Abstract

Comparison of Efficacy between Dexmedetomidine and Lignocaine

for Attenuation of Extubation Responses

Dr.E ARAVINDARAGHAVAN, Final year postgraduate student

ISA No : A 4607/A
Dr.SHEETAL JAYAKAR, Associate Professor
Dr POONAM VIJAY BHARAMBE, Assistant Professor

DR.D.Y.PATIL MEDICAL COLLEGE AND HOSPITAL AND RESEARCH

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Introduction: Tracheal extubation is associated with haemodynamic changes due to reflex sympathetic
discharge resulting in hypertension, tachycardia and arrhythmias. Extensive research has been done to attenuate
hemodynamic responses to intubation, but a reliable technique for rapid and smooth extubation is still not fully
evolved. The aim of this study was to compare the effect of single-dose dexmedetomidine and lignocaine on the
attenuation of circulatory and airway response to endotracheal extubation.
Methods: This observational comparative study was conducted in 60 patients in the age group of 18-65years
posted for surgery under general anaesthesia. Inclusion criteria: Patients in ASA grade I or II , Hemodynamically
stable patients with all routine investigations within normal limits, duration of surgery less than 3hrs. Exclusion
criteria: Pregnant Women, patients with heart diseases like congestive heart failure, coronary heart disease, any
degree of heart block and cardiogenic shock, patients taking drugs like β-blockers, digoxin, α2-agonists, patient
with pre-operative heart rate < 45 beats/minute, Patient with renal insufficiency and liver impairment, Patient
with coagulopathy and psychiatric disorders, patient with known allergy to studied drugs and patients who
required postoperative mechanical Ventilation. Clinical monitoring parameters included were non-invasive blood
pressure measurement, heart rate, and oxygen saturation. Hemodynamics were recorded preoperatively
(baseline), intra-operatively (for every 15 mins), until the completion of surgery. Primary outcome namely the
smoothness of extubation was noted by four-point scale 5 minutes after extubation. Secondary outcomes namely
the level of sedation during suction and extubation was assessed using observer assessment sedation score and
airway response under direct laryngoscopy to suction was noted by five-point scale.
Results: Airway response for suctioning and extubation was better in dexmedetomidine group and it
was associated with better sedation score than lignocaine group.
Conclusion: Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides
smooth extubation when compared to lignocaine bolus.
Keywords: Dexmedetomidine, extubation, lignocaine, hemodynamic response

1
INTRODUCTION

Tracheal extubation is associated with haemodynamic changes due to reflex sympathetic

discharge caused by epipharyngeal and laryngopharyngeal stimulation. This increase in

sympatho-adrenal activity may result in hypertension, tachycardia and arrhythmias. [1,2] This

increase in blood pressure and heart rate are usually transitory, variable and unpredictable. It is

more hazardous to the patient with hypertension, myocardial insufficiency or cerebrovascular

diseases.[3] At the same time, airway irritation appearing during tracheal extubation could

cause cough or difficulties in breathing and may contribute to an increase in blood pressure.

[4,5]

Extensive research has been done to attenuate hemodynamic responses to intubation, but the

same care and precautions are seldom carried out for extubation. A reliable technique for rapid

and smooth extubation is still not fully evolved

Smooth tracheal extubation requires the absence of straining, movement, coughing, breath

holding or laryngospasm.[6] Various techniques and antihypertensive drugs are available to

attenuate airway and circulatory reflexes during extubation but none have been completely

successful.[7-10] Attempts have been made to attenuate the pressor response by the use of

drugs such as narcotic analgesics, deep anaesthesia induced by inhalational anaesthetics, local

anaesthetics, adrenoceptor blockers and vasodilator agents.[11] Studies have been carried out
2
with use of diltiazem,[1-3] lignocaine,[2,7-10] esmolol,[11] labetalol,[12] nicardipine,[13] and

opioids[14] as sole agent or in comparison with each other. To attenuate airway and pressor

response during tracheal extubation, dexmedetomidine, a, highly selective alpha-2

adrenoceptor agonist has been studied as single dose, [15,16] at the time of extubation and as

an anaesthetic adjuvant. [16-20] It has a sympatholytic effect through decreases in

concentration of norepinephrine. This, in turn, decreases the blood pressure (BP) and the heart

rate (HR).[21-23] Dexmedetomidine, therefore, is theoretically appropriate for reducing airway

and circulatory reflexes during emergence from anaesthesia.

Lignocaine, an amide local anaesthetic, injected intravenously or topically applied to larynx and

trachea, is variably effective at blunting the haemodynamic response to tracheal stimulation.

[9,10] It also prevents the rise in intracranial pressure associated with tracheal suctioning and

may prevent the rise in intraocular pressure seen with tracheal intubation. It also decreases

intracellular calcium concentration in airway smooth muscle, decreases myofilament calcium

sensitivity and has been shown to suppress coughing and prevent reflex bronchoconstriction.

Lignocaine has several beneficial effects, such as analgesia, anti-hyperalgesia and anti-

inflammation. Moreover, lignocaine can depress spike activity, amplitude and conduction time

in both myelinated A and unmyelinated C nerve fibers. Several studies have shown that

lignocaine can reduce the incidence and severity of cough during anesthetic emergence.

Shabnum et al. found that both IV and intratracheal lignocaine are effective in the attenuation

of cough
3
.

In this prospective study, we like to study the difference in effectiveness of injection of

Dexmedetomidine when compared to injection of Lignocaine infusion in attenuation of

circulatory and airway responses to endotracheal extubation after surgery done under general

anaesthesia.

Dexmedetomidine hydrochloride (C13H16N2)

Dexmedetomidine is a selective alpha-two adrenergic receptor agonist that has anti-

nociceptive, analgesic, opioid sparing and sedative properties that has shown to lower

postoperative pain, opioid consumption and accordingly, opioid related side effects. [5]

It also has anxiolytic and sympatholytic properties, and blunting of exaggerated hemodynamic

response is being extensively studied.

It’s easy administration, predictability with anaesthetic agents, and lack of toxic side effect

while maintaining adequate perfusion of the vital organs makes it an ideal agent during
4
extubation.

We have chosen dexmedetomidine as it has dual activity, presynaptic activation of the α2-

adrenoceptor which inhibits the release of norepinephrine, thus causing termination of pain

signals, while decrease in blood pressure (BP) and heart rate (HR) is due to the postsynaptic

activation of α2-adrenoceptors in the central nervous system which inhibits sympathetic

overactivity. [7]

Lignocaine chemical formula: C14H22N2O

The mode of action of lidocaine appears to be similar to that of procaine, procainamide and

quinidine. Ventricular excitability is depressed and the stimulation threshold of the ventricle is

increased during diastole. The sinoatrial node is, however, unaffected. Lignocaine in

recommended doses does not produce a significant decrease in arterial pressure nor in cardiac

contractile force.

Lignocaine is metabolized predominantly and rapidly by the liver, and metabolites and

unchanged drug are excreted by the kidneys

The onset of action following a single intravenous injection varies from 45 to 90 seconds and

duration of action is 10 to 20 minutes. Lidocaine plasma levels have been correlated with

clinical effectiveness. The therapeutic range is 1.2 to 6 mcg/mL. Plasma drug concentration

higher than 5 to 6 mcg/mL increases the risk of toxicity

5
AIM

The aim of this study was to compare the effect of single-dose dexmedetomidine and

lignocaine on the attenuation of circulatory and airway response to endotracheal extubation

OBJECTIVES

To compare between dexmedetomidine and lignocaine bolus injection15 minutes before

extubation

Comparison in variability of hemodynamic parameters

To compare the airway response between the two groups

6
REVIEW OF LITERATURE

In 2008, Turan et al., in their study on ‘Advantageous effects of Dexmedetomidine on

haemodynamic and recovery responses during extubation for intracranial Surgery’ examined

the effects of dexmedetomidine given at the end of procedure to prevent hyperdynamic

responses during extubation and to allow a comfortable and high-quality recovery. They found

that dexmedetomidine 0.5 µg/kg administered 5 minutes before the end of surgery stabilised

haemodynamics, allowed easy extubation, provided a more comfortable recovery and early

neurological examination following intracranial operations.[15].

In 2005, Guler et al., in the article on ‘Single-dose dexmedetomidine attenuates airway and

circulatory reflexes during extubation’ studied the effect of a single bolus dose of

dexmedetomidine 0.5 µg/kg as bolus intravenously over 60 seconds in patients undergoing

intraocular surgery. The authors’ findings suggested that a single bolus dose of

dexmedetomidine before tracheal extubation attenuated airway-circulatory reflexes during

extubation without affecting emergence time, an effect possibly mediated via its sedative and

analgesic properties.[16]

In 2006, Tanskanen et al., in their paper on ‘Dexmedetomidine as an anaesthetic adjuvant in

patients undergoing intracranial tumor surgery’ observed that decrease in the hypertensive

response to extubation was related to the dose of dexmedetomidine used as intravenous

infusion; a higher dose was more effective than a lower dose in 54 patients undergoing
7
supratentorial brain tumor surgery.[20]

In 2007, Turan et al., in the article on ‘The effects of two different doses of dexmedetomidine

on extubation’ studied the effects of two different doses of dexmedetomidine during the

extubation period in patients operated for intracranial lesions. They concluded that

dexmedetomidine used in a dose of 0.5 µg/kg in 1 min before extubation is a suitable agent for

optimal haemodynamic state and good recovery condition for intracranial operations. [24 ]

8
MATERIALS AND METHODS

Type of study: Observational comparative study.

Place of study: Dr.D.Y.Patil Medical College and Research Centre

Pimpri

Period of study: 6 months

Period of data processing, analysis and dissertation writing: 6 months

The institute ethics committee clearance will be obtained before start of study

All subjects will be subjected thorough pre-anaesthetic evaluation and relevant laboratory

investigations.

Informed written consent will be obtained from patients.

The study will be conducted in 60 patients randomly dividing into two groups of 30 each of

either sex in age group of 18-60 years posted for surgery under General anaesthesia

60 patients between age group of 18-60 years who are included in the study will be divided into

two groups of30 each i.e., Dexmedetomidine group and Lignocaine group and will be given

their respective drug.

Patients will be segregated into 2groups:

Group D:Dexmedetomidine group (n=30)will receive bolus dose of ………0.75

microgm……./kg before extubation.

Group L: Lignocaine group (n=30) will receive bolus dose ………………../kg before extubation
9
10
MATERIALS REQUIRED

Standard anesthesia machine

Wide bore IV access

Intravenous fluids – Crystalloids and colloids.

Closed circuit with appropriate face mask size.

Standard Monitoring equipments (Pulse oximeter, ECG monitor and non- invasive blood

pressure

Drugs for premedication and general anesthesia

Standard intubation kit with Macintosh laryngoscope and appropriately sized Cuffed

Flexometallic Endotracheal Tubes

Study drugs - Dexmedetomidine and Lignocaine

Disposable syringes

Resuscitation Equipment and drugs

INCLUSION CRITERIA

ASA grade I or II.

Age between 18 to 65 years.

Availability of a written and informed consent.

11
Patients undergoing surgery under general anesthesia

Hemodynamically stable patients with all routine investigations within normal limits.

Duration of surgery less than 3hrs

12
EXCLUSION CRITERIA

Pregnant Women

Patients with heart diseases like congestive heart failure, coronary heart disease, any degree of

heart block and cardiogenic shock

Patients taking drugs like β-blockers, digoxin, α2-agonists,

anticonvulsants or psychotropic medications

Patient with pre-operative heart rate < 45 beats/minute

Patient with renal insufficiency and liver impairment

Patient with coagulopathy and psychiatric disorders

Patient with known allergy to studied drugs

Patients who required postoperative mechanical Ventilation

Patient with ASI > II

Patient unwilling to get enrolled in the study

13
PROCEDURE

After obtaining Ethical committee approval from institutional ethical committee, 60 patients

aged between 18-60 who are posted for elective surgery under general anaesthesia will be

included in the study after obtaining written informed consent. Thorough preanesthetic

evaluation will be done. Routine investigations will be carried out prior to surgery. All patients

will be kept nil per oral for at least 6 h prior to surgery.

On arrival to the operation theatre, wide bore IV access will be secured, standard monitors

attached and baseline vital parameters (Heart rate (HR), non-invasive blood pressure (NIBP),

oxygen saturation (SPO2), electrocardiography (ECG) recorded.

14
Premedication (glycopyrrolate 0.2 mg, midazolam 0.1 mg/kg IV will be administered.

After preoxygenation, anesthesia will be induced with propofol 2.0mg/kg IV and scoline

2mg/kg/IV. After ensuring ability to ventilate, vecuronium 0.1 mg/kg IV will be administered for

muscle relaxation. Trachea will be intubated with an appropriately sized cuffed endotracheal

tube under direct laryngoscopy.

Anesthesia will be maintained using oxygen, nitrous oxide (50:50), and sevoflurane (1%–3%)

with closed circuit using a total fresh gas flow of 2 L min-1. Vecuronium will be supplemented in

increments of0.01mg/kg.

Bolus injection of trial drug will be administered 15 minute before extubation

Group D: …………0.75microgm/kg………….. Dexmedetomidine

Group L: …………………………..of Lignocaine

Following vitals will be recorded:

T0-baseline vitals before injection of trial drug

T1- At the time of bolus injection of trial drug

T2-1min after trial drug bolus injection

T3- 5 min after Extubation

T4- 15 min after extubation

15
Thereafter vitals are checked for every 30 minutes for next 2 hours.

T(E) At the time of extubation.

Monitoring included non-invasive blood pressure measurement, heart rate, and oxygen

saturation. Hemodynamics were recorded preoperatively (baseline), intra-operatively (for every

15 mins), until the completion of surgery. After extubation and full recovery, patients were

transferred to the post anesthesia care unit.

Drug Preparation:

The study drug will be prepared in …………………….

Dexmedetomidine Injection :

Lignocaine Injection

At ‘T1’ time, an IV bolus injection of dexmedetomidine ……………………..will be given in Group D.

Patients in Group L will be administered bolus injection of Lignocaine…………….. at the same

time.

Hemodynamics was assessed at 5 min interval from the time of study drug administration up to
16
15 min after extubation. The level of sedation during suction and extubation was assessed using

observer assessment sedation score [Table 1]. The level of sedation during suction was

assessed, and airway response under direct laryngoscopy to suction was noted by five-point

scale [Table 2]. After 5 min interval, the level of sedation was assessed, and smoothness of

extubation was noted by four-point scale [Table 3]. When mean arterial BP fall more than 10%

of baseline value, 200 ml fluid bolus was given, and injection mephentermine was

supplemented intravenously if there was no improvement. Drop in HR more than 20% from

baseline was treated with injection atropine 0.6 mg intravenously.

Any episode of tachycardia (defined as heart rate >20% of baseline value) and hypertension

(defined as blood pressure >20% of baseline value), lasting for more than a minute, will be

controlled using labetalol 5mg IVboluses.

Any episode of bradycardia, (heart rate <50/min will be treated by reducing Sevoflurane and

atropine 0.6 mg given intravenously and decreasing the dexmedetomidineinfusion. Any episode

of hypotension, (mean arterial blood pressure

<60 mm Hg) will be treated by administering a bolus of IV fluids and ephedrine 3 mg

intravenously. Infusion of study drug (dexmedetomidine) will be discontinued if

hypotension/bradycardia is resistant to treatment with two doses of atropine and ephedrine.

Such patients will be excluded from the study.

17
Total IV fluids, fentanyl, labetalol, and blood products if administered will be recorded as an

indirect measure for intraoperative hemodynamiclability.

All patients will be administered ondansetron 8 mg IV. Sevoflurane and Nitrous Oxide will be

discontinued after dressing of the incision.

After wound dressing, the patient will be made supine, 100% oxygen administered, and the

residual neuromuscular block will be reversed with neostigmine 2.5 mg IV and glycopyrrolate

0.4 mg IV, and tracheal extubation will be done.

18
STATISTICAL ANALYSIS

All cases will be completed within stipulated time. Data will be compiled and tabulated. The

statistical analysis will be done using parametric test and the final interpretation will be based

on ‘anova’ test (standard normal variant) with 95% level of significance.

19
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