The effect of two different doses of dexmedetomidine to attenuate cardiovascular and airway responses to tracheal extubation: a double blind randomized controlled trial
Keywords:
Bradycardia, Breath holding, Dexmedetomidine, Respiratory depression, Tracheal extubation
Abstract
Background: The objective of the study is to assess the effectiveness of two different doses of dexmedetomidine, an alpha 2 adrenergic agonist, to attenuate the cardiovascular and airway responses to tracheal extubation and to observe the adverse effects.
Methodology: Ninety ASA grade I and II patients aged 18-50 years were randomized into three groups; A, B, and C to receive dexmedetomidine 0.5µg/kg, 1µg/kg and normal saline placebo respectively about 15 minutes before discontinuation of inhalational agent. The heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded during administration of drug, before extubation, during extubation, at 1, 3 minutes and every 5 minutes thereafter. Extubation quality was assessed on a 5 point scale and sedation by Ramsay sedation score.
Results: There was significant decrease in heart rate and mean arterial pressure (p<0.001) during extubation in group A and B. Ninety percent of patients in group A, 93.3% patients in group B and 16.7% in group C could be extubated smoothly. The average time to extubate was 12.13±2.11, 14.08±3.19 and 10.27±2.09 minutes in groups A, B, and C respectively (P value <0.001). Higher incidence of bradycardia (p<0.001) was observed in Group A and B whereas incidence of breath holding was higher in group C (p=0.024).
Conclusion: A dose of 0.5µg/kg of dexmedetomidine administered as a bolus infusion before extubation attenuates the stress response to extubation as effectively as 1µg/kg. Higher sedation scores and longer time to extubate are seen with a dose of 1µg/kg without causing respiratory depression.
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References
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8. Cranfield KA, Bromley LM. Minimum alveolar concentration of desflurane for tracheal extubation in deeply anaesthetized, unpremedicated children. British journal of anaesthesia. 1997 Apr 1;78(4):370-1.
9. Lepousé C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth. 2006 Jun;96(6):747-53. Epub 2006 May 2. [PubMed]
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11. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia. 1998 Jun 1;53(6):540-4.
12. Gonzalez RM, Bjerke RJ, Drobycki T, Stapelfeldt WH, Green JM, Janowitz MJ, Clark M. Prevention of endotracheal tube-induced coughing during emergence from general anesthesia. Anesthesia & Analgesia. 1994 Oct 1;79(4):792-5.
13. Galinkin JL, Fazi LM, Cuy RM, Chiavacci RM, Kurth CD, Shah UK, Jacobs IN, Watcha MF. Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology. 2000 Dec;93(6):1378-83.
14. Davis PJ, Greenberg JA, Gendelman M, Fertal K. Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion. Anesth Analg. 1999 Jan;88(1):34-8.
15. Lapin SL, Auden SM, Goldsmith LJ, Reynolds AM. Effects of sevoflurane anaesthesia on recovery in children: a comparison with halothane. Paediatr Anaesth. 1999;9(4):299-304.
16. Kulka PJ, Bressem M, Tryba M. Clonidine prevents sevoflurane-induced agitation in children. Anesth Analg. 2001 Aug;93(2):335-8, 2nd contents page. [PubMed]
17. Guler G, Akin A, Tosun Z, Eskitascoglu E, Mizrak A, Boyaci A. Single-dose dexmedetomidine attenuates airway and circulatory reflexes during extubation. Acta anaesthesiologica scandinavica. 2005 Sep 1;49(8):1088-91. [PubMed]
18. Bloor BC, Flacke WE. Reduction in halothane anesthetic requirement by clonidine, an alpha-adrenergic agonist. Anesth Analg. 1982 Sep;61(9):741-5.
19. Pouttu J, Scheinin B, Rosenberg PH, Viinamäki O, Scheinin M. Oral premedication with clonidine: effects on stress responses during general anaesthesia. Acta Anaesthesiol Scand. 1987 Nov;31(8):730-4.
20. Gold MS, Redmond DE Jr, Kleber HD. Clonidine blocks acute opiate-withdrawal symptoms.Lancet. 1978 Sep 16;2(8090):599-602. [PubMed]
21. Virtanen R, Savola JM, Saano V, Nyman L. Characterization of the selectivity, specificity and potency of medetomidine as an alpha 2-adrenoceptor agonist. Eur J Pharmacol. 1988 May 20;150(1-2):9-14. [PubMed]
22. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology. 1992 Dec;77(6):1125-33. [PubMed]
23. Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992 Dec;77(6):1134-42. [PubMed]
24. Aho M, Lehtinen AM, Erkola O, Kallio A, Korttila K. The effect of intravenously administered dexmedetomidine on perioperative hemodynamics and isoflurane requirements in patients undergoing abdominal hysterectomy. Anesthesiology. 1991 Jun;74(6):997-1002.
25. Talke P, Richardson CA, Scheinin M, Fisher DM. Postoperative pharmacokinetics and sympatholytic effects of dexmedetomidine. Anesthesia & Analgesia. 1997 Nov 1;85(5):1136-42.
26. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesthesia & Analgesia. 2000 Mar 1;90(3):699-705.
27. Shelly MP. Dexmedetomidine: a real innovation or more of the same? Br J Anaesth. 2001 Nov;87(5):677-8. [PubMed]
28. Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care. Crit Care. 2000;4(5):302-8. Epub 2000 Jul 31. [PubMed]
29. Tanskanen PE, Kyttä JV, Randell TT, Aantaa RE. Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: a double-blind, randomized and placebo-controlled study. British journal of anaesthesia. 2006 Nov 1;97(5):658-65.
30. Carollo DS, Nossaman BD, Ramadhyani U. Dexmedetomidine: a review of clinical applications. Curr Opin Anaesthesiol. 2008 Aug;21(4):457-61. doi: 10.1097/ACO.0b013e328305e3ef.
31. Yazbek-Karam VG, Aouad MM. Perioperative uses of dexmedetomidine. Middle East J Anaesthesiol. 2006 Oct;18(6):1043-58. [PubMed]
32. Aksu R, Akin A, Biçer C, Esmaoğlu A, Tosun Z, Boyaci A. Comparison of the effects of dexmedetomidine versus fentanyl on airway reflexes and hemodynamic responses to tracheal extubation during rhinoplasty: A double-blind, randomized, controlled study. Current therapeutic research. 2009 Jun 30;70(3):209-20. [PubMed]
33. Bindu B, Pasupuleti S, Gowd UP, Gorre V, Murthy RR, Laxmi MB. A double blind randomized controlled trial to study the effect of on haemodynamic and recovery responses during tracheal extubation.Journal of Anaesthesiology Clinical Pharmacology. 2013 Apr;29(2):162-7.
34. Sağıroğlu AE, Celik M, Orhon Z, Yüzer S, Sen B. Dıfferent doses of dexmedetomidine on controlling haemodynamic responses to tracheal intubation. Internet J Anesthesiol. 2010;27:2.
35. Turan G, Ozgultekin A, Turan C, Dincer E, Yuksel G. Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgery. Eur J Anaesthesiol. 2008 Oct;25(10):816-20. doi: 10.1017/S0265021508004201. Epub 2008 Apr 10. [PubMed]
36. Ramsay MA, Huddleston P, Hamman B, Tai S, Matter G. The patient state index correlates well with the Ramsay sedation score in ICU patients. Anesthesiology. 2004;101(A338):A338. [PubMed]
37. Miller KA, Harkin CP, Bailey PL. Postoperative tracheal extubation. Anesth Analg. 1995 Jan;80(1):149-72.
38. Mikawa K, Nishina K, Maekawa N, Obara H. Attenuation of cardiovascular responses to tracheal extubation: verapamil versus diltiazem. Anesthesia & Analgesia. 1996 Jun 1;82(6):1205-10.
39. Dodds TM, Stone JG, Coromilas J, Weinberger M, Levy DG. Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia. Anesth Analg. 1993 Apr;76(4):705-13.
40. Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Br J Anaesth. 2001 Oct;87(4):608-24. [PubMed]
41. Liu C, Zhang Y, She S, Xu L, Ruan X. A randomised controlled trial of dexmedetomidine for suspension laryngoscopy. Anaesthesia. 2013 Jan;68(1):60-6. doi: 10.1111/j.1365-2044.2012.07331.x. Epub 2012 Oct 29. [PubMed]
42. Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Pediatric Anesthesia. 2005 Sep 1;15(9):762-6.
43. Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, Heard S, Cheung A, Son SL, Kallio A. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg. 2000 Apr;90(4):834-9.
44. Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg. 2004 Jan;98(1):60-3, table of contents.
45. Kim YS, Kim YI, Seo KH, Kang HR. Optimal dose of prophylactic dexmedetomidine for preventing postoperative shivering. Int J Med Sci. 2013 Aug 13;10(10):1327-32. doi: 10.7150/ijms.6531. eCollection 2013.
46. Kim SY, Kim JM, Lee JH, Song BM, Koo BN. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. British journal of anaesthesia. 2013 Aug 1;111(2):222-8.
47. Ramsay MA. Bariatric surgery: the role of dexmedetomidine. Seminars in Anesthesia, Perioperative Medicine and Pain. 2006 Jun 30;25(2):51-56.
48. Karaaslan K, Yilmaz F, Gulcu N, Colak C, Sereflican M, Kocoglu H. Comparison of dexmedetomidine and midazolam for monitored anesthesia care combined with tramadol via patient-controlled analgesia in endoscopic nasal surgery: A prospective, randomized, double-blind, clinical study. Curr Ther Res Clin Exp. 2007 Mar;68(2):69-81. doi: 10.1016/j.curtheres.2007.04.001.
2. Rex MA. A review of the structural and functional basis of laryngospasm and a discussion of the nerve pathways involved in the reflex and its clinical significance in man and animals. British Journal of Anaesthesia. 1970 Oct 1;42(10):891-9. [PubMed]
3. Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth. 1993 Oct;71(4):561-8. [PubMed]
4. Padley SP, Downes MO. Case report: pulmonary oedema secondary to laryngospasm following general anaesthesia. Br J Radiol. 1994 Jul;67(799):654-5.
5. Lowrie A, Johnston PL, Fell D, Robinson SL. Cardiovascular and plasma catecholamine responses at tracheal extubation. Br J Anaesth. 1992 Mar;68(3):261-3. [PubMed]
6. Edwards N, Alford A, Dobson P, Reilly C. Myocardial ischemia during intubation and extubation. British Jornal of Anaesthesia. 1994 Apr 1;72(4):483-84. [PubMed]
7. Barham NJ, Boomers OW, Sherry KM, Locke TJ. Myocardial ischaemia during tracheal extubation in patients after cardiac surgery: an observational study. British journal of anaesthesia. 1998 Jun 1;80(6):832-3. [PubMed]
8. Cranfield KA, Bromley LM. Minimum alveolar concentration of desflurane for tracheal extubation in deeply anaesthetized, unpremedicated children. British journal of anaesthesia. 1997 Apr 1;78(4):370-1.
9. Lepousé C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth. 2006 Jun;96(6):747-53. Epub 2006 May 2. [PubMed]
10. Rogers MP, Liang MH, Daltroy LH, Eaton H, Peteet J, Wright E, Albert M. Delirium after elective orthopedic surgery: risk factors and natural history. The International Journal of Psychiatry in Medicine. 1990 Jun 1;19(2):109-21. [PubMed]
11. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia. 1998 Jun 1;53(6):540-4.
12. Gonzalez RM, Bjerke RJ, Drobycki T, Stapelfeldt WH, Green JM, Janowitz MJ, Clark M. Prevention of endotracheal tube-induced coughing during emergence from general anesthesia. Anesthesia & Analgesia. 1994 Oct 1;79(4):792-5.
13. Galinkin JL, Fazi LM, Cuy RM, Chiavacci RM, Kurth CD, Shah UK, Jacobs IN, Watcha MF. Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology. 2000 Dec;93(6):1378-83.
14. Davis PJ, Greenberg JA, Gendelman M, Fertal K. Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion. Anesth Analg. 1999 Jan;88(1):34-8.
15. Lapin SL, Auden SM, Goldsmith LJ, Reynolds AM. Effects of sevoflurane anaesthesia on recovery in children: a comparison with halothane. Paediatr Anaesth. 1999;9(4):299-304.
16. Kulka PJ, Bressem M, Tryba M. Clonidine prevents sevoflurane-induced agitation in children. Anesth Analg. 2001 Aug;93(2):335-8, 2nd contents page. [PubMed]
17. Guler G, Akin A, Tosun Z, Eskitascoglu E, Mizrak A, Boyaci A. Single-dose dexmedetomidine attenuates airway and circulatory reflexes during extubation. Acta anaesthesiologica scandinavica. 2005 Sep 1;49(8):1088-91. [PubMed]
18. Bloor BC, Flacke WE. Reduction in halothane anesthetic requirement by clonidine, an alpha-adrenergic agonist. Anesth Analg. 1982 Sep;61(9):741-5.
19. Pouttu J, Scheinin B, Rosenberg PH, Viinamäki O, Scheinin M. Oral premedication with clonidine: effects on stress responses during general anaesthesia. Acta Anaesthesiol Scand. 1987 Nov;31(8):730-4.
20. Gold MS, Redmond DE Jr, Kleber HD. Clonidine blocks acute opiate-withdrawal symptoms.Lancet. 1978 Sep 16;2(8090):599-602. [PubMed]
21. Virtanen R, Savola JM, Saano V, Nyman L. Characterization of the selectivity, specificity and potency of medetomidine as an alpha 2-adrenoceptor agonist. Eur J Pharmacol. 1988 May 20;150(1-2):9-14. [PubMed]
22. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology. 1992 Dec;77(6):1125-33. [PubMed]
23. Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992 Dec;77(6):1134-42. [PubMed]
24. Aho M, Lehtinen AM, Erkola O, Kallio A, Korttila K. The effect of intravenously administered dexmedetomidine on perioperative hemodynamics and isoflurane requirements in patients undergoing abdominal hysterectomy. Anesthesiology. 1991 Jun;74(6):997-1002.
25. Talke P, Richardson CA, Scheinin M, Fisher DM. Postoperative pharmacokinetics and sympatholytic effects of dexmedetomidine. Anesthesia & Analgesia. 1997 Nov 1;85(5):1136-42.
26. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesthesia & Analgesia. 2000 Mar 1;90(3):699-705.
27. Shelly MP. Dexmedetomidine: a real innovation or more of the same? Br J Anaesth. 2001 Nov;87(5):677-8. [PubMed]
28. Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care. Crit Care. 2000;4(5):302-8. Epub 2000 Jul 31. [PubMed]
29. Tanskanen PE, Kyttä JV, Randell TT, Aantaa RE. Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: a double-blind, randomized and placebo-controlled study. British journal of anaesthesia. 2006 Nov 1;97(5):658-65.
30. Carollo DS, Nossaman BD, Ramadhyani U. Dexmedetomidine: a review of clinical applications. Curr Opin Anaesthesiol. 2008 Aug;21(4):457-61. doi: 10.1097/ACO.0b013e328305e3ef.
31. Yazbek-Karam VG, Aouad MM. Perioperative uses of dexmedetomidine. Middle East J Anaesthesiol. 2006 Oct;18(6):1043-58. [PubMed]
32. Aksu R, Akin A, Biçer C, Esmaoğlu A, Tosun Z, Boyaci A. Comparison of the effects of dexmedetomidine versus fentanyl on airway reflexes and hemodynamic responses to tracheal extubation during rhinoplasty: A double-blind, randomized, controlled study. Current therapeutic research. 2009 Jun 30;70(3):209-20. [PubMed]
33. Bindu B, Pasupuleti S, Gowd UP, Gorre V, Murthy RR, Laxmi MB. A double blind randomized controlled trial to study the effect of on haemodynamic and recovery responses during tracheal extubation.Journal of Anaesthesiology Clinical Pharmacology. 2013 Apr;29(2):162-7.
34. Sağıroğlu AE, Celik M, Orhon Z, Yüzer S, Sen B. Dıfferent doses of dexmedetomidine on controlling haemodynamic responses to tracheal intubation. Internet J Anesthesiol. 2010;27:2.
35. Turan G, Ozgultekin A, Turan C, Dincer E, Yuksel G. Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgery. Eur J Anaesthesiol. 2008 Oct;25(10):816-20. doi: 10.1017/S0265021508004201. Epub 2008 Apr 10. [PubMed]
36. Ramsay MA, Huddleston P, Hamman B, Tai S, Matter G. The patient state index correlates well with the Ramsay sedation score in ICU patients. Anesthesiology. 2004;101(A338):A338. [PubMed]
37. Miller KA, Harkin CP, Bailey PL. Postoperative tracheal extubation. Anesth Analg. 1995 Jan;80(1):149-72.
38. Mikawa K, Nishina K, Maekawa N, Obara H. Attenuation of cardiovascular responses to tracheal extubation: verapamil versus diltiazem. Anesthesia & Analgesia. 1996 Jun 1;82(6):1205-10.
39. Dodds TM, Stone JG, Coromilas J, Weinberger M, Levy DG. Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia. Anesth Analg. 1993 Apr;76(4):705-13.
40. Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Br J Anaesth. 2001 Oct;87(4):608-24. [PubMed]
41. Liu C, Zhang Y, She S, Xu L, Ruan X. A randomised controlled trial of dexmedetomidine for suspension laryngoscopy. Anaesthesia. 2013 Jan;68(1):60-6. doi: 10.1111/j.1365-2044.2012.07331.x. Epub 2012 Oct 29. [PubMed]
42. Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Pediatric Anesthesia. 2005 Sep 1;15(9):762-6.
43. Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, Heard S, Cheung A, Son SL, Kallio A. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg. 2000 Apr;90(4):834-9.
44. Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg. 2004 Jan;98(1):60-3, table of contents.
45. Kim YS, Kim YI, Seo KH, Kang HR. Optimal dose of prophylactic dexmedetomidine for preventing postoperative shivering. Int J Med Sci. 2013 Aug 13;10(10):1327-32. doi: 10.7150/ijms.6531. eCollection 2013.
46. Kim SY, Kim JM, Lee JH, Song BM, Koo BN. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. British journal of anaesthesia. 2013 Aug 1;111(2):222-8.
47. Ramsay MA. Bariatric surgery: the role of dexmedetomidine. Seminars in Anesthesia, Perioperative Medicine and Pain. 2006 Jun 30;25(2):51-56.
48. Karaaslan K, Yilmaz F, Gulcu N, Colak C, Sereflican M, Kocoglu H. Comparison of dexmedetomidine and midazolam for monitored anesthesia care combined with tramadol via patient-controlled analgesia in endoscopic nasal surgery: A prospective, randomized, double-blind, clinical study. Curr Ther Res Clin Exp. 2007 Mar;68(2):69-81. doi: 10.1016/j.curtheres.2007.04.001.
CITATION
DOI: 10.17511/ijmrr.2016.i08.18
Published: 2016-08-31
How to Cite
1.
Antony D, C V D, Koshi Thomas M, Shenoy U, V M, Kochuthresia J P. The effect of two different doses of dexmedetomidine to attenuate cardiovascular and airway responses to tracheal extubation: a double blind randomized controlled trial. Int J Med Res Rev [Internet]. 2016Aug.31 [cited 2024Nov.8];4(8):1392-403. Available from: https://ijmrr.medresearch.in/index.php/ijmrr/article/view/658
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Original Article
OAI - Open Archives Initiative
