Peri-extubation Period Research Articles

Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients

IntroductionWeaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes.Materials and methodsThis prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value.ResultsThirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure.ConclusionsIn difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.

Haemodynamic Responses Following Lidocaine Infusion on Hypertensive Patient Undergoing Laparoscopic Cholecystectomy

Many pharmacological methods have been evaluated to attenuate the adverse haemodynamic responses resulting from airway manipulation and pneumoperitoneum. Intravenous lidocaine infusion is one of them; bolus dose of intravenous lidocaine is used to reduce haemodynamic changes resulting from intubation and extubation reflex whereas intraoperative infusion of lidocaine has been used for post-operative analgesia in laparoscopic cholecystectomy. This randomized controlled trial was conducted to observe the effectiveness of lidocaine infusion in obtundation of haemodynamic responses on hypertensive patient undergoing laparoscopic cholecystectomy. A total number of 80 patients were enrolled in this study. Patients were allocated into two groups by computer generated random chart according to a 1:1 ratio. The patients of group A were given general anaesthesia with placebo normal saline infusion and the patients of group B were given general anaesthesia with lidocaine infusion (1.5mg/kg). Mean differences of blood pressure (SBP &amp; MAP) and heart rate at different time periods from baseline were compared between two groups. The demographic profiles were almost similar between the groups (p&gt;0.05). In comparison between two groups, heart rate, systolic blood pressure and mean arterial pressure rise from baseline value was more in normal saline group (group A) than lidocaine test group (group B) during peri-intubation, pneumoperitoneum and peri-extubation period. Statistical difference was significant between two groups (p&lt;0.05) in different haemodynamic parameters. Adverse events such as tachycardia premature ventricular contraction (PVC) and hypertension were observed much more in group A, which was higher than that of group B. We observed that administration of lidocaine infusion attenuates haemodynamic responses of hypertensive patient during laparoscopic cholecystectomy. CBMJ 2024 July: vol. 13 no. 02 P: 148-157

Effect of different head-high lateral extubation on adverse reactions in the peri-extubation period of pediatric OSAS surgery under general anesthesia

BackgroundChildren with OSAS are prone to various airway complications during tracheal extubation after tonsillectomy and adenoidectomy due to oropharyngeal secretions and oozing blood. However, few studies have examined the effect of position on airway complications after tracheal extubation in children with OSAS. The aim of this study was to investigate the appropriate position for extubation in children with OASA.MethodsA total of 459 children aged 3–14 years with OSAS who underwent tonsillectomy and adenoidectomy were recruited for this study. All children were treated with the same surgical approach and standard anesthesia methods of induction of anesthesia, tracheal intubation and maintenance of anesthesia. At the end of surgery, the children were delivered to the post anesthesia care unit and randomly divided into three groups: Group A: Head-high 0° in lateral position; Group B: Head-high 15° in lateral position; Group C: Head-high 30° in lateral position. The main outcomes of this study were the pulse oxygen saturation (SpO2) and the Sedation-Agitation Scale (SAS) scores of the children after extubation, the outflow of oral-nasal secretions and the respiratory complications. Secondary outcomes were blood pressure, heart rate, end-respiratory carbon dioxide, respiratory rate, and post-operative awakening time of the children in three groups.ResultsData from a total of 423 children were statistically analyzed, 141 in Group A, 142 in Group B, and 140 in Group C. The main results showed a significant decrease in choking response after extubation in Group B (46.5%) and Group C (40.7%) compared to Group A (60.3%) (P < 0.05). The SAS score for postoperative agitation was higher in Group A (4.6 pm 0.9) than in Group B (4.4 pm 0.7) and Group C (4.3 pm 0.6) (P < 0.05). Also the SpO2 after extubation was higher in Group B (97.2%) and Group C (97.1%) than in Group A (95.8%) (P < 0.05). In contrast, there was no difference in the occurrence of respiratory complication and postoperative agitation in children between Group B and Group C (all P > 0.05). In addition, there was no difference in the amount of oral-nasal secretions among the children in the three groups (all P > 0.05).ConclusionThe head-high 15° lateral position and head-high 30° lateral position can reduce the incidence of airway complications and agitation and provide safe and comfortable extubation conditions for children during the peri-extubation period after tonsillectomy and adenoidectomy, which has certain clinical guidance value.Trial registrationRegistration Number: NO.ChiCTR2200055835(20,01,2022) https://www.chictr.org.cn

Ethical Considerations in Supporting Donation after Circulatory Death: The Role of the Dead-Donor Rule

There is a conflict between the wishes of terminally ill patients to allow withdrawal of treatment and become donors after cardiac death (DCD) and the limit on interventions required by the dead-donor rule (DDR). Once a breathing tube is removed, hours can pass before the patient expires. This interim time complies with the DDR, but often makes donation impossible. The consequences are the nullification of donors' wishes and the waste of organs for transplantation. Since the DDR was developed, attitudes on end-of-life interventions have evolved, organ donation has been embraced, and the field of organ transplantation has been firmly established. A new ethical approach is needed that, based on patients' autonomy, considers organ donation a goal of care and views the donated organs as having a profound value for the donor and recipient. It is time to prioritize patients' autonomous desire to donate life-giving organs to others and thus promote continuity of care for the donated organs over the modality of death pronouncement. To support patients' desire to be organ donors, the conversation should be open to allow medical intervention in the peri-extubation period.

EFFECTIVENESS OF INTRAVENOUS LIDOCAINE AND FENTANYL ON ATTENUATION OF HEMODYNAMIC RESPONSE TO EXTUBATION FOR EAR, NOSE AND THROAT SURGERIES AT JLNMCH, BHAGALPUR, BIHAR

Background: Tracheal extubation, the purposeful removal of the endotracheal tube from the trachea, can be associated with detrimental hemodynamic and airway responses. Lidocaine and fentanyl are known to suppress hemodynamic response to extubation during Ear, nose, and throat surgeries. Smooth tracheal extubation is important after Ear, nose, and throat surgeries. To compare the effect of intravenousObjective: lidocaine and fentanyl on attenuation of hemodynamic response to extubation for Ear, nose, and throat (ENT) surgeries at JLNMCH, Bhagalpur, Bihar. This prospective cohort study recruits 74 American Society of Anesthesiologist (ASA) class I and II, age between 18 and 60Methods: patients who underwent Ear, Nose and Throat surgeries. Unpaired T test was used to compare the mean of heart rate and mean arterial blood pressure between groups. Mann Whitney U Test was used for distribution free data. Association of categorical independent variables between two groups were analyzed using Chi Square or sher exact test. P-values &lt; 0.05 were considered as statistically signicant with a power of 80%. Results: The demographic and clinical characteristics were comparable between groups. The pulse rate and mean arterial blood pressure were signicantly lower in fentanyl group at 1, 5, and 10 min after extubation with p values &lt; 0.05. There was no statistically signicant difference between two groups with decreasing the incidence of coughing in the Periextubation period with a p value of 0.857.Conclusion and Recommendation: The ndings of our study demonstrate that fentanyl 1μg/kg IV, administered 10 min before end of operation, was more effective in attenuating hemodynamic response to tracheal extubation compared with lidocaine 1.5 mg/kg IV in patients underwent ENT surgeries. We recommend that fentanyl administered 10 minutes before the end of operation for ENT surgeries is effective in attenuating hemodynamic response to extubation.

Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team‐focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

Subclinical Hypoventilation in Dogs Undergoing Ventral Slot Decompressive Surgery for Cervical Myelopathy Due to Intervertebral Disc Herniation.

The objective of this prospective cohort study was to document the occurrence of post-operative hypoventilation in dogs undergoing decompressive ventral slot or hemilaminectomy for the treatment of intervertebral disc herniation (IVDH). Twenty dogs undergoing ventral slot surgery and 20 dogs undergoing hemilaminectomy surgery for the treatment of IVDH that presented to XX between 2017 and 2020 were enrolled. Dogs were anesthetized using a standard protocol. Blood gas samples were taken at up to 11 time points beginning during anesthetic recovery and continuing for a maximum of 72 h post-operatively. Dogs with cervical lesions that were non-ambulatory before surgery had more evidence of subclinical hypoventilation in the immediate peri-extubation period than dogs with less severe injuries or those undergoing hemilaminectomy surgery. We found no difference in the ventilation status in dogs undergoing cervical or thoracolumbar decompressive surgery for IVDH from 8 to 72 h post-operatively. Other markers of acid-base status indicated that subclinical hypoventilation within the peri-extubation period was transient and self-limiting. There was a moderate positive correlation between sedation scores and estimated PaCO2. These data suggest that dogs with severe cervical spinal cord injuries may be at risk for subclinical hypoventilation in the immediate peri-extubation period. Increased sedation may be correlated with decreased ventilatory status in dogs recovering from decompressive vertebral column surgery.

Efficacy of a single dose of esmolol to prevent extubation-related complications during emergence from anesthesia: a randomized, double-blind, placebo-controlled trial

BackgroundFew trials have examined the efficacy of esmolol to attenuate hemodynamic and respiratory responses during extubation. However, the most appropriate dose of esmolol and an optimal protocol for administering this beta-blocker are uncertain. MethodsNinety patients ASA physical status I, II, and III (aged 18–60 years) scheduled to procedures with general anesthesia and tracheal extubation were selected. Patients were randomized into esmolol and placebo group to evaluate the efficacy and safety of a single bolus dose of esmolol (2 mg.kg-1) on cardiorespiratory responses during the peri-extubation period. The primary outcome was the rate of tachycardia during extubation. ResultsThe rate of tachycardia was significantly lower in esmolol-treated patients compared to placebo-treated patients (2.2% vs. 48.9%, relative risk (RR): 0.04, 95% confidence interval (95% CI) = 0.01 to 0.32, p = 0.002). The rate of hypertension was also significantly lower in the esmolol group (4.4% vs. 31.1%, RR: 0.14, 95% CI 0.03 to 0.6, p = 0.004). Esmolol-treated patients were associated with higher extubation quality compared to patients who received placebo (p < 0.001), with an approximately two-fold increase in the rate of patients without cough (91.1%) in the esmolol group compared to the placebo group (46.7%). The rate of bucking was approximately 5-fold lower in the esmolol group (8.9% vs. 44.5%, respectively, RR: 0.20 (95% CI, 0.1 to 0.5, p = 0.002, with an NNT of 2.8). ConclusionA single bolus dose of esmolol is an effective and safe therapeutic strategy to attenuate cardiorespiratory responses during the peri-extubation period.

P0332 / #807: FAILED EXTUBATION - RATE AND CAUSES IN A PAEDIATRIC CARDIAC INTENSIVE CARE UNIT IN UNITED KINGDOM

Aims & Objectives: To determine the rate of failed extubation and to find out the common causes in a paediatric cardiac intensive care. Methods: Design: Descriptive study with prospective data collection from medical documentation over 9 months (01/04/2019 till 31/12/2019) Place: Paediatric cardiac intensive care unit, Glenfield Hospital,UK Study Population: All children who were mechanically ventilated in PICU during the study period were included. Children who had failed extubation(defined as re-intubation within 48 hours of planned extubation)were analysed to find out the causes of extubation failure. Main outcome: Rate of Failed extubation Results: 258 patients admitted during the study period required mechanical ventilation. Among them, 15 patients required re-intubation within 48 hours(15/258= 5.8%). Among these 15 patients, 4 had failed extubation more than once. Among these 15 patients, airway problems(n=4), lung issues(n=4), infection(n=3) and cardiac lesions(n=4) were the main reasons for re-intubation. Among airway issues, pre-existent airway problems in 3 patients required further optimisation, and 1 had airway oedema from intubation. Lung collapse/consolidation and pneumothorax were the lung problems leading to re-intubation. Abdominal distension from infection and bacteraemia were infectious complications causing extubation failure. Cardiac causes included increased pulmonary blood flow due to various cardiac lesions in 3 children and poor ventricular function in one. Conclusions: Rate of failed extubation was comparable to available published data. Airway problems, lung issues, infection and cardiac lesions were found to be the causes leading to failed extubation. Addressing these issues and having a plan during the peri-extubation period will help in improving outcome of these patients.

Remifentanil injected during analepsia shortens length of postanesthesia care unit stay in patients undergoing laparoscopic surgery for endometrial cancer: a randomized controlled trial.

To guarantee efficient operating room (OR) activity, tracheal extubation is often performed in the postanesthesia care unit (PACU). Therefore, the ability of PACU to accommodate postoperative patients is crucial. Optimizing extubation management may speed up the turnover of PACU beds. The aim of the present study was to investigate the effect of remifentanil, which is used during analepsia, on the length of PACU stay in patients undergoing laparoscopic surgery for endometrial cancer. In this prospective trial, we recruited a total of 99 patients, who were scheduled for laparoscopic surgery for endometrial cancer. At the end of the surgery, all patients were immediately transferred to the PACU and continued mechanical ventilation. Upon PACU admission, sputum aspiration was routinely performed. If the hemodynamic parameters fluctuated >30% of the baseline level, or patients moved unconsciously without reaching the criteria of extubation, a bolus injection of either 1 μg/kg remifentanil (Rem group, n=51) or propofol 1.0 mg/kg (Pro group, n=48) was randomly administered. The primary outcome was the duration of PACU stay. The secondary outcomes included time to respiratory breath recovery and time to extubation, along with bispectral index (BIS) values and hemodynamic status after remifentanil or propofol intervention. Times of repeated intervention, rescue administration of vasoactive drugs, and the incidence of adverse events were recorded. Visual analog scale and satisfaction scores at the time of PACU discharge were also evaluated. The duration of PACU stay was shorter in the Rem group than in the Pro group [49 (46.47-51.06 minutes) vs. 62 minutes (60.75-69.29 minutes), P<0.0001]. Compared with the Pro group, the time to spontaneous breathing recovery, the time to extubation, and the incidence of hypoxemia after extubation were reduced in the Rem group (P<0.0001, P<0.0001, P=0.03, respectively). After anesthetic administration, the BIS value decreased less in the Rem group (P<0.0001); blood pressure and heart rate (HR) declined, but were comparable in both groups. Remifentanil, which is injected during analepsia, significantly shortens the duration of PACU stay without increasing adverse events in the peri-extubation period.

Effects of lidocaine versus fentanyl on attenuation of hemodynamic responses to extubation after ear, nose and throat surgery in a resource limited setting: A prospective observational study

BackgroundTracheal extubation, the purposeful removal of the endotracheal tube from the trachea, can be associated with detrimental hemodynamic and airway responses. Lidocaine and fentanyl are known to suppress hemodynamic responses to extubation during Ear, nose, and throat surgeries. Smooth tracheal extubation is important after Ear, nose, and throat surgeries. ObjectiveTo compare the effects of lidocaine versus fentanyl on attenuation of hemodynamic responses to extubation after ear, nose and throat surgery in a resource limited setting from January 01, 2018 to March 30, 2018. MethodsThis is a prospective cohort study recruits 74 American Society of Anesthesiologist class I and II, age between 18 and 60 patients who underwent Ear, Nose, and Throat surgeries. Unpaired T test was used to compare the mean heart rate and arterial blood pressure between lidocaine and fentanyl groups. Mann Whitney U Test was used for distribution free data. Association of categorical independent variables between two groups was analyzed using Chi Square or fisher exact test. P-values < 0.05 were considered as statistically significant with a power of 80%. ResultsThe demographic and clinical characteristics were comparable between groups. The pulse rate and mean arterial blood pressure were statistically significantly lower in fentanyl group at 1, 5, and 10 min after extubation with p values < 0.05. There was no statistically significant difference between two groups in decreasing the incidence of coughing in the Peri-extubation period with a p value of 0.857. ConclusionThe findings of our study demonstrate that fentanyl 1 μg/kg IV, administered 10 min before end of operation might be effective in attenuating hemodynamic response to tracheal extubation compared with lidocaine 1.5 mg/kg IV in patients underwent ENT surgeries.

Non-invasive ventilation in children and adults in low- and low-middle income countries: A systematic review and meta-analysis

PurposeWe systematically reviewed the effects of NIV for acute respiratory failure (ARF) in low- and low-middle income countries. Materials and methodsWe searched MEDLINE, CENTRAL, and EMBASE (to January 2016) for observational studies and trials of NIV for ARF or in the peri-extubation period in adults and post-neonatal children. We abstracted outcomes data and assessed quality. Meta-analyses used random-effect models. ResultsFifty-four studies (ten pediatric/n=1099; 44 adult/n=2904), mostly South Asian, were included. Common diagnoses were pneumonia and chronic obstructive pulmonary disease (COPD). Considering observational studies and the NIV arm of trials, NIV was associated with moderate risks of mortality (pooled risk 9.5%, 95% confidence interval (CI) 4.6–14.5% in children; 16.2% [11.2–21.2%] in adults); NIV failure (10.5% [4.6–16.5%] in children; 28.5% [22.4–34.6%] in adults); and intubation (5.3% [0.8–9.7%] in children; 28.8% [21.9–35.8%] in adults). The risk of mortality was greater (p=0.035) in adults with hypoxemic (25.7% [15.2–36.1%]) vs. hypercapneic (12.8% [7.0–18.6%]) ARF. NIV reduced mortality in COPD (relative risk [RR] 0.47 [0.27–0.79]) and in patients weaning from ventilation (RR 0.48 [0.28–0.80]). The pooled pneumothorax risk was 2.4% (0.8–3.9%) in children and 5.2% (1.0–9.4%) in adults. Meta-analyses had high heterogeneity. ConclusionsNIV for ARF in these settings appears to be effective.

Managing Extubation and the Post Extubation Period in the Intensive Care Unit

The process of successfully weaning patients from invasive mechanical ventilation is a great challenge for all healthcare providers working in critical care. Despite several recent advances in the care of intensive care patients, failed extubation remains a significant problem that may result in poor patient outcomes. A lack of consensus in many areas regarding clinical approach to extubation and the peri-extubation period exists, and the numerous strategies described in this review add to the complexity of the decision faced by the clinicians involved. The process of weaning and timing of extubation may be improved by implementation of a consistent multidisciplinary approach to weaning, with a number of easily identifiable risk factors available to support clinical decision making. There are also many known risk factors that can be used to predict the likelihood of extubation failure; whilst these factors may not be easily modifiable, they do allow the identification of patients at a high risk of extubation failure who may require more detailed care and planning post extubation. Finally, a number of strategies, including non-invasive ventilation and high flow nasal oxygen therapy, are available to support carefully selected groups in the post extubation period. Evidence is emerging linking these adjuncts to a reduction in the risk of extubation failure. This article will discuss these risk factors and the evidence supporting their use in this challenging patient group.

Effection of combining dexmedetomidine with lidocaine cream on response to tracheal extubation in pediatric tonsillectomy

Objective: To evaluate the effects of combining dexmedetomidine with lidocaine cream on extubation reaction in pediatric tonsillectomy. Methods: Eighty children scheduled for tonsillectomy from January to June 2016 in the Lanzhou University Second Hospital, were randomly divided into group C (controll group), group D (dexmedetomidine group), group L (lidocaine cream group)and group R (combing dexmedetomidine with lidocaine group) by digital random table method (n=20). In group D and R, dexmedetomidine 1 μg/kg was injected intravenously after general anesthesia induction, and the same volume of normal saline was given in group L and C. Meanwhile, the children in group L and R were intubated with endotracheal tube coated with compound lidocaine cream at first third, while the children were intubated with endotracheal tube coated with liquid paraffin in group D and C. Heart rate(HR), systolic blood pressure(SBP), diastolic blood pressure(DBP) and saturation of pulse oximetry(SPO(2)) were recorded at the time of baseline(T0), before(T1) and immediately (T2) extubation, 1(T3), 5(T4), 10(T5)minutes after extubation. The time of spontaneous breathing recovery and extubation were recorded. Cough score, agitation score and adverse reactions were evaluated during the peri-extubation period. Results: During extubation, HR were (86.70±6.53), (89.30±4.93), (86.00±4.05) beats per minute at T1, T2, T3 respectively in group D, and they were (90.35±6.60), (91.20±6.44), (90.20±5.43) beats per minute in group L and were (85.70±8.67), (88.10±8.75), (86.95±7.73) beats per minute in group R. HR were (96.15±10.16), (97.75±10.93), (94.35±7.26) beats per minute at T1, T2, T3 respectively in group C. HR were significantly lower in group D, R and L than that in group C at T1, T2, T3(F=6.754, 5.655, 7.191, all P<0.05). Cough score were (1.80±0.70), (1.55±0.69), (1.25±0.44) in group D, L and R respectively. All of them were significantly lower than that in group C(2.45±1.05) (F=0.614, P<0.05). Cough score were significantly lower in group R than that in group D(P<0.05). Agitation score were (1.95±0.83), (1.75±0.72) in group D and R respectively, and they were significantly lower than that in group C(2.90±1.21)(F=9.245, P<0.05). Agitation incidence were 20%, 15% respectively in group D and R, and they were significantly lower than that in group C(60%) (χ(2)=21.554, P<0.05). Conclusion: Combining dexmedetomidine with lidocaine cream can effectively alleviate stress and cough reaction during extubation in pediatric tonsillectomy.

The Prophylactic Use of Remifentanil for Delayed Extubation After Elective Intracranial Operations: a Prospective, Randomized, Double-Blinded Trial.

Endotracheal extubation is a painful and stressful procedure. The authors hypothesized that the prophylactic use of remifentanil would attenuate the pain intensity and stress responses resulting from extubation in neurosurgical patients. In this prospective, randomized, double-blinded, controlled trial, 160 patients with planned delay extubation after elective intracranial operation were randomized 1:1 to receive either remifentanil or normal saline (control) before their extubation. The dose regime of remifentanil was a bolus of 0.5 μg/kg over 1 minute, followed by a continuous infusion of 0.05 μg/kg/min for 20 minutes. The primary outcome was the incidence of severe pain during the periextubation period. Secondary outcomes included changes in the pain intensity and vital signs, failing to pass an extubation evaluation after the study drug infusion, severe adverse events, postextubation complications, and clinical outcomes. Two patients in the remifentanil group did not pass the extubation evaluation. The incidence of severe pain during the periextubation period was significantly lower in the remifentanil group compared with the control group (25.0% vs. 41.3%, P=0.029). Compared with the control group, the visual analog scale in the remifentanil group was significantly lower after the bolus of remifentanil (12±18 vs. 25±27, P=0.001) and immediately after extubation (19±25 vs. 34±30, P=0.001). There were no significant differences in the vital signs immediately after extubation between the 2 groups (P>0.05). The prophylactic use of remifentanil decreases the incidence of severe pain. Our preliminary findings merit a larger trial to clarify the effect of the prophylactic use of remifentanil on clinical outcomes and adverse events.

Continuous postoperative infusion of remifentanil inhibits the stress responses to tracheal extubation of patients under general anesthesia.

PurposeThe study aimed to assess the combined effects of parecoxib with three different doses of remifentanil and its effect on the stress and cough responses following tracheal extubation under general anesthesia.MethodsA total of 120 patients with American Society of Anesthesiologists (ASA) scores of I or II, undergoing selective thyroidectomy with total intravenous anesthesia (propofol-remifentanil) and tracheal intubation, were randomly allocated to be treated with an intravenous injection of parecoxib and a continuous infusion of remifentanil at 0.1 μg/kg/min (R1), 0.2 μg/kg/min (R2), 0.3 μg/kg/min (R3), or an isotonic saline injection (the control group). Hemodynamic vital signs, emergence time, extubation time, sedation-agitation scale (SAS) score, pain visual analog scale (VAS) score, occurrence of coughing, and side effects were recorded before surgery and during the peri-extubation period. The vital signs included blood pressure (BP), heart rate (HR), respiratory rate (R), and peripheral arterial oxygen saturation (SPO2).ResultsBP, HR, the occurrence rate of coughing, and extubation awareness decreased with the dose of remifentanil, and the differences among the groups were significant (P < 0.05). Emergence and extubation time increased with the dose of remifentanil, and the differences among the groups were significant (P < 0.05). The occurrence rates of respiratory depression and bradycardia in group R3 were significantly higher than those in other groups (P < 0.05). SAS and VAS were lowest in group R3, and the differences among the groups were significant (P < 0.05). BP, HR, SAS, and VAS increased with time in the remifentanil groups.ConclusionThe combined use of parecoxib and a moderate dose of remifentanil can effectively suppress the stress and coughing responses during the peri-extubation period. The appropriate quantity of remifentanil was found to be 0.2 μg/kg/min, as this dosage caused no side effects.

A Comparative Study of Inflation of Endotracheal Tube Cuff with Buffered Lidocaine, Saline and Air for Smooth Periextubation Period in Patient with Hyperactive Airway

A Comparative Study of Inflation of Endotracheal Tube Cuff with Buffered Lidocaine, Saline and Air for Smooth Periextubation Period in Patient with Hyperactive Airway

A Randomized Comparison of Remifentanil Target-Controlled Infusion Versus Dexmedetomidine Single-Dose Administration

Remifentanil target-controlled infusion and dexmedetomidine single-dose administration are known to reduce airway response and hemodynamic stimulation during anesthetic recovery. We compared the effects of 2 drugs on the prevention of cough during emergence. We enrolled 70 female patients aged 20-60 years with American Society of Anesthesiologists (ASA) I-II who underwent general anesthesia for elective thyroidectomy. The patients were randomly assigned to remifentanil (group R) or dexmedetomidine (group D). Anesthesia was maintained with sevoflurane and effect-site target-controlled infusion of remifentanil. In group D, remifentanil was discontinued, and dexmedetomidine 0.5 μg/kg was given 10 minutes before the end of surgery. In group R, remifentanil target-controlled infusion at an effective-site concentration of 2.0 ng/mL was maintained during emergence until extubation. The cough grade, hemodynamic values, respiration, and other recovery profiles were evaluated during the periextubation period. The proportion of patients with no cough or just a single cough during extubation was significantly higher in group R than in group D (96.8% vs. 55.9%). The change of mean arterial pressure and heart rate were not significantly different during extubation in both groups. Respiratory rate and the incidence of residual sedation after extubation were lower in group R. There were no desaturation events and no differences in time to extubation or duration of postanesthesia care unit stay in both groups. Remifentanil target-controlled infusion reduces emergence cough from general anesthesia more effectively than single-dose dexmedetomidine. However, a single-dose of dexmedetomidine has the effect with respect to respiratory and hemodynamic stability during emergence.

Influence of Sex on Remifentanil's Cough-prevention Effect during Anesthetic Emergence.

To investigate the influence of sex on the cough-preventing effect of target-controlled infusion(TCI)of remifentanil during anesthetic emergence. A total of 25 female(group F)and 25 male(group M)patients undergoing thyroidectomy were recruited in the current study. Anesthesia was maintained with sevoflurane and remifentanil TCI.At the end of the surgery,inhalational anesthetics were discontinued,and remifentanil TCI at an effect-site concentration(Ce)of 2.0 ng/ml was maintained during emergence until extubation. The cough score,blood pressure,and heart rate(HR)during peri-extubation period as well as the respiratory rate,calm score,and sore throat score after extubation were evaluated. During extubation,the proportion of patients with no cough or just a single cough was significantly higher in group F than in group M(88% vs. 64%,P=0.047). Mean arterial pressure(P=0.025,P=0.037)and HR(P=0.035)were significantly increased during extubation compared with preoperative levels in group M. Sex may influence the cough-preventing effect of remifentanil TCI during anesthetic emergence. At a Ce of 2.0 ng/ml,remifentanil has better cough-preventing effect and more stable hemodynamic status in females than in males.

Effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia.

Background and Aims:Lignocaine in intravenous (IV) bolus dose has been used for minimising haemodynamic changes associated with intubation and extubation. Furthermore, IV infusion has been used for post-operative analgesia. We investigated whether IV peri-operative lignocaine (bolus and infusion) would be able to produce both the effects simultaneously in elective laparoscopic cholecystectomies.Methods:In this randomised prospective study, 60 patients undergoing elective laparoscopic cholecystectomy were randomly divided into two groups of 30 each. In Group A, patients received 6 ml normal saline as bolus over 10 min followed by 6 ml/h infusion whereas in Group B, patients received preservative free 2% lignocaine 1.5 mg/kg IV bolus (made to a volume of 6 ml with normal saline) administered over a period of 10 min and thereafter an infusion at a rate of 1.5 mg/kg/h (pre-diluted in normal saline made to a volume of 6 ml/h. P < 0.05 was considered as significant.Results:The rise in pulse rate (PR) and mean arterial pressure (MAP) were less in Group B as compared to the Group A (P < 0.05) during intubation as well as during extubation. Furthermore, the Group B had significant longer mean pain-free post-operative period of 5½ h as compared to 54.43 min in the Group A (P < 0.05).Conclusion:Administration of lignocaine infusion attenuates the rise in PR as well as MAP during the peri-intubation and peri-extubation period. Furthermore, infusion of lignocaine significantly increases the mean pain-free period post-operatively.