A SMOOTH EMERGENCE Jerod Schell SRNA Oakland UniversityBeaumont

A SMOOTH EMERGENCE Jerod Schell, SRNA Oakland University-Beaumont Hospital Graduate Program of Nurse Anesthesia Lidocaine vs. Alfentanil: its uses perioperatively

Why so concerned? What is the incidence of coughing on emergence from general anesthesia (GA) with an endotracheal tube? ? Adverse side effects: HTN, tachycardia, tachyarrhythmia, ICP, IOP to name a few… Current methods for a smooth emergence = deep extubation, lidocaine jelly, LITA, short acting opioids.

Research Study Info: Sadegi, M. , Firozian, A. , Ghafari, M. H. and Esfehani, F. (2008). Comparison in Effect of Intravenous Alfentanil and Lidocaine on Airway-Circulatory Reflexes during Extubation. International Journal of Pharmacology. 4(3). 223 -226. Dr. Ali Shariati Hospital, Medical Sciences/University of Tehran, Iran.

Materials with Inclusion/Exclusion: RCT, double-blind study Female patients undergoing Cesarean Section with ETT GA. Ages 18 -35 ASA I or II -------------------------------- Respiratory Disease, recent URI, previous laryngeal pathology or surgery, CAD, HTN (taking cardiac meds), smokers, opioid addiction, local anesthetic allergy – All Excluded.

Methods: 1) 2) 3) 4) 5) Standard Induction using Thiopental and Succinylcholine 1. 5 mg/kg. Used cuffed 7. 0 mm OET, inflated with 2 ml greater than minimal leak pressure GA with Isoflurane at 1 MAC before delivery and 0. 5 MAC after, with Oxygen and Nitrous Oxide (50%). Muscle relaxant sustained with Atracurium then IV morphine given after birth. After delivery, anesthetic gases turned off, oropharynx suctioned then 100% oxygen delivered for remainder of case. Then……

Now the actual experiment… 1) 2) “Randomly generated computer assignment” 15 mcg/kg Alfentanil -or 1. 5 mg/kg 2% Lidocaine IV Anesthetists would administer the given dose after return of spontaneous respiration, then after 2 minutes the patient was extubated.

What was measured? Systolic and Diastolic BP Heart Rate Cough: yes or no. -Hemodynamics measured 2 minutes after the end of surgery and served as baseline values Then re-assessments 2 minutes after study drug given and 1 minute after extubation with comparisons made.

Coughing

Statistics

Hemodynamic Statistics Statistically significant data for both categories except baseline values.

Statistical analysis Distribution was checked by Kolmogorov Test Statistical comparison by T-test, Mann. Whitney U-test, and Chi-square Test. Significant when P <. 05, two tailed.

How were subjects treated? ? Narcotics and Lidocaine are both used in practice today, merely a comparison to current acceptable therapies. Typically do not have scheduled Cesarean Sections with a GETA…

Study Notes: Discussion No patients excluded No laryngospasm or bronchospasm Negative effects avoided: -Stress reactions -Intracranial, Intrabdominal pressure -Avoid bleeding or severe injury during emergence.

Study Notes (cont. ) Controlled timing very well. Previous Lidocaine studies cannot statistically prove an improved emergence, only clinical experience with practitioners. Narcotic delay? ? -No clinically significant delay in emergence with narcotic use.

Study Limitations: Narrow patient population Healthy individuals Not all institutions use Alfentanil

Can we use this tomorrow? Alfentanil = opioid agonist -Precaution with Respiratory disease, can use as surgical anesthesia or analgesia. Cost: 500 mcg/ml = $5. 26 per ml. - about $10 per 70 kg patient.

The Art of Anesthesia…. Emergence