Research Article | Volume 5 Issue 2 (July-Dec, 2024) | Pages 1 - 6
Effect of Intratracheal Dexmedetomidine Combined with 4% Lignocaine before Intubation on Hemodynamic Changes During Intubation in Head Injury Patients
 ,
 ,
 ,
1
Junior resident, Department of Anaesthesiology ,RMRI Bareilly Uttar Pradesh.
2
Professor, Department of Anaesthesiology ,RMRI Bareilly Uttar Pradesh.
3
Professor and Head Department of Anaesthesiology,RMRI Bareilly Uttar Pradesh.
4
Senior Resident Department of Anaesthesiology ,RMRI Bareilly Uttar Pradesh
Under a Creative Commons license
Open Access
Received
July 8, 2024
Revised
July 18, 2024
Accepted
Aug. 22, 2024
Published
Oct. 10, 2024
Abstract

Introduction: hemodynamic changes during tracheal intubation it is more challenging in head injury patients . Dexmedetomidine is a selective α2 adrenoreceptor agonist used as a sedative and adjuvant with local anesthetic. We hypothesized that adding dexmedetomidine to lignocaine before intubation have positive outcome on hemodynamic changes. Aim and objective: To assess the effect of Intratracheal Dexmedetomidine with lignocaine on hemodynamic changes during intubation in head injury patient .Methodology: Sixty patients admitted in ICU with head injury and need intubation randomly divided into two groups 30 subjects in each group, namely, Group 1 and Group 2. Group 1 received dexmedetomidine 0.5 ml with 4% lignocaine 0.5 ml whereas Group 2 receive normal saline before endotracheal intubation, respectively. The outcomes were the incidence hemodynamic fluctuations during intubation and after intubation .Results: The incidence and severity of hemodynamic fluctuation in Group 1 than in the group 2, during intubation and post intubation is significantly lower . Moreover, compared with Group 2, Group 1 exhibited more stable haemodynamics during intubation as well as post intubation .Conclusion: The combined use of dexmedetomidine and lignocaine intratracheally before intubation significantly reduced the incidence and severity of haemodynamic fluctuations during and after intubation.

Keywords
INTRODUCTION

In order to effectively provide mechanical ventilation and protect the airway for head injury patients undergoing surgical procedures under general anaesthesia, endotracheal intubation is a standard practice. The most common cause of hemodynamic disturbances, however, is endotracheal intubation because of the reflex activity that results in variability in hemodynamic parameters  [1].

 

Laryngoscopy and intubation may result in a hemodynamic stress response that can be managed with the use of the right medications. Several medications, including lignocaine, nifedipine, beta blockers, nitro glycerine, etc., are used to lessen the hemodynamic stress response following laryngoscopy and intubation. 

 

To reduce stress response during laryngoscopy some anesthesiology practiced nebulisation with local anesthetics like 4% lignocaine . and some centers uses parentral lignocaine 2% to reduce hemodynamic fluctuations .[2]

 

Some litratures shows , hypertensive surgical patients, topical anaesthetic with lignocaine has been shown to lessen the intubation response, as has trans-cricothyroid membrane injection. But the impact of topical lignocaine anaesthesia in general populations and with other modes of administration was unclear. [3] 

 

Dexmedetomidine is an extremely selective adrenergic -2 receptor agonist that reduces anxiety and induces drowsiness.[4] A sodium channel blocker, lignocaine, can affect sensory-motor block. Lignocaine has good liposolubility, long- lasting effects, and passes through the mucosal membrane to achieve a suitable blood concentration. [5] Topical lignocaine anaesthesia can effectively lessen hemodynamic reactions during intubation and extubation as well as the likelihood of postoperative throat pain and coughing.[6]

 

According to reports, giving intra-tracheal dexmedetomidine 30 minutes before the completion of the procedure facilitates a smooth extubation and a balanced anaesthesia recovery. [7]. Dexmedetomidine and lignocaine together effectively enhance analgesia's effectiveness and prolong its duration following surgery, according to a number of studies. [8)

In light of this, we postulated that intra-tracheal dexmedetomidine and lignocaine would lessen the frequency and severity of hemodynamic fluctuation following tracheal intubation.

 

AIMS AND OBJECTIVES

  1. To study intra-tracheal injection Dexmedetomidine and lignocaine combination can optimise hemodynamic changes due to stress to laryngoscopy and tracheal intubation.

  2. Look minimal variation in hemodynamic during laryngoscopy and intubation.

METHEDOLOGY

Source of Data: With approval from the institutional ethical council, the study was conducted in the anesthesiology department of Rajshree medical research institute Bareilly. The research was done over the course of a year, from June 2022 to July 2023.Clinical trial with double blinding and randomization.

 

METHOD OF COLLECTION OF DATA

Criteria for Inclusion:

  1. Patient or patients relative providing legally valid consent.

  2.   Head injury patients getting general anaesthesia for surgery.

  3.   Patients between the ages of 18 and 55.

 

EXCLUSION CRITERIA

  1. Patients having a history of alcohol or drug misuse are excluded.

  2. People who are sensitive to any of the test medications.

  3. A general anaesthesia contraindication.

  4. Patients who take more than 20 seconds to successfully intubate their trachea.

 

Sample Size: Purposive sampling was employed to select the study's 60 total sample subjects, with 30 being drawn from each group that met the inclusion and exclusion requirements.

 

60 patients between 18 to 55 age group who were either both sex and undergoing a surgical treatment for a head injury under general anaesthesia with endotracheal intubations Rajshree medical research institute Bareilly were the subjects of the study. An extensive pre-anaesthetic examination was performed. Systems were checked, and a thorough history was obtained. BP, HR, and RR were all recorded. We measured patients height and weight.

 

Pre-operative Preparation: consent was obtained in written from each of the selected pts or patients' relatives after thorough explanation of the study method. Patients are given 0.2 mg of intravenous glycopyrrolate and 2 mg of intravenous midazolam 30 minutes before to surgery as premedication. Pulse oximeter, NIBP, Eelectro cardio graphy, and ETCO2 were all used for intraoperative monitoring.

 

Dexmedetomidine, 50mcg, is added to injection 4% lignocaine, 0.5 ml, in a 3 ml syringe during the preparation of the medicine. Patients were split into two groups at random.

 

Group I patients get lignocaine and dexmedetomidine prior to cricothyroid membrane intubation. Patients in Group II: the Control Group got standard saline in the same way.

 

grp. Succinyl choline 2 mg/kg was given after that, and an adequate size endotracheal tube was used for endotracheal intubation.

 

Blood pressure readings, including systolic and diastolic, were taken just prior to intubation, immediately following intubation, and then every five min for the first fortyfive mins of procedure . Fentanyl administered intravenously replaced any further requirement for analgesia. After the procedure, neuro-muscular blockage was treated with injections of neostigmine and glycopyrrolate , and the patients were watched for two hours in the PACU. if any S/E were noted

RESULT

The data is expressed in mean and standard error of mean. The data was analysed by SPSS (20.0) version. Significant between group -I and group-II was analysed by independent t test.


 

 

Table-1 : Comparison of heart rate changes between group satvarioustime intervals

 

Time(min)

Heartrate(MEAN±SEM)

 

Pvalue

Group- I( Study)

Group-

II( Control)

Baseline

83. 54±1.03

81. 34±1.26

0.279

Before intubation

67. 80±7. 71*

88. 20±1.14

0.042

Afterintubation

76. 77±7. 63*

100.37±1.31

0.002

1min

76. 11±8. 13*

98. 46±1.29

0.030

2min

73. 82±7. 07*

94. 48±1.18

0.005

3min

71. 03±7. 09*

90. 26±1.18

0.005

4min

69. 14±6. 62*

86. 60±1.22

0.000

5min

70. 00±5. 98*

86. 51±1.10

0.001

10min

69. 91±6. 12*

86. 29±1.08

0.001

15min

70. 14±6. 05*

87. 00±1.05

0.003

20min

69. 94±6.21

87. 48±9.66

0.050

25min

70. 20±5.95

86. 06±16. 23

0.031

30min

70. 03±6.21

88. 79±9.09

0.047

Table 1 shows variation of heart rate at different time interval in the study subjects before the intubation and at different time interval post intubation. On applying t test we found that before intubation the heart rate is comparable in both the group  with non  significant difference whereas post intubation at each time  interval the heart rate is significantly different with  less variation in the drug group.

Table-2 : Comparison of mean          systolic blood pressure changes between groups at various time  intervals

 

Time(min)

Blood pressure( MEAN±SEM)

 

Pvalue

Group- I( Study)

Group- II( Control)

Baseline

128.17±1.73

127.66±1.53

0.825

Before intubation

105.54±1.59 *

123.23±1.42

0.000

After intubation

112.80±1.43 *

147.31±1.66

0.000

1min

113.54±1.47 *

143.94±2.03

0.000

2min

113.69±1.45 *

140.40±1.89

0.000

3min

113.33±1.56 *

137.09±1.74

0.000

4min

112.57±1.52 *

137.14±1.79

0.000

5min

112.57±1.49 *

135.43±1.64

0.000

10min

111.71±1.38*

131.77±1.67

0.000

15min

110.17±1.37*

127.71±1.30

0.000

20min

107.14±3.28*

125.66±1.20

0.000

25min

109.40±1.70 *

125.94±1.22

0.000

30min

108.69±1.71*

128.69±1.25

0.000

 

Table 2 shows variation of SBP at different time interval in the study subjects before the intubation and at different t ime interval post intubation. On applying t test we found that before intubation the SBP is comparable in both the group with non signif icant difference whereas post intubation at each t ime interval the SBP is significantly different with less variation in the drug group.

Table-3 : Comparison of mean diastolic blood pressure changes between groups at various time intervals

Time(min)

Diastolic blood pressure( MEAN±S)

Pvalue

Group- I

Group- II 

Baseline

82 .62 ±1`. 08

82 .31 ±1.01

0.768

Before intubation

68 . 17 ± 0 .70 *

79 .33 ±0.88

0.000

After intubation

74 .85 ± 0 .73 *

90 .05 ±0.89

0.000

1min

74 . 80 ± 0 .72 *

86 .85 ±0.98

0.000

2min

74 .40 ± 0 .68 *

85 .94 ±1.10

0.000

3min

74 . 97 ± 0 .78 *

84 .62 ±1.07

0.000

4min

74 . 51 ± 0 .84 *

83 .65 ±1.05

0.000

5min

73 .88 ± 0 .79 *

83 .08 ±0.99

0.000

10min

76 . 05 ± 0 .78 *

82 .74 ±0.87

0.000

15min

72 .68 ± 0 .84 *

82 .05 ±0.85

0.000

20min

73 . 94 ± 0 .89 *

82 .28 ±1.06

0.000

25min

72 . 68 ± 0 .79 *

82 .74 ±1.11

0.000

30min

71 .42 ± 0 .76 *

84 .57 ±1.18

0.000

 

Table 3 shows variation of DBP at different t ime interval in the study subjects before the intubation and at different t ime interval post intubation. On applying t test we found that before intubation the DBP is

comparable in both the group with non significant difference whereas post intubation at each t ime interval the DBP is significantly different with less variation in the drug group.

 

Table4 : Comparison of meanarterial pressure changes between groups at various time intervals

 

Time(min)

Mean   arterial pressure( MEAN± )

Pvalue

Group- I

Group- II 

Baseline

97 .80 ±1.15

97 .46 ±7.03

0.834

Before intubation

80 .62 ± 0 .75 *

93 .56 ±5.63

0.000

After intubation

87 .50 ± 0 .75 *

108.85±5.68

0.000

1min

87 . 71 ± 0 .82 *

105.86±6.63

0.000

2min

87 .49 ± 0 .75 *

103.28±1.84

0.000

3min

87 . 75 ± 0 .86 *

101.60±7.44

0.000

4min

87 .20 ± 0 .87 *

99 .47 ±7.45

0.000

5min

86 .78 ± 0 .792 *

100.78±7.24

0.000

10min

87 .94 ±0 .87 #

98 .51 ±5.71

0.001

15min

85 . 18 ± 0 .816 #

97 .27 ±4.79

0.001

20min

85 . 00 ± 1 .40 *

96 .80 ±5.30

0.000

25min

84 .92 ± 0 .89 *

96 .79 ±5.70

0.000

30min

83 . 84 ± 0 .89 *

99 .22 ±6.20

0.000

 


 

Table 4 shows variation of MAP at different t ime interval in the study subjects before the intubation and at different t ime interval post intubation. On applying t test we found that before intubation the MAP is comparable in both the group with non signif icant difference whereas post intubation at each t ime interval the MAP is significantly different with less variation in the drug group.

 

SideEffects

Two patients developed bradycardia in the study group but it settled without intervention. None of the patients de veloped hypotension

DISCCUSION

The tracheal intubation and laryngoscopy procedures are regarded as the most crucial parts of GA because they trigger a brief but considerable sympathetic and sympathetic adrenal response. This forward looking, randomised, dual-blind, placebo controlled study was carried out to determine the efficacy of dexmedetomidine, an alpha2-agonist combined with lignocaine that also has other effects such as sedative, reduce anxiety, and sympathetic inhibition, for minimise the vital changes during airway handaling.

 

Dexmedetomidine significantly attenuated the response of BP and HR to bronchoscopy & Intubation. In our study, the age, gender, and weight of the two grps were comparable. There was no significant difference between the two groups' pre-operative heart rates and blood pressures (p>0. 05). Dexmedetomidine + lignocaine infusion resulted in a decrease in HR and BP in the study group. Lawrenceetal [9] found that a single dose of 2mcg/kg of dexmedetomidine before induction of anaesthesia reduced the hemodynamic response to intubation as well as that to extubation. Bradycardia was observed at 1 and 5 minutes following         injection. This may have been brought on by the somewhat higher dose administered by bolus. A previous study    assessed several bolus dosages of dexmedetomidine for pre-medication [10], and we choose the 1ug/kg bolus dose as  advised in the literature.

 

Dexmed and lignocaine provide cardiovascular stability by reducing stress from sympathetic system stimulation after emergance of anesthesia . Jaakolaetal [10]. dexmedetomidine minimise the increase HR and BP at the time intubation, according to a study.[11] investigated and concluded that need of thiopenton , post op use of painkilles and during airway management less hemodynamic variation and noradrenaline levels in blood sample in dexmed grp was also less .Dexmedetomidine reduces sympathetic endotracheal reactivity and minimises the need for perioperative anaesthesia, Thiopentone and isoflurane requirements were 30% and 32% less in the dexmedetomidine group than in the control group, respectively.

 

VillelaNRetal [12] noted that the group receiving dexmedetomidine consumed fewer anaesthetics. Preoperative administration of a single dosage of dexmedetomidiner decreased the need for anaesthesia and opioids, according to YildizM et al. [13].

 

Dexmedetomidine [14] was utilised in a prospective, randomised research [14] to reduce the cardiovascular response to airway management with minimal dose fentanyl&etomidate in patients going for myocardiac revascularization and taking B-blocker therapy. Systolic, diastolic, and mean arterial pressures were all less in the dexmedetomidine grp than they were in the control group at all periods. After the induction of anaesthesia, the indexmedetomidinegroup saw a greater drop in heart rate than theplacebogroup.

 

Heart rate significantly increased in the placebo group one minute after intubation, while it significantly decreased in the dexmedetomidine group. In the placebo group, the incidence of hypertension requiring treatment was significantly greater. Dexmedetomidine can be safely used to lessen the hemodynamic reaction to intubation in patients having myocardial revascularization and receiving beta-blockers, it has been determined. Similar research was done [15] on the effectiveness of intravenous dexmedetomidine for reducing hemodynamic reactions to laryngoscopy and endotracheal intubation in patients with coronary artery disease. In patients undergoing cardiac revascularization, dexmedetomidine at a dose of.5 mcg/kg given as a 10-minute infusion prior to the onset of general anaesthesia lessens the sympathetic activation to airway handaling . It can be administered even to individuals using beta blockers, according to the scientists.This supports the findings from our study.

CONCLUSION

Before intubation, intratracheal dexmedetomidine and 4% lignocaine can significantly minimise the incidence and severity of hemodynamic variability, lower the amount of anaesthetic medication needed, and lessen intraoperative hemodynamic fluctuations without having any negative side effects.

Conflict of Interest:

The authors declare that they have no conflict of interest

Funding:

 No funding sources

Ethical approval:

The study was approved by the RMRI Bareilly Uttar Pradesh.

REFERENCES
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  8. Wang F, Zhong H, Xie X, Sha W, Li C, Li Z, Huang Z, Chen C. Efect of intratrachealdexmedetomidine administration on recovery from general anaesthesia after gynaecological laparoscopic surgery: a randomised double-blinded study. BMJ Open. 2018;8(4): e020614.

  9. Lawrence CJ, De Lange S. Effects of a single preoperative dexmedetomidine dose on isoflurane requirements and perioperative hemodynamic stability, Anaesthesia 1997; 52: 736 -44

  10. Jaakola ML, Ali-Melkkila T, Kanto J, et al: Dexmedetomidine reduces intraocular pressure, intubation responses and anaesthetic requirements in patients undergoing ophthalmic surgery. Br JAnaesth 1992; 68:570 -575.

  11. Scheinin B, Lindgren L, Randell T, et al: Dexmedetomidine attenuates sympathoadrenal responses to tracheal intubation and reduces the need for thiopentone and perioperative fentanyl. Br J Anaesth 1992; 68:126 -131.

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