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Year : 2019 | Volume : 7 | Issue : 3 | Page : 73 - 76  


Original Articles
Attenuation of Cardiovascular response to Intubation: A double blind Comparative study of Esmolol and Lignocaine with hemodynamic response

Sunil Kumar K 1, Kishore K2*, Syed Ali Aasim3, Inugula Rajkumar Reddy 4, Rajesh Verma 4

1, 4Assoc. Professor, 3Professor, 4Resident, Department of Anesthesiology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India.

Correspondence:

Dr. K. Kishore                                                                                                                                     

E-mail: saisahasra28@gmail.com                                                                                                  

Abstract:

Background: The present study aim was to determine the efficacy of lignocaine 2 mg/kg bolus and esmolol 200 mg bolus in attenuating the sympathetic responses to laryngoscopy and tracheal intubation.

Objective: To determine the efficacy of lignocaine 2 mg/kg bolus and esmolol 200 mg bolus in attenuating the sympathetic responses to laryngoscopy and tracheal intubation

Methods: A clinical comparative study of attenuation of sympathetic response to laryngoscopy and intubation was done in 150 patients posted for elective surgeries. Study was conducted in Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. General Anesthesia was provided with endotracheal Intubation for all the patients. 150 cases were divided into three groups with 50 cases in each group. An informed consent was taken in all the patients.

Results: The age range was 20-50 years for control and study groups. The mean values of age with standard deviations are 31.18±9.79, 32.18±10.64 and 33.66±10.83 for control, lignocaine and esmolol groups respectively. In combination of esmolol and lignocaine test dose a significant decrease in SBP occurred after 1min (p <0.001), and 3 min (p <0.001) groups respectively.

Conclusion: Among the both study groups superiority of esmolol over lignocaine in attenuating the sympathetic responses to laryngoscopy and intubation is evident and statistically highly significant at all times.

Keywords: Attenuation, cardiovascular response, esmolol, lignocaine

INTRODUCTION:

Endotracheal intubation has become an integral part of anesthetic management and critical care since its description in 1921 by Rowbotham and Magill. Laryngoscopy and tracheal intubation induces changes in circulating catecholamine levels significantly. Nor epinephrine, epinephrine and dopamine levels rise, but the raise in nor epinephrine levels is consistently associated with elevation of blood pressure and heart rate. [1, 2]

Esmolol is an ultra short acting blocker and has been consistently associated with control of pressor response to laryngoscopy and intubation. The present study is undertaken to determine the efficacy of IV lignocaine 2 mg/kg bolus and IV esmolol 200mg bolus in attenuating the sympathetic responses to laryngoscopy and tracheal intubation.

The aim of study was to determine the efficacy of lignocaine 2 mg/kg bolus and esmolol 200 mg bolus in attenuating the sympathetic responses to laryngoscopy and tracheal intubation.

METHODS:

A clinical comparative study of attenuation of sympathetic response to laryngoscopy and intubation was done in 150 patients posted for elective surgeries. This study was conducted at Department of Anesthesiology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. General anesthesia was provided with endotracheal intubation for all the patients. Patients undergoing various orthopedic, ENT, Gynecological, General Surgical, Neurosurgical and Laparoscopic procedures were selected.

Inclusion criteria:

  1. Patients scheduled for elective surgeries
  2. Age between 20 to 50 years of both the sexes.
  3. Patients with ASA grade I or II.
  4. Mallampati airway assessment of grade I.

Exclusion Criteria:

  • Anticipated difficult intubation
  • Patients with ASA grade III or higher
  • Patients with cardiovascular diseases
  • Patients on beta blockers or calcium channel blockers.
  • Patients in whom laryngoscopy and intubation proved to be prolonged or difficult.

Group-I was Lignocaine group. Patients received 2mg/kg lignocaine IV, 3 minutes before laryngoscopy and intubation.

Group-II was esmolol group. All the patients in this group received 200 mg IV bolus 3 minutes before laryngoscopy and intubation.

Anesthesia Technique

All the patients were pre-oxygenated with 100% oxygen for 3 minutes before induction. Induction was achieved with Inj. Thiopentone sodium 5mg/kg IV given in 2.5% solution. Inj. Glycopyrrolate 0.2 mg IV was given along with Thiopentone. After induction of anesthesia (loss of eyelash reflex), heart rate, systolic and diastolic blood pressures were recorded.

Succinylcholine was administered at a dose of 2 mg/kg IV Laryngoscopy was done using rigid laryngoscope with standard Macintosh blade. Intubation was done with appropriate sized, disposable, high volume low pressure cuffed endotracheal tube. Oral intubation was done for all surgical procedures. Laryngoscopy and intubation was done within 15 to 20 seconds.

Heart rate, systolic and diastolic blood pressure were recorded and 10 minute intervals from the onset of laryngoscopy.

Ethics Approval

The study was approved by the Institute Ethics Committee, CAIMS, Karimnagar.

Statistical analysis

Descriptive data presented as Mean ± SD and in percentage. Pair wise comparison between the groups was done by `z test. For all tests a `z value of 1.96 was considered significant and a `p value of £ 0.05 was considered significant.

RESULTS:

The table 1 shows the age distribution in control and the two study groups. The age range was 20-50 years for control and study groups. The mean values of age with standard deviations are 31.18±9.79, 32.18±10.64 and 33.66±10.83 for control, lignocaine and esmolol groups respectively. There was no significant difference between the three groups (p>0.05).

Table 1: Age distribution

 

Control

Lignocaine

Esmolol

Mean

31.18

32.18

33.66

Standard deviation

9.79

10.64

10.83

 Table 2: Sex distribution

Gender

Number

%

Male

26

52

Female

24

48

In esmolol group 42% of the patients were male and 58% of the patients were females. No significant difference was observed in sex wise distribution of the cases between the three groups (p>0.05).

Table 3: Changes of heart rate

Heart rate

Lignocaine

Esmolol

T test

P value

Mean

SD

Mean

SD

Pre Induction

79.18

6.818

78.42

6.627

0.565

0.573

Post Induction

81.61

6.251

82.96

6.091

-1.086

0.28

1 Min

104.63

8.141

89.28

5.904

10.723

0.001**

3 Min

103.24

8.666

90.56

5.99

8.456

0.001**

5 Min

90.82

6.244

87.44

4.958

2.976

0.004**

7 Min

85.45

5.853

81.96

3.917

3.479

0.001**

10 Min

81.51

5.531

79.1

3.394

2.607

0.01**

 

Table 3 shows that the pre-induction mean heart rate and standard deviations (SD) in this group were 6.818±6.627 respectively. The heart rate at the end of 10 minutes was significant difference than the pre induction values.

Table 4: Comparison of Systolic blood pressure (SBP) changes

Systolic blood pressure

Lignocaine

Esmolol

T test

P value

Mean

SD

Mean

SD

Pre Induction

131.98

11.618

128.86

11.658

1.333

0.186

Post Induction

131.06

11.557

125.52

10.983

2.445

0.016

1 Min

151.24

13.856

133.86

10.546

7.015

0.001**

3 Min

148.63

14.265

134.62

10.128

5.626

0.001**

5 Min

136.9

11.388

133.12

9.835

1.765

0.081

7 Min

131.98

11.618

128.86

11.658

1.333

0.186

10 Min

131.06

11.557

125.52

10.983

2.445

0.016

 

Table 4 shows that there was a significant decrease in systolic pressure (SBP) in both the groups after induction. In combination of esmolol and lignocaine test dose a significant decrease in SBP occurred after 1min (p <0.001), and 3 min (p <0.001) groups respectively. The control group was associated with a significant rise in SBP after laryngoscopy which lasted till 2 min (P < 0.001).

Table 5: Diastolic Blood Pressure (DBP) changes between two groups

Diastolic blood pressure

Lignocaine

Esmolol

T test

P value

Mean

SD

Mean

SD

Pre Induction

76.65

5.808

76.4

5.083

0.231

0.818

Post Induction

75.65

5.387

88.28

100.78

-0.885

0.381

1 Min

86.27

5.267

80.9

4.621

5.383

0.001**

3 Min

84.92

5.342

81.74

3.848

3.391

0.001**

5 Min

79.73

4.31

80.24

3.926

-0.61

0.544

7 Min

76.06

4.741

78.96

4.04

-3.271

0.001**

10 Min

75.04

4.458

78.02

3.846

-3.557

0.001**

 

Table 5 shows in the combination group DBP were significantly less than control from  1min after giving the test dose till 3 min (P<0.001) after induction.

Table 6: MAP changes

Mean arterial blood pressure

Lignocaine

Esmolol

T test

P value

Mean

SD

Mean

SD

Pre Induction

95.0953

6.61213

109.5112

11.32

-0.922

0.361

Post Induction

94.1237

6.10727

91.166

5.15924

2.601

0.011*

1 Min

107.9258

7.059109

98.606

5.240712

7.447

0.001**

3 Min

106.1569

7.331751

119.376

6.23

-0.651

0.518

5 Min

98.78908

5.245817

97.856

4.663893

0.935

0.352

7 Min

94.21753

5.499581

96.292

4.416612

-2.067

0.042*

10 Min

92.84359

5.502277

95.294

4.170176

-2.494

0.014*

** p <0.001, * p<0.05

Table 6 showed that on comparing lignocaine with esmolol in mean arterial pressure (MAP) there was no significant difference was found after laryngoscopy.

DISCUSSION:

Laryngoscopy and intubation is associated with rise in heart rate, blood pressure and incidence of cardiac arrhythmias. These potentially dangerous changes disappear within 5 minutes of onset of laryngoscopy. [3] Although these responses of blood pressure and heart rate are transient and short lived they may prove to be detrimental in high risk patients especially in those with cardiovascular disease, increased intracranial pressure or anomalies of the cerebral blood vessels. [4]

Esmolol is a beta blocking agent with several desirable properties. It is relatively cardio selective, ultra short acting, with rapid onset of action. Previous studies have shown that the unique pharmacokinetic behavior of esmolol makes it well suited for controlling the cardiovascular responses to tracheal intubation when used as a continuous infusion technique. [5, 6]

However, the dosing schedule and the time required for preparation of infusion may add a degree of complexity. A single alternative is using bolus doses of esmolol and many studies have investigated this and concluded it to be efficacious.  [7, 8]

In our study showed that the heart rate increased by a maximum of 41.1% when compared to pre induction value in the control group (p<0.001). Both lignocaine and esmolol attenuated the heart rate significantly (p value <.001).

It reaches a level which is clinically less significant by the end of 7 minutes in control group and by the end of 1 and 3 minutes in lignocaine and esmolol group. Attenuation of maximum rise in the heart rate by esmolol is evident and statistically significant difference when compared with control group.

In control group systolic blood pressure increased maximally after 1 minute from the onset of laryngoscopy and intubation. It gradually decreased to pre-induction values over 10 minutes. With lignocaine group the maximum rise in systolic blood pressure was 14.5% above pre induction values and with esmolol it was only 6.6% above pre-induction values by the end of 1 minute. Both drugs compared with control showed significant attenuation (p>0.001).

Attenuation of diastolic blood pressure is very significant in the two groups as compared to control group until the end of 5 minutes (p<0.001). Among the two study groups esmolol showed a better attenuation of diastolic blood pressure compared to lignocaine.

Singh et al study concluded that prophylactic treatment with esmolol (2 mg/kg) is most effective in blunting HR response to laryngoscopy and intubation. [10] Studies done by Gupta and Tank also showed that esmolol (2mg/kg) given 90 s and 3 min before intubation, respectively, prevents a rise in HR. [11]

The efficiency of esmolol over lignocaine in attenuation of cardiovascular responses similar to our study has been verified by many other studies.  In present study showed that a combination of both lignocaine and esmolol has been recommended for better responses.

CONCLUSION:

In esmolol group very highly significant and consistent attenuation of sympathetic responses as compared to control group was noted. Heart rate and blood pressures rose steadily over 1 and 3 minutes with a gradual return to near basal levels of heart rate and below basal levels of blood pressure. Among the both study groups superiority of esmolol over lignocaine in attenuating the sympathetic responses to laryngoscopy and intubation is evident and statistically highly significant at all times.

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  8. Helfman SM, Gold MI, DeLisser EA, Everard A, Herrington CA. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl or esmolol? Anaesth Analg. 1991; 72(4):482-6.
  9. Feng CK, Chan KH, Liu KN, Or CH, Lee TY. A comparison of lidocaine fentanyl and esmolol for attenuation of cardiovascular response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Sin. 1996; 34(2):61-7.
  10. Singh S, Laing EF, Owiredu WK, Singh A, Annamalai A. A study of efficacy of cardiac anti dysrhythmic drugs in attenuating haemodynamic responses to laryngoscopy and endotracheal intubation in Black population. J Anesthesiol. 2013; 1:1‑8.
  11. Gupta S, Tank P. A comparative study of efficacy of esmolol and fentanyl for pressure attenuation during laryngoscopy and endotracheal intubation. Saudi J Anaesth. 2011; 5:2‑8.




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