Comparison of esmolol versus combination of esmolol and fentanyl in preventing cardiovascular stress response to intubation
Keywords:Esmolol, Fentanyl, Cardiovascular Stress, Laryngoscopy, Endotracheal intubation
Background: A number of cardiovascular responses occur during laryngoscopy and intubation which can have serious consequences during anaesthesia.We planned to conduct a study to evaluate effectiveness of intravenous Esmolol and intravenous Fentanyl in attenuating hemodynamic stress response to laryngoscopy and endotracheal intubation.
Methods: A prospective, observational, randomized, double blind comparative clinical study, conducted on 60 cases of ASA grade I/II patients undergoing elective abdominal surgery under general anesthesia. The data obtained was divided in the two groups based on drug used 5 min prior to induction, Group 1 (I.V. Esmolol 2 mg/kg) and Group 2 (I.V. Esmolol 2 mg/kg & I.V. Fentanyl 2 µg/kg). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were measured at various time intervals.
Results: There was no significant difference in HR, SBP, DBP, MAP after premedication and induction in both the groups. However at intubation, both groups showed an increase in HR, SBP, DBP and MAP but the rise was attenuated in both groups. Increase in HR was more in group 1 as compared to group 2 and it was statistically significant at 01 and 02 minutes post intubation. The increase in SBP was statistically significant at 00, 01 and 02 minutes post intubation. The increase in MAP was statistically significant immediately after induction, at 00, 01, 02, 05 and 10 minutes post intubation.
Conclusions: Combination of intravenous Esmolol and intravenous Fentanyl is more effective in attenuating heart rate, systolic, diastolic and mean arterial pressure response to intubation than intravenous Esmolol alone.
King BD, Harris LC Jr, Griefenstein FE, Elder JD Jr, Dripps RD. Reflex circulatory response to direct laryngoscopy and tracheal intubation. Anaesthesiol. 1951;12:556-66.
Bruder N, Ortega D, Granthil C. consequences and prevention methods of hemodynamic changes during laryngoscopy and intratracheal intubation. Ann Fr Anaesth Reanim.1992;11(1):57-71.
Slogoff S, Keats AS. Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anaesthesiol. 1985;62(2):107-8.
Stoelting RK. Circulatory response to laryngoscopy and tracheal intubation with or without prior oropharyngeal viscous Lidocaine. Anaesth Analg. 1977;56(5):618-21.
Venus B, Polasssani V, Pham CG. Effects of aerosolized Lidocaine on circulatory responses to laryngoscopy and tracheal intubation. Crit Care Med. 1984;12(4):391-4.
Sklar BZ, Jurie S, Ezri T, Krichelli D, Savir I, Soroker D. Lidocaine inhalation attenuates the circulatory response to laryngoscopy and endotracheal intubation. J Clin Anaesth. 1992;4(5):382-5.
Takita K, Morimoto Y, Kemmotsu O. Tracheal Lidocaine attenuates the cardiovascular response to endotracheal intubation. Can J Anaesth. 2001;48(8):732-6.
Mostafa SM, Murthy BV, Barret PJ, McHugh P. Comparison of the effects of topical Lignocaine spray applied before or after induction of anaesthesia on the pressor response to direct laryngoscopy and intubation. Eur J Anaesthesiol. 1999;16(1):7-10.
Singh H, Vichitvejpaisal P, Guines AY, White PF. Comparative effects of Lidocaine, Esmolol, and Nitroglycerine in modifying the hemodynamic response to laryngoscopy and intubation. Am J Clin Anaesth. 1995;7(1):5-8.
Van den Berg AA, Savva D, Honjol NM. Attenuation of hemodynamic responses to noxious stimuli in patients undergoing cataract surgery: A comparison of Magneshium Sulphate, Esmolol, Lignocaine, Nitroglycerine and Placebo given IV with induction of anaesthesia. Eur J Anaesthesiol. 1997;14(2):134-47.
Wilson IG, Meiklejohn BH, Smith G. Intravenous Lignocaine and sympathoadrenal responses to laryngoscopy and intubation: the effect of varying time of injection. Anaesthesia.1991;46(3):177-80.
Malde AD, Sarode V. Attenuation of hemodynamic response to endotracheal intubation: Fentanyl versus Lignocaine. Int J Anaesthesiol. 2007;12:1.
Seong-Hoon Ko, Dong-Chan Kim, Young-Jin Han, He-Sun Song. Small- Dose Fentanyl: Optimal time of injection for blunting the circulatory responses to tracheal intubation. Anaesth Analg. 1998;86:658-61.
Helfman SM, Martin I Gold, Everard A, DeLisser, Claire A, Herrington RN. Which drug prevents tachycardia and hypertension associated with tracheal intubation: Lidocaine, Fentanyl, Esmolol? Anaesth Analg. 1991;72:482-6.
Dahlgreen N, Messeter K. Treatment of stress response to laryngoscopy and intubation with Fentanyl. Anaesthesia. 1981;36:1022-6.
Kautto UM. Attenuation of circulatory response to laryngoscopy and intubation by Fentanyl. Acta Anaesth Scand. 1982;26:217
Chung F, Evans D. Low-dose Fentanyl: hemodynamic response during induction and intubation in geriatric patients. Can Anaesth Soc. 1985;32(6):622-8.
Martin DE, Rosenberg H, Aukburg SJ, Bartkowski RR, Edwards MW, Greenhow DE. Low dose Fentanyl blunts circulatory responses to tracheal intubation. Anaesth Analg. 1982;61:680-4.
Yushi U, Adachi, Satomoto M, Higuchi H, Watanabe K. Fentanyl attenuates the hemodynamic response to endotracheal intubation more than the response to laryngoscopy. Anaesth Analg. 2002;95:233-7.
Maguire AM, Kumar M Parker JL, Rowbotham DJ, Thompson JP. Comparison of effects of Remifentanil and Alfentanil on cardiovascular response to tracheal intubation in hypertensive patients. Br J Anaesth. 2001;86(10):90-3.
Stoelting RK. Attenuation of blood pressure response to laryngoscopy and tracheal intubation with Sodium Nitroprusside. Anaesth Analg. 1979;58:116-24.
Wig J, Sharma M, Baichoo N, Agarwal A. Nicardipine and Verapamil attenuate the pressor response to laryngoscopy and intubation. Can J Anaesth. 1994;41(12):1185-8.
Kulka PJ, Tryba M, Zenz M, MD. Dose-response effects of intravenous Clonidine in stress response during induction of anaesthesia in coronary artery bypass graft patients. Anaesth Analg. 1995;80:263-8.
Kamran M, Parviz K, Azim H, Mohammadreza S, Anahita H. Attenuation of the pressor response to direct laryngoscopy and tracheal intubation: oral Clonidine vs. oral Gabapentin premedication. JRMS. 2011;16:377-86.
Takki S, Tammisto T, Nikki P. Effect of laryngoscopy and intubation on plasma catecholamine levels during intravenous induction of anaesthesia. Br J Anaesth. 1972;44:1323-8.
Cork RC, Weiss JL, Homerroff SR, Bentley J. Fentanyl preloading in rapid sequence induction of anaesthesia. Anaesth Analg. 1984;63:60-4.
Hill AB, Bowley CJ, Nahrwold ML, Knight PR, Kirsh MM, Denliger JK. Intranasal administration of Nitroglycerine. Anaesthesiol. 1981;54:346-8.
Koc S, Memis D, Sut D. The preoperative use of Gabapentin, Dexamethasone and their combination in varicocele surgery: A randomized control trial. Anaesth Analg. 2007;105(4):1137-42.
Chung KS, Raymond SS, Jonathan DH, Darcy P, David GS. A comparison of Fentanyl, Esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesht 1992;39(8):774-9.
Miller DR, Martineau RJ, Wynands JE, Hill J. Bolus administration of Esmolol for controlling the haemodynamic response to tracheal intubation: the Canadian multicentre trial. Can J Anaesth. 1991;38(7)849-58.
Arti Rathore, Gupta HK, Tanwar GL, Rehman H. Attenuation of the pressure response to laryngoscopy and endotracheal intubation with different doses of Esmolol. Indian J Anaesth. 2002;46(6):449-52.
Ghaus MS, Singh V, Kumar A, Wahal R. Bhatia VK, Agarwal J. A study of cardiovascular response during laryngoscopy and intubation and their attenuation by ultrashort acting alpha-blocker Esmolol. Indian J Anaesth. 2002;46(2):104-6.
Sheppard S, Chris JE. A bolus dose of Esmolol attenuates tachycardia and hypertension after tracheal intubation. Can J Anaesth. 1990;37(2):202-5.
Singh SP, Quadir A, Malhotra P. Comparison of Esmolol and Labetalol, in low doses, for attenuation of sympathomimetic response to laryngoscopy and intubation. Saudi J Anaesth. 2010;4(3):163-8.
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(1):2-8.
Derbyshire DR, Chmielewski A, Fell D, Vater M, Achola K, Smith G. Plasma catecholamine responses to tracheal intubation. 1983;55(9):855-6.
Harris CE, Murray AM, Anderson JM, Grounds RM, Morgan M. Effects of Thiopentone, Etomidate and Propofol on the haemodynamic response to tracheal intubation. Anaesthesia. 2007;43(1):32-5.
Singhal SK, Neha. Haemodynamic response to laryngoscopy and intubation; Comparison of McCoy and Macintosh laryngoscope. Intern J Anaesth. 2008;17:1.
Burnstein CL, Woloshin G, Newman W. Electrocardiographic studies during endotracheal intubation: Effect during anaesthesia and intravenous Procaine. Anaesthesiol. 1950;11:299-14.