Back
Year : 2019 | Volume : 7 | Issue : 2 | Page : 62 - 64  


Original Articles
Comparative Evaluation of Bolus Administration of Esmolol and Fentanyl for Attenuation of Pressor Response during Laryngoscopy and Endotracheal Intubation

Rajabhushanam M 1, Sunil Kumar K 2*, SA Aasim 3, Vimalatha P 4 

1,2Associate Professor, 3Professor, PG Student, Department of Anesthesiology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India. 

*Corresponding author:

Dr. K. Sunil Kumar                                                                                                              

E-mail: sunilanaesthesia@yahoo.co.in                                                                          

Abstract:

Background: The haemodynamic responses to laryngoscopy and endotracheal intubation have been recognized since 1951.

Objective: To compare the efficacy of bolus administration of IV Esmolol and IV Fentanyl to suppress the pressor response during laryngoscopy and endotracheal intubation.

Methods: 75 patients of ASA physical status I & II undergoing elective surgical procedure under General Anesthesia with endotracheal intubation were included in the study. Patients belonging to age group of 18-60 years of both sexes were included. The present study was done at Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar during 2014 to 2016.

Results: Total 75 patients under this study were categorized into 3 groups. They comprised both sexes with age ranging from 18-60 years. There is high statistically significant difference in mean heart rate across the 3 groups (p < 0.001). The mean heart rate, blood pressure and mean arterial pressure of the esmolol group are the least and this difference with the control group and fentanyl group are statistically significant.

Conclusion: We concluded that bolus injection of esmolol (2mg/kg) given 3 minutes prior to intubation provided consistent and reliable protection against increases in mean heart rate and mean systolic and diastolic blood pressure during laryngoscopy and endotracheal intubation and thereafter, compared to control group and fentanyl group.

Keywords: Esmolol, Fentanyl, laryngoscopy, endotracheal intubation

INTRODUCTION: 

The haemodynamic responses to laryngoscope and endotracheal intubation have been recognized since 1951. Though these pressor responses have been observed frequently they have been interpreted differently by many authors. The induction of anesthesia, laryngoscopy, endotracheal intubation and surgical stimulation often evoke cardiovascular responses characterized by alterations in systemic blood pressure, heart rate and cardiac rhythm. The response following laryngoscopy and intubation peaks at 1-2 min and returns to baseline within 5-10 minutes. 1, 2

The hemodynamic responses during laryngoscopy and endotracheal intubation should be abolished to balance the myocardial oxygen supply and demand which is a key note in the safe conduct of Anesthesia. Attempts to reduce these untoward cardiovascular responses during laryngoscopy and endotracheal intubation lead to the trial of various systemic as well as topical agents.

The purpose of study was to compare the efficacy of bolus administration of IV Esmolol and IV Fentanyl to suppress the pressor response during laryngoscopy and endotracheal intubation. 

METHODS:

Study Design: This study was a prospective randomized controlled study.

Sampling Size: 75 patients of ASA physical status I & II undergoing elective surgical procedure under General Anesthesia with endotracheal intubation were included in the study. Patients belonging to age group of 18-60 years of both sexes were included. The present study was done at Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar during 2014 to 2016.

Inclusion Criteria:

  • ASA I & II physical status
  • Patients with airway with modified Mallampati Grade I & II
  • Patients belonging to age group of 18-60 years of both sexes were included.

Exclusion Criteria:

  • Patients with full stomach
  • Patients posted for emergency surgery
  • Patients with difficult airway
  • Hypertension, diabetes mellitus, Ischemic heart disease, pregnancy.
  • Patients with contraindication to study drug. 

The study was conducted after getting approval by our institution ethical committee and after obtaining written informed consent from the patient. The surgeon was also duly informed of the study.

Procedure

Patients of both the sexes of ASA physical status I &II undergoing surgical procedure were randomly allocated into 3 groups.

Group C: Control 10 ml of normal saline

Group E: Esmolol 2 mg / kg

Group F: Fentanyl 3 mcg /kg

All the patients were admitted and they underwent routine investigations. All patients received injection Midazolam 0.05 mg/kg and Injection Preoperative heart rate and blood pressure were recorded. Preoxygenation was done for 3 minutes. Base line heart rate and blood pressure were recorded. This was followed by administration of normal saline 10ml in group C, Esmolol 2 mg/kg in Group E and Fentanyl 3 mcg/kg in Group F. 1 minute after the study drug all patients were induced with thiopentone sodium in a dose of 5 mg/kg body weight followed by succinyl choline 1.5 mg / kg body weight. Intubation was performed by the same person with the correct size cuffed endotracheal tube. Anesthesia was maintained with controlled ventilation with nitrous oxide 66% and oxygen 33%. No surgical stimulation was permitted for 7 minutes after intubation.

Statistical Analysis

Data was analyzed using SPSS (statistical package for social sciences) trial version 16 and Excel spread sheet. Results were expressed in terms of Percentages, Means, and Proportions and relevant tests of significance like ANOVA were applied and P < 0.05 was considered as statistically significant. 

RESULTS:

Total 75 patients under this study were categorized into 3 groups. They comprised both sexes with age ranging from 18-60 years.

  1. Group C (Control): consisting of 25 patients who received 10 ml normal saline, 3 minutes prior to laryngoscopy.
  2. Group E (Esmolol): consisting of 25 patients who received 2 mg / kg, 3 minutes prior to laryngoscopy.
  3. Group F (Fentanyl): consisting of 25 patients who received 3mcg/kg, 3 minutes prior to laryngoscopy.

Table 1: Demographic profile of cases included in the study

Age(in years)

Control

Fentanyl

Esmolol

Less than 20

-

3

2

20-29

15

14

7

30-39

7

4

7

40-49

3

3

2

50 and Above

-

1

2

Total

25

25

25

Mean

29.2

28.7

31.4

S.D

7.2

9.9

8.6

p-value

No significant

No significant

No significant

Table 1 showing aged distribution, There is no significant difference between the mean ages of the 3 groups.

Table 2: Sex distribution

Sex

Control

Fentanyl

Esmolol

Male

12(48%)

12(48%)

13(52%)

Female

13(52%)

13(52%)

12(48%)

Table 3: Baseline Heart Rate, Systolic Blood Pressure, Diastolic blood Pressure and Mean arterial pressure

 

Control

Fentanyl

Esmolol

p-value

 

Significance

 

Mean       S.D  

Mean       S.D

Mean    S.D

 

 

HR

81.52      5.5   

 88          11.3

87.56      7.7

0.15

No significant

SBP

125.12    10.0

127.12   9.4

126.76   9.5

0.74

No significant

DBP

78.6         5.9

82.4        8.4

81.56      9.7

0.235

No significant

MAP

93.40       5.8

97.2        6.0

96.75     5.9

0.052

No significant

 

Table 3 showing, there is no statistical difference in the mean heart rate; mean systolic, mean diastolic blood pressure across 3 groups. (P > 0.05)

Table 4: Heart Rate, Systolic Blood Pressure, Diastolic blood pressure and Mean arterial Pressure at laryngoscopy and endotracheal intubation

 

Control group

Fentanyl

Esmolol

p-value

 

Significance

 

Mean       S.D  

Mean       S.D

Mean    S.D

 

 

HR

109.68    13.5   

102.88      7.1

92.92     4.6

0.01

Significant

SBP

151.92     9.8

142.04     11.0

139.36    10

0.01

Significant

DBP

94.64       6.7

 92.80       6.6

87.56     9.2

0.005

Significant

MAP

113.48     5.4

110.32      10.5

104.53   4.2

0.001

Significant

Table 4 showing the mean heart rate, mean systolic and diastolic blood pressure at laryngoscopy and endotracheal intubation. There is high statistically significant difference in mean heart rate across the 3 groups (p < 0.001). The mean heart rate, blood pressure and mean arterial pressure of the esmolol group are the least and this difference with the control group and fentanyl group are statistically significant.

DISCUSSION:

Laryngoscopy and endotracheal intubation frequently induce a cardiovascular stress response characterized by hypertension and tachycardia. In view of the frequent occurrence of hypertension and tachycardia during laryngoscopy even in normotensive individuals, it is perhaps rather surprising that complications have not been met very often. One reason for this may be the transient nature of hypertension which usually lasts less than 10 minutes. It is possible however that some of the complications that occur during intubation or even later in the course of anesthesia may be precipitated by an episode of hypertension and tachycardia, following endotracheal intubation.

King et al and Wycoff et al study used combination of topical anesthesia of larynx together with superior laryngeal nerve block to attenuate the stress response to endotracheal intubation. 3, 4 So, this study was done to compare the effects of single bolus esmolol and fentanyl versus control group in attenuating the haemodynamic response to intubation.

Bolus injection of fentanyl (3 mcg/kg) given 3 minutes prior to intubation failed to attenuate the heart rate to the same extent as esmolol during laryngoscopy and endotracheal intubation and thereafter. At each level the difference in mean heart rate between esmolol group & fentanyl group is statistically insignificant compared to control group.

In the present study with esmolol, mean systolic and diastolic blood pressure returned to baseline value within 3 minutes after intubation, whereas it was 5 minutes with fentanyl. This is in accordance with the study of Helfmman M et al. 5 Thus esmolol; a cardio selective β blocker would be useful to attenuate the sympathoadrenal response accompanying laryngoscopy and endotracheal intubation.

Our study correlates with this study during first five minutes. Attenuation with Esmolol group is highly significant than Fentanyl group (p=0.0001). In present study bolus injection of Fentanyl 2 mcg/kg 3 minute prior to laryngoscopy and intubation failed to protect against elevation of mean pulse rate, whereas Esmolol at 2 mg/kg provided consistent and reliable protection against the increase of the mean pulse rate.

H Boston and Ahmet Eroglu et al 6 concluded that when administered before induction of anesthesia 1mg/kg of Esmolol, lidocaine 1mg/kg and 1 mcg/kg of Fentanyl are effective in suppressing the hemodynamic response to laryngoscopy, intubation and extubation. Esmolol was more effective to prevent rise in mean SBP as compared to the other two.

The findings of this study correlates with our study as rise in mean SBP after laryngoscopy and intubation was seen lower at all interval in Esmolol group than Fentanyl group. So Esmolol attenuates SBP better than Fentanyl. Difference in the mean SBP in the two group was significant only at 1 minute after laryngoscopy and intubation but in the subsequent minutes from 2nd, 3rd, 4th, 5th was non-significant (p>0.05). In our study showing that Fentanyl attenuates mean DBP more significantly than Esmolol from 3rd minute onwards following laryngoscopy and intubation.

In present study, maximum attenuation of mean MAP occurred in Esmolol group at first minute after laryngoscopy and intubation than in Fentanyl group (p=0.0001, significant). But after subsequent 2nd, 3rd, 4th, 5th and finally at 10th minute after laryngoscopy and intubation Esmolol does not attenuate mean MAP. Fentanyl attenuates mean MAP significantly on 5th minute after laryngoscopy and intubation. Overall Esmolol attenuates mean MAP at 1 minute after laryngoscopy and intubation significantly (p=0.008), but not so in subsequent minutes.

CONCLUSION:

We concluded that bolus injection of esmolol (2mg/kg) given 3 minutes prior to intubation provided consistent and reliable protection against increases in mean heart rate and mean systolic and diastolic blood pressure during laryngoscopy and endotracheal intubation and thereafter, compared to control group and fentanyl group.

Esmolol and fentanyl both attenuated the rise in blood pressure though Esmolol was better. Esmolol attenuated the rise in heart rate with laryngoscopy and endotracheal intubation whereas fentanyl failed tom protect against the rise in heart rate.

REFERENCES:

  1. Dahlgren N, Messeter K. Treatment of stress response to laryngoscopy and intubation with Fentanyl. J Anesth 1981; 36(11):1022-6.
  2. Dorn GW. Adrenergic signaling polymorphisms and their impact on cardiovascular Disease. Physiol Rev. 2010; 90(3):1013-1062.
  3. King BD, Harris L.C., Greifenstein FE et al. Reflex circulatory responses to direct laryngoscopy and tracheal intubation performed during general anesthesia Anesthesiology.1951;12(5): 556-66.
  4. Wycoff CC. Endotracheal intubation: Effects on blood pressure and pulse rate. Anesthesiology. 1960; 21:153.
  5. Helfman SM, Gold MI, De Lisser EA, Herrington CA. Which drug prevents tachycardia and hypertension associated with tracheal intubation: Lidocaine, Fentanyl or Esmolol. Anesthesia Analgesia.1991; 72:482-486.
  6. Bostan H, Ahmet E. Comparison of the clinical efficacies of fentanyl, esmolol and lidocaine in preventing the hemodynamic responses to endotracheal intubation and extubation. J Curr Surg. 2012; 2(1):24-8




img

Important links

adv apply rec

Open Access Journal

MRIMS Journal of Health Sciences is an open access journal which means that all content is freely available without charge to the user or his/her institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal without asking prior permission from the publisher of the author. This is in accordance with the BOAI definition of open access.

Visitor Count


445301
© 2019 Chandramma Education society . All Rights Reserved.