Abstract
Emergence from general anesthesia is often complicated by the endotracheal tube (ETT) induced airway and circulatory reflexes which can lead to potentially dangerous complications. Considerable research has been focused on prevention of these emergence phenomena (EP). Nevertheless, the problem is still far from its final solution. Objective: To compare the efficacy of intracuff alkalinized lidocaine (ICL) vs low dose remifentanil infusion in attenuating the ETT-induced EP. Methods: 120 ASA I-III patients, aged 18-65 years, were randomly assigned to receive intracuff alkalinized lidocaine (2% lidocaine mixed 1:1 with 1.4% NaHCO 3 ) or an intravenous (IV) remifentanil infusion (0.05-0.5 mcg/ kg/min) combined with intracuff saline during desflurane-based general anesthesia. At the end of surgery, after desflurane was turned off in the assigned group, low dose remifentanil, or its equivalent placebo was decreased to one-tenth of the mean dose but not less than 0.01 mcg/kg/min and it was continued until extubation. A blinded researcher observed each patient from the time desflurane was discontinued until at least five minutes after extubation. Coughing was evaluated as either present or not, and graded on a point scale based on severity. The patients were also observed for development of any adverse events along with the vital signs during this emergence phase. Results: The incidence (44% vs 67%, p=0.02) and severity of coughing, overall, was significantly less in the lidocaine group compared to remifentanil group). The lidocaine group also had a lower incidence of significant coughing (2-3 on point scale) (25% vs 49%, p=0.009). The mean arterial pressure (MAP) in the lidocaine group was lower than the remifentanil group at extubation and 5 minutes after extubation.
Highlights
Emergence from general anesthesia is often complicated by the endotracheal tube (ETT)-induced emergence phenomena (EP) which includes coughing, sympathetic stimulation, sore throat and dysphonia [1,2,3,4,5].The reported incidence of patient coughing during emergence is as high as 80-95% [1,2,3]
The mean arterial pressure (MAP) in the lidocaine group was lower than the remifentanil group at extubation and 5 minutes after extubation
Emergence from general anesthesia is often complicated by the ETT-induced EP which includes coughing, sympathetic stimulation, sore throat and dysphonia [1,2,3,4,5]
Summary
Emergence from general anesthesia is often complicated by the ETT-induced EP which includes coughing, sympathetic stimulation, sore throat and dysphonia [1,2,3,4,5].The reported incidence of patient coughing during emergence is as high as 80-95% [1,2,3]. Various strategies have been employed to attenuate this response including extubation in a deep plane of anesthesia [10], administration of IV agents like short acting narcotics [11,12,13], IV lidocaine [14,15,16] or dexmedetomidine [17] and the topical or intracuff application of lidocaine [1,2,3,4,5] Each of these methods has its own limitations and a reliable technique which would increase the ETT tolerance while facilitating rapid and complete emergence from general anesthesia has not been proven to date. Estebe et al showed successful suppression of cough reflex and sore throat with as little as 40 mg of intra cuff alkalinized Lidocaine [23,24,25] Encouraged by these reports, we decided to use low dose of alkalinized lidocaine to inflate the ETT cuff
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