Perbandingan Skor Insersi LMA antara Pemberian Petidin-propofol dan Fentanil-propofol Intravena

ABSTRAKLatar Belakang Pemberian adjuvan seperti opioid, lidokain, midazolam dan pelumpuh otot dosis kecil bersama propofol mampu meningkatkan keberhasilan insersi LMA. Petidin adalah opioid yang memiliki aktivitas seperti anestetik lokal dengan harga relatif murah dibanding opioid lain.  Tujuan penelitian Membandingkan skor insersi LMA antara antara pemberian petidin-propofol intravena dengan fentanil-propofol intravena.Metode Lima puluh empat pasien ASA PS 1 dan 2 dengan rentang umur 17-60 tahun, BMI 18,5-30 kg/m2 dan mallampati I-II yang direncanakan operasi elektif dengan prosedur GA-LMA diacak kedalam 2 grup dengan menggunakan desain acak tersamar ganda. Grup P mendapatkan petidin 1 mg/kgBB 10 menit sebelum induksi dan grup F mendapatkan fentanil 1 µg/kgBB 3 menit sebelum induksi. Induksi menggunakan propofol 2 mg/kgBB selama 60 detik. Ventilasi dengan oksigen 100% melalui sungkup muka selama 60 detik dilakukan setelah refleks bulu mata hilang, selanjutnya dilakukan insersi LMA dan penilaian skor insersi LMA berdasarkan Lund & Stovener (gerakan anggota tubuh, laringospasme, menelan, batuk dan tersedak).Hasil Skor insersi LMA sangat memuaskan pada kelompok P lebih kecil dibandingkan kelompok F (29,6% vs 48,1%), namun tidak bermakna setelah uji statistik Chi-Square (p=0,264).Simpulan Skor insersi LMA dengan pemberian petidin-propofol intravena samabaiknya dengan pemberian fentanil-propofol intravena.Kata kunci :laryngeal mask airway, fentanyl, petidin, , propofol

A Paradigm Shift: The Implementation of Utilizing Dexmedetomidine and Propofol for Laryngeal Mask Airway Insertion

ABSTRACT Background: Laryngeal mask airway (LMA) is a common airway device used intraoperatively for anesthetic airway management. The insertion of LMA requires anesthesia and adequate suppression of airway reflexes. The factors that affect the insertion and positioning of LMA are jaw relaxation, mouth opening, episodes of coughing or movement during insertion, and the depth of anesthesia. If all these parameters are satisfactory, then there will be a minimal hemodynamic stress response, which is required for LMA insertion. In search of an optimum drug, recent studies have suggested that dexmedetomidine is superior to fentanyl as an anesthetic adjuvant in decreasing the requirement of propofol and maintaining stable hemodynamics intraoperatively. Objectives: This literature review aimed to evaluate the current randomized controlled trials (RCTs) on the impact of dexmedetomidine as an adjunct to propofol during LMA insertion. Methodology: A literature search was conducted to identify studies on patients receiving propofol and fentanyl or propofol and dexmedetomidine while undergoing laryngeal mask airway (LMA) insertion. Evidence selection requires the selection of credible databases and sources. Many databases are available with a wide range of articles in different fields of healthcare provisions. The search was conducted in October 2020; thus, the search was current and up to date. The selected databases resulted in a different number of articles related to the search terminologies. PubMed yielded 98 articles, Medline resulted in 112 articles, and CINAHL revealed 143, and Scopus resulted in 56 results. A total of 409 articles were retrieved from the selected databases. Duplicated articles were removed, leaving 204 articles for further evaluation. Thirteen randomized control trials (RCTs) were evaluated in this systematic review. Data sources: Data sources included MedLine, CINAHL, EMBASE, Pubmed, and Google Scholar. Sources were chosen to answer the Population, Intervention, Comparison, and Outcome (PICO) question: (P) In adult surgical patients who present for laryngeal mask insertion (I), does Dexmedetomidine- Propofol IV (C) compared to Fentanyl- Propofol IV (O) decrease hemodynamic instability, ensure spontaneous respirations, and reduce the propofol dosage requirement for induction? Study selection: The inclusion criteria for the articles included: Studies published after 2019, RCTs published in English, dexmedetomidine as the treatment, and opioid consumption as the primary outcome. Exclusion criteria included: meta-analyses and systematic analyses, failure to focus on LMA insertion, and dexmedetomidine not used as treatment. Results: The evidence search, and screening resulted in 15 RCTs. Eleven studies demonstrated dexmedetomidine is a superior adjuvant in preserving respirations and a stable hemodynamic profile. Four studies demonstrated dexmedetomidine could reduce propofol dose requirements by as much as 38%. Conclusion: Evidence shows that dexmedetomidine as a co- induction agent with propofol not only gives excellent overall insertion conditions and hemodynamic stability but also reduces the requirement of induction as well as incremental doses of propofol. Keywords: Dexmedetomidine, LMA, fentanyl, surgical units, surgery, postoperative, perioperative

Comparison of Haemodynamic Responses to Laryngeal Mask Airway Insertion and Laryngoscopy with Endotracheal Intubation in Adults Undergoing Elective Surgery at Muhimbili

Airway management is of utmost importance during delivery of general anaesthesia. Traditionally, laryngoscopy and endotracheal tube (ETT) insertion has been the mainstay in providing adequate airway management and delivering anaesthesia. The laryngeal mask airway (LMA) offers a much less invasive way of maintaining the airway as it does not pass through the glottis but is placed over the glottis. It does not require the use of the laryngoscope. Laryngoscopy and tracheal intubation or laryngeal mask airway insertion are noxious stimuli which provoke a transient but marked sympathetic response manifesting as hypertension and tachycardia. In susceptible patients particularly those with systemic hypertension, coronary heart disease, cerebrovascular disease and intracranial aneurysm, even these transient changes can result in potentially deleterious effects like left ventricular failure, arrhythmias, myocardial ischaemia, cerebral haemorrhage and rupture of cerebral aneurysm. To determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at Muhimbili national Hospital (MNH) and Muhimbili Orthopaedic Institute (MOI) in 2011. A hospital based prospective randomized comparative study was conducted to determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at MNH and MOI . After induction of anaesthesia either an ETT or LMA was inserted. Evaluations included measurement of blood pressure and heart rates before insertion, after insertion of device, 1 minute, 3 minutes and 5 minutes after insertion. Measuments were taken from the Drager infinity gamma XL monitor. Time and ease of insertion was also noted.Results There was an increase in HR, SBP and DBP seen after laryngoscopy and ETT insertion as well as after laryngeal mask insertion. The change in haemodynamic parameters after laryngoscopy and ETT insertion were significantly greater than those elicited by LMA insertion (p<0.0001). The increase took about 5 minutes to return to pre insertion values in the ETT group, while it took about 3 minutes for the same values to return to pre insertion values in the LMA group. It took a significantly shorter time to insert an LMA (12.63 sec) as compared to time taken to insert an ETT (22.76 sec). Insertion of an LMA was rated easy in 84% of the patients while it was rated easy in 60% of the ETT patients. The haemodynamic changes elicited by LMA insertion are less and short lived compared to those elicited by laryngoscopy and ETT insertion. It takes a shorter time and is much easier to insert an LMA as compared to laryngoscopy and ETT insertion. These changes might be insignificant in a normotensive patient, but could be harmful in a patient with cerebrovascular or cardiovascular abnormalities. The use of an LMA is recommended in these groups of patient

The Effect of Propofol on the Success Rate of Transurethral Lithotripsy by Holmium Laser: A Randomized Clinical Trial

Introduction: Urinary stone disease is the third most common affliction of the urinary tract that has been associated with an increasing incidence. Over decades, great advances have been made in the minimally invasive treatment of urinary stones. Recently, transurethral lithotripsy (TUL) by holmium laser was introduced as a possible therapeutic option. This study evaluated the effect of propofol on the success rate of TUL by holmium laser.Methods: A double-blind randomized controlled trial was conducted on 180 patients to investigate the effect of propofol on the success and complication rate of TUL by holmium laser. The enrolled patients were divided into two groups: the first group received sodium thiopental (n = 89) while the second group received propofol (n = 91). The two groups were compared in terms of the fluctuations of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), operation time, future stone-free rate (SFR), stone migration, post-operative fever, and ureteral complications such as perforation and mucosal damage. Other developed complications were also recorded. After data gathering, statistical analysis was performed with SPSS version 21.Results: the patients’ data such as age, sex, stone diameter, stone laterality, duration of stone impaction, primary SBP, DBP and HR were not significantly different between the two groups (P &gt; 0.05). TUL and anesthesia duration, first-minute and fifth-minute SBP and DBP, and also changes of HR were significantly lower in the propofol group compared with the sodium thiopental group (P &lt; 0.001). Moreover, SFR of TUL was more evident in the propofol group. Ureteral mucosal damage was significantly less in the propofol group.Conclusion: Propofol was associated with a higher reduction in SBP and DBP, decreased duration of TUL, fewer fluctuations in HR, and an increased success rate of stone removal by TUL with holmium laser

A Pharmacological Evidence-Based Algorithm in the Management of Awake Fiberoptic Intubation

Awake Fiberoptic Intubation (AFOI) is the gold standard technique for difficult airway management. AFOI requires sedation, anxiolysis, and relief of discomfort without impairing ventilation, depressing cardiovascular function, a patent airway with blunting reflexes and spontaneous ventilation when the airway is difficult. Many agents like fentanyl, midazolam, ketamine, propofol and remifentanil have been used to facilitate AFOI. This quality improvement project composed of 13 randomized control trials (RCTs) reviewed different drug regimens for AFOI anticipated difficult airway, it also included studies examining elective awake fiberoptic intubation for scheduled surgery. The empirical evidence demonstrated that the occurrence of desaturation was less with dexmedetomidine or alfentanil when compared against fentanyl, remifentanil, and propofol. This quality improvement educational module seeks to assess anesthesia providers knowledge, on the efficacy of drugs, and drug regimens for AFOI. Anesthesia providers receiving the educational intervention will include Anesthesiologists and Certified Nurse Anesthetists (CRNA). The sample will include approximately 5-10 participants. The quality improvement project will involve three phases, pre-assessment testing, an online educational presentation, and a post-assessment exam. Pre-assessment and post-assessment testing will be used to measure the effects of the intervention. Statistical analysis will be applied to assess the knowledge of the educational intervention. It is projected that provider education will improve, providing the knowledge in dosages, side effects, complications, and pharmacological therapy needed to optimize sedation when performing an AFOI

Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Awake fiberoptic intubation is one of the recommended strategies for surgical patients with anticipated difficult airway, especially when concurrent difficult ventilation is expected. We performed the first systematic review of randomized controlled trials assessing different protocols for awake fiberoptic intubation in anticipated difficult airway, including studies investigating elective awake fiberoptic intubation for scheduled surgery; randomized controlled trials comparing different methods for performing awake fiberoptic intubation; and adult patients with anticipated difficult airway. We excluded studies in the nonoperating theater settings, randomized controlled trials comparing awake fiberoptic intubation with other techniques, and studies based on simulation. Primary outcomes were success rate and death; secondary outcomes were major adverse events. Thirty-seven randomized controlled trials evaluating 2045 patients and 4 areas were identified: premedication, local anesthesia, sedation, and ancillary techniques to facilitate awake fiberoptic intubation. Quality of evidence was moderate-low and based on small-sampled randomized controlled trials. Overall, 12 of 2045 intubation failures (0.59%) and 7 of 2045 severe adverse events (0.34%) occurred, with no permanent consequences or death. All evaluated methods to achieve local anesthesia performed similarly well. No differences were observed in success rate with different sedatives. Dexmedetomidine resulted in fewer desaturation episodes compared to propofol and opioids with or without midazolam (relative risk, 0.51 [95% CI, 0.28-0.95]; P = .03); occurrence of desaturation was similar with remifentanil versus propofol, while incidence of apnoea was lower with sevoflurane versus propofol (relative risk, 0.43 [95% CI, 0.22-0.81]; P = .01). A high degree of efficacy and safety was observed with minimal differences among different protocols; dexmedetomidine might offer a better safety profile compared to other sedatives

Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial.

Succinylcholine remains the muscle relaxant of choice for rapid sequence induction (RSI) but has many adverse effects. High-dose rocuronium bromide may be an alternative to succinylcholine for RSI but recovery times are nearly doubled compared with a standard intubating dose of rocuronium. Magnesium sulfate significantly shortens the onset time of a standard intubating dose of rocuronium. We set out to investigate whether intravenous (IV) pretreatment with MgSO4 followed by a standard intubating dose of rocuronium achieved superior intubation conditions compared with succinylcholine. Adults were randomized to receive a 15-minute IV infusion of MgSO4 (60 mg·kg-1) immediately before RSI with propofol 2 mg·kg-1, sufentanil 0.2 μg·kg-1 and rocuronium 0.6 mg·kg-1, or a matching 15-minute IV infusion of saline immediately before an identical RSI, but with succinylcholine 1 mg·kg-1. Primary end point was the rate of excellent intubating conditions 60 seconds after administration of the neuromuscular blocking agent and compared between groups using multivariable log-binomial regression model. Secondary end points were blood pressure and heart rate before induction, before and after intubation, and adverse events up to 24 hours postoperatively. Among 280 randomized patients, intubating conditions could be analyzed in 259 (133 MgSO4-rocuronium and 126 saline-succinylcholine). The rate of excellent intubating conditions was 46% with MgSO4-rocuronium and 45% with saline-succinylcholine. The analysis adjusted for gender and center showed no superiority of MgSO4-rocuronium compared with saline-succinylcholine (relative risk [RR] 1.06, 95% confidence interval [CI], 0.81-1.39, P = .659). The rate of excellent intubating conditions was higher in women (54% [70 of 130]) compared with men (37% [48 of 129]; adjusted RR 1.42, 95% CI, 1.07-1.91, P = .017). No significant difference between groups was observed for systolic and diastolic blood pressures. Mean heart rate was significantly higher in the MgSO4-rocuronium group. The percentage of patients with at least 1 adverse event was lower with MgSO4-rocuronium (11%) compared with saline-succinylcholine (28%) (RR 0.38, 95% CI, 0.22-0.66, P &lt; .001). With saline-succinylcholine, adverse events consisted mainly of postoperative muscle pain (n = 26 [19%]) and signs of histamine release (n = 13 [9%]). With MgSO4-rocuronium, few patients had pain on injection, nausea and vomiting, or skin rash during the MgSO4-infusion (n = 5 [4%]). IV pretreatment with MgSO4 followed by a standard intubating dose of rocuronium did not provide superior intubation conditions to succinylcholine but had fewer adverse effects