optimization of nutrients, the use of standard anesthesia and analgesy drugs, as well asearly mobilization using the concept of preemptive analgesia. The use of low-dose ketamine for postoperative analgesia has evolved in part due to nmdaantagonistic properties that reduce central sensitization and opioid tolerance but are still controversial. This study aims to study the effects of low-dose ketamineas a preemptive and evaluate the total needs of opiods, as well as the length of time extubation with single blind experimental research. Patients with label A gotpreemptive therapy of subdose ketamine while label B got perioperative standard analgesia therapy. Analgesia in groups A and B is administered before surgery.Treatment control is done with single blind control that is the patient does not know the type of drug given. The comparison of the amount of fentanyl in the controlgroup and treatment in this study was significantly different (p=0.044). The old comparison of extubation in both groups obtained a significant p value (<0.0001).Preemptive administration of subdose ketamine effectively decreases the amount of fentanyl administration used during surgery and shortens the extucation time. Keywords: Preemptive; Ketamin subdose; Fentanil; Extucation Time.

Effectiveness of Huffing Manoeuvre on Fentanyl Induced Cough

Aim: To determine the effect of huffing manoeuvre to preventing cough caused by intravenous administration of fentanyl during induction of anaesthesia. Study Design: Cross-sectional study Place and duration of study: General Anaesthesia Department, SICU and Pain Management, Civil Hospital Karachi from 1st June 2019 to 30th November 2019. Methodology: One hundred and sixty four patients meeting were enrolled. Every patient was taught to perform huffing manoeuvre by primary investigator visiting patient in ward at night before surgery. The act of huffing manoeuvre was lasts within 5 seconds. Any episode of cough within 60 seconds of fentanyl administration was classified as fentanyl induced cough. All patients were received Propofol (2mg/kg) for induction of anaesthesia. Results: The mean age was 46.42±8.92 years. Incidence of fentanyl induced cough was observed in 4.3% cases and huffing manoeuvre was effective in 95.7% cases. Conclusion: Huffing manoeuvre is an effecting method of reducing fentanyl induced cough in patients undergoing surgery, especially the manoeuvre prevents developing of severe fentanyl induced cough. Keywords: Fentanyl, Cough, Huffing manoeuvre, Analgesic opioids

The Effectiveness of Intraoperative Ketamine and Fentanyl as Preemptive Analgesia Assessed with qNOX Score

Background: Inadequate management of intraoperative pain poses a risk of postoperative chronic pain complications. The use of preemptive analgesia before the onset of surgical incision stimulation was considered to prevent central sensitization. Clinical research around the terms of preemptive analgesia needs to be proven by nociception-based intraoperative monitoring. An objective modality with EEG guidance can provide information on noxious stimuli.Objective: To determine the effectiveness of ketamine and fentanyl administration as preemptive analgesia measured by qNOX scores through the CONOX tool.Methods: This study is a single-blinded randomized experiment with the division of two groups: control and treatment. The control group received preemptive fentanyl, and the treatment group received preemptive ketamine and fentanyl. Then the qNOX score was assessed during operation.Result: The qNOX score of the treatment group in minute-15 and 30 was lower than the control group (p = 0.007; p = 0.025), while in the minute-90 it was higher than the control group (p = 0.001). The mean first 1-hour qNOX score was lower in the treatment group (p <0.001), while in the second 1-hour was higher in the treatment group (p = 0.003). The mean total dose of fentanyl supplementation in the treatment group was lower than in the control group (71.3 ± 25.1 grams vs. 92.0 ± 28.3 grams; p = 0.044).Conclusion: The administration of combined ketamine and fentanyl as preemptive analgesia is more effective in the first hour of surgery compared to single preemptive fentanyl measured by qNOX score. Preemptive ketamine and fentanyl decrease the total dose of intraoperative fentanyl supplementation compared with single-dose preemptive fentanyl administration.

Remifentanil provides an increased proportion of time under light sedation than fentanyl when combined with dexmedetomidine for mechanical ventilation

Objective To compare the effects of remifentanil versus fentanyl during light sedation with dexmedetomidine in adults receiving mechanical ventilation (MV) in the intensive care unit. Methods In this retrospective cohort study, we compared the use of remifentanil versus fentanyl in adults receiving MV with dexmedetomidine sedation. The primary outcome was the proportion of time under light sedation (Richmond Agitation–Sedation Scale score between −1 and 0) during MV. Results We included 94 patients and classified 58 into the remifentanil group and 36 into the fentanyl group. The mean proportion of time under light sedation during MV was 66.6% ± 18.5% in the remifentanil group and 39.9% ± 27.3% in the fentanyl group. In the multivariate analysis with control for confounding factors, patients in the remifentanil group showed a significantly higher proportion of time under light sedation than patients in the fentanyl group (mean difference: 24.3 percentage points; 95% confidence interval: 12.9–35.8). Conclusions Remifentanil use might increase the proportion of time under light sedation in patients receiving MV compared with fentanyl administration.

Comparative study of analgesia nociception index (ANI) vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration among mastectomy patients

Background The Analgesia Nociception Index (ANI) has been suggested as a non-invasive guide for analgesia. Our objective was to compare the efficacy of ANI vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration. Methods This was a prospective, randomized, controlled study of adult female patients undergoing elective mastectomy under general anesthesia. The patients were randomized to the ANI-guided group receiving a loading dose of 75 μg of fentanyl followed by 25 μg when the ANI score was under 50. The Control group received the same loading dose followed by 25 μg every 30 min with additional doses when there were signs of inadequate analgesia (viz., tachycardia or hypertension). Results Sixty patients—30 in each group—were recruited. Although the actual mean ANI score was higher in the ANI-guided than in the Control group (mean difference 2.2; 95% CI: 0.3 to 4.0, P = 0.022), there was no difference in the primary outcome—i.e., intraoperative fentanyl consumption (mean difference − 4.2 μg; 95% CI: − 24.7 to 16.4, P = 0.686 and − 0.14 μg·kg− 1·h− 1; 95% CI: − 0.31 to 0.03, P = 0.105). No difference between groups was shown for either intraoperative blood pressure and heart rate, or for postoperative outcomes (i.e., pain scores, morphine consumption, or sedation scores) in the postanesthesia care unit. Conclusions Intraoperative fentanyl administration guided by ANI was equivalent to that guided by a modified pharmacologic pattern. In a surgical model of mastectomy, the ANI-guided intraoperative administration of fentanyl had no impact on clinical outcomes. Trial registration The study was registered with ClinicalTrials.gov (NCT03716453) on 21/10/2018.

The usage of personalized scheme of fentanyl administration during coronary artery stenting

The aim – to develop a personalized scheme of fentanyl administrationfor coronary artery stenting. Materials and methods. Ninety patients with ischemic heart disease who underwent planned stenting of the coronary arteries were studied. The patients who underwent surgery were evenly divided into three study groups, depending on mode of the intraoperative analgesic sedation and the approaches to anesthesia. The first comparison group consisted of patients who received slow intravenous administration of diazepam and fentanyl solutions. The second comparison group consisted of patients with balanced administration of fentanyl and propofol solutions to provide analgesic sedation at the level of conscious anesthesia. The study group consisted of patients with a personalized approach to the administration of opiates, namely, we used the original fentanyl test described in the article. Analgesic sedation at the level of conscious anesthesia (ІІІ by Ramsey) was maintained by propofol infusion. Results. The usage of a personalized scheme of fentanyl administration for stenting of the coronary arteries, compared to the standard sedation using combination of diazepam and fentanyl, was accompanied by better indicators of intraoperative blood saturation with oxygen and carbon dioxide (respectively (103.67 ± 22.05) and (39.64 ± 6.85) mm Hg in group 1, (105.70 ± 31.64) and (37.68 ± 7.11) in group 2 and (109.42 ± 34.36) and (36.25 ± 6.52) mm Hg in patients of the 3rd group), lower blood pressure after surgery ((127.85 ± 9.87)/(79.64 ± 8.62) mm Hg in patients of group 1, (129.48 ± 8.73)/(81.05 ± 7.92) mm Hg in group 2 and (131.15 ± 10.64)/(82.68 ± 9.72) mm Hg in group 3), lower level of stress markers (blood cortisol during surgery in patients of the 1st group (8.83 ± 4.58) mmol/L, in patients of the 2nd group – (7.73 ± 2.79) mmol/L, in patients of the 3rd group – (7.55 ± 4.35) mmol/L), as well as lower frequency of detecting episodes of perioperative pain of various origins. Conclusions. A method of personalized anesthesia was elaborated, based on individual scheme of fentanyl administration («fentanyl test») during coronary artery stenting. Its usage is safe (due to the optimal parameters of gas exchange and hemodynamics and fewer side effects, such as nausea and residual sedation) and effective (due to the lower level of stress markers and less frequent complaints of pain of various origins) than when the routine technique was used. Key words: analgesic sedation, individual sensitivity, fentanyl, diazepam, propofol.