- Email: [email protected]
Comparative effects of lidocaine, esmolol, and nitroglycerin in modifying the hemodynamic response to laryngoscopy and intubation
Comparative Effects of Lidocaine, Esmolol, and Nitroglycerin in Modifying the Hemodynamic Response to Laryngoscopy and Intubation Harbhej Singh, MB BS,* Phongthara Vichitvejpaisal, MD,? George Y. Gaines& Paul F. White,
PhD,
Department of Anesthesiology and Pain Management, Southwestern Medical Center at Dallas, Dallas, TX.
MD8
University
of Texas,
Study Objective: To compare the safety and eff icac y of 1i d ocaine, esmolol, and nitroglycerin in modifying the hemodynamic response to laryngoscopy and intubation. Design: Randomized, placebo-controlled, double-blind study. Setting: University-affiliated VA medical center.
*Fellow tvisiting
Assistant
Professor
$Associate
Clinical
Professor
PProfessor thesiology
and McDermott
Chair
in Anes-
Address reprint requests to Dr. White at the Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75235 9068, USA. Received for publication November 10, 1993; revised manuscript accepted for publication February 8, 1994.
Journal of Clinical Anesthesia 7:5-S, 1995 0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY
Patients: 40 ASA physical status I and II patients undergoing elective surgery with general endotracheal anesthesia. Interventions: Anesthesia was induced with thiopental sodium5 mglkg, and intubation was facilitated with vecuronium 0.15 mglkg. Isoflurane (0.5% to I %) and 50% nitrous oxide in oxygen were used for maintenance of anesthesia. In addition, patients received one of the following four study drugs intravenously (IV) prior to laryngoscopy: Group 1 (control) = saline 5 ml; Group 2 = lidocaine 1.5 mglkg; Group 3 = esmolol 1.4 mglkg; Group 4 = nitroglycerin 2 pglkg. Measurements and Main Results: Mean arterial pressure (MAP) and heart rate (HR) were recorded every minute for 20 minutes following induction of anesthesia. Following laryngoscofi and intubation, MAP increased significantly in all four treatment groups (control 49% + 19%, lidocaine 55% + 26%, esmolol 25% 2 ll%, nitroglycerin 45Yo +- 21%) compared with preinduction baseline values. In the esmololpretreated patients, the increase in HR was significantly lower (20% + 3 %) compared with the nitroglycerin (37% * 8%), lidocaine (52% + 8%), and control (29% 2 4%) groups. Conclusions: Lidocaine 1.5 mglkg IV and nitroglycerin 2 kglkg IV were ineffective in controlling the acute hemodynamic response following laryngoscopy and intubation. Esmolol 1.4 mglkg IV was significantly moreeffective than either lidocaine or nitroglycerin in controlling the HR response to laryngoscopyand intubation (p < 0.05). Esmolol also was significantly more effective than lidocaine in minimizing the increase in MAP (25% vs. 55%).
10010
SSDI
0952-8180195/$10.00 0952-8180(94)00013-T
Original Contributions
Keywords: Esmolol; hypertension; intubation, intratracheal-cardiovascular responses; laryngoscopy; lidocaine; nitroglycerin; tachycardia.
Introduction Transient tachycardia and hypertension are common cardiovascular responses to laryngoscopy and intubation.’ Several different cardiovascular drugs-including lidocaine,’ esmolo1,3x4 nitroprusside,’ isosorbide,6 nitroglycerin,’ verapamil,’ and clonidineg-have been evaluated with respect to their ability to blunt the acute hemodynamic response to tracheal intubation. Intravenous (IV) lidocaine is still used for this purpose, even thou h published studies have questioned its efficacy.B‘*11 Beta-adrenergic-receptor blocking drugs appear to be more effective in preventing the increase in heart rate (HR) than the rise in blood pressure (BP).4Z’2 Nitroglycerin infusion also has been used to control the acute hypertensive responsesduring surgery. However, the safety and efficacy of IV bolus administration of nitroglycerin for control of the hyperdynamic response to tracheal intubation requires further evaluation. Although verapamil and clonidine are effective, they have failed to gain widespread clinical acceptance becauseof their variable onsets and relatively long durations of action. Therefore, we designed a randomized, double-blind, placebo-controlled study to compare the safety and efficacy of standard IV bolus dosesof lidocaine, esmolol, and nitroglycerin in modifying the acute hemodynamic response to laryngoscopy and tracheal intubation.
Materials
and Methods
After obtaining University of Texas, Southwestern Medical Center Institutional Review Board approval, 40 consenting, normotensive ASA physical status I and II adult malesundergoing elective surgery with general endotracheal anesthesia were randomized via a computergenerated table to one of four treatment groups according to a double-blind, placebo-controlled protocol. Patients with clinically significant cardiovascular disease were excluded from the study. Anesthesia was induced with thiopental 5 mglkg IV and vecuronium 0.15 mg/kg IV (at time 0 minutes). Anesthesia was maintained with 0.5% to 1% isoflurane and 50% nitrous oxide in oxygen (0,). Opioid analgesics and other adjunctive drugs were administered after the 20-minute study period. Patients received one of four standardized treatment regimens prior to laryngoscopy: Group 1 = saline 5 ml IV at time 0 minutes; Group 2 = lidocaine 1.5 mgikg IV at time 1 minute; Group 3 = esmolol 1.4 mglkg IV at time 2 minutes; Group 4 = nitroglycerin 2 kg/kg IV at time 3 minutes. Laryngoscopy wasinitiated 3.5 minutes after the thiopental induction by the same anesthesiologist, and tracheal intubation was accomplished within 30 seconds. Mean arterial pressure (MAP) and HR were subse6
J. Clin. Anesth.,vol. 7, January/February1995
quently recorded at 1 minute intervals for 20 minutes. In addition, hemoglobin O2 saturation and ECG lead Vj were monitored continuously for 20 minutes. Data were analyzed using repeated-measures of analysisof variance and Student’s paired t-test for evaluating changes within groups; an unpaired t-test with Bonferroni’s correction was used for comparisons between treatment groups. A p-value less than 0.05 was considered statistically significant.
Results The four treatment groups were comparable with respect to age, weight, and ASA physical status (Table I). MAP increased significantly following tracheal intubation in all four treatment groups (control 49% * 19%, lidocaine 55% 2 26%, esmolol 25% * ll%, nitroglycerin 45% +- 21%) compared with preinduction baseline values. In the saline (control) group, the maximum pressor response was observed 1 minute following intubation, with the value returning to baseline 5 minutes later. In the esmolol, nitroglycerin, and lidocaine groups, the maximum pressor response was observed at the time of tracheal intubation, with the values returning to baseline 3 minutes, 5 minutes, and 6 minutes, respectively, after intubation (Figure I). HR increased significantly in the control (29% * 4%), nitroglycerin (37% + 8%), and lidocaine (52% + 8%) groups. In the esmolol group, the increase in HR was significantly lower than in the other three groups (20% + 3%). The maximum increase in HR occurred 1 minute, 1 minute, 0 minutes, and 1 minute after intubation and returned to preinduction baseline by 10 minutes, 6 minutes, 8 minutes, and 7 minutes following tracheal intubation in the control, lidocaine, nitroglycerin, and esmolol groups, respectively (Figure 2). During the study period, no patient developed cardiac arrhythmias or evidence of ischemic changes on ECG lead Vs. One esmolol-pretreated patient developed transient hypotension (MAP lessthan 70 mmHg), which was treated with ephedrine 10 mg IV.
Discussion The magnitude (MAP 49% 2 19% and HR 29% -C 4%) and duration (MAP 6 minutes and HR 10 minutes) of 1. DemographicCharacteristicsof the Four Drug Treatment Groups
Table
Saline
Lidocaine
W-) 53 k 11 48 ? 15 Weight (kg) 78 ?I 8 82 5 14 ASA-PS I (n) 5 4 ASA-PS II (n) 5 6 Age
Note: Somedata are means* SD. = ASA physicalstatus.
ASA-PS
Esmolol 53 + 15 84 k 18 6 4
Nitroglycerin 56-+ 15 14 6 4
90 -t
Lidocaine,
0
1
2
3
4
5
6
7
8
--t
Control Lidocaine
-
Esmolol Nitroglycerin
9
10
11
12
13
14
15
Time (min)
1. Changes in mean arterial pressure (MAP) as a function of time following induction of anesthesia.Note: Data are means? SEM. Figure
-
Control
-t
Lidocaine
-
Esmolol
-
Nitroglycerin
-_ 0
1
2
3
4
5
6
7 8 Time(min)
9
10
11
12
13
14
15
2. Changesin heart rate (HR) asa function of time following induction of anesthesia.Note: Data are means+SEM. Figure
the acute hemodynamic responsesto tracheal intubation in our study population are consistent with other published values.’ Although transient hemodynamic changes may not be of any clinical importance in healthy patients, these changes are undesirable in patients with hypertension, myocardial insufficiency, or cerebrovascular disease.I3 Tam et al. l4 reported that lidocaine 1.5 mg/kg IV administered 3 minutes prior to intubation was highly effective in blunting the hyperdynamic response to intubation. They also demonstrated that lidocaine administered 1 minute, 2 minutes, or 5 minutes prior to intubation failed to attenuate the increase in HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), or MAP. Although it was administered 3 minutes prior to intubation, we found lidocaine 1.5 mg/kg IV ineffective in blunting the acute hemodynamic response to laryn-
esmolol, and nitroglycerin
and hemodynamic
response:
Singh et
al.
goscopy and intubation. Our findings are consistent with those of other studies that failed to show that IV lidocaine was effective for this purpose.“,” In a 1992 study, Sklar et al. l5 demonstrated that inhalational lidocaine 120 mg was effective in attenuating the hemodynamic response to laryngoscopy and tracheal intubation, whereas IV lidocaine 1 mg/kg failed to attenuate this response. These investigators suggested that topical analgesia, rather than a central action of lidocaine, was responsible for attenuating the hemodynamic response. Longmire et al. l6 studied the effectiveness of an IV infusion of nitroglycerin 0.1 kg/kg/min for controlling the hemodynamic response to endotracheal intubation in primigravid women with severe preeclampsia. HOWever; they observed that HR, MAP, and systemic vascular resistance still increased 28%, 22.5%, and 7.5%, respectively, following intubation. Mikawa et al.’ reported that an IV bolus of nitroglycerin 1.5 or 2.5 pg/kg administered at the start of laryngoscopy and intubation was effective in attenuating the hypertensive response. They reported that MAP began to decrease 30 seconds after IV nitroglycerin administration, was maximal after 45 seconds, and returned to baseline values within 2 minutes. When nitroglycerin 2 pg/kg IV was administered 30 secondsprior to laryngoscopy, we found it to be ineffective in preventing the hyperdynamic response to tracheal intubation. This finding could be due to the shorter duration of action of nitroglycerin compared with the untreated hyperdynamic response (1 to 2 minutes vs. 6 to 10 minutes). The pharmacokinetic profile of esmolol makes it well suited for controlling the cardiovascular response to tracheal intubation when it is administered as a continuous infusion. ” For example, Vucevic et al.” demonstrated that the pressor response to laryngoscopy was significantly less marked in patients receiving a continuous infusion of esmolol 500 kglkgimin for 2 minutes followed by an infusion of esmolol 100 pg/kg/min. Furthermore, Parnass et d4 reported that an IV bolus of esmolol 1.4 t 0.3 or 2.6 2 0.7 mg/kg administered 2.5 to 3 minutes prior to intubation significantly blunted increasesin HR and MAP following intubation. However, the frequency of hypotension was greater in patients receiving the higher dose of esmolol. We found that esmolol 1.4 mg/kg IV administered 2 minutes prior to intubation was only partially effective in blunting the tachycardic response to laryngoscopy and intubation. Miller et al. lg demonstrated that esmolol 1.4 ? 0.4 mgikg IV, in combination with low-dose fentanyl 2 to 3 *g/kg IV, suppressed the acute hypertensive response to tracheal intubation while avoiding hypotension. In conclusion, lidocaine 1.5 mg/kg IV and nitroglycerin 2 pg/kg IV were ineffective in controlling the acute hemodynamic response following laryngoscopy and intubation. Esmolol 1.4 mg/kg IV was significantly more effective than either lidocaine or nitroglycerin in controlling the increase in HR, and it was also more effective than lidocaine in minimizing the increase in MAP following tracheal intubation. In situations where opioid analgesicsare contraindicated, esmolol would appear to J. Clin. Anesth., vol. 7, February 1995
7
Original
Contributions
be the cardiovascular modynamic stability tion.
drug of choice in maintaining heduring laryngoscopy and intuba-
References 1. Bruder N, Ortega D, Granthil C: Consequences and prevention methods of hemodynamic changes during laryngoscopy and intratracheal intubation. Ann Fr An&h Reanim 1992; 11: 57-71. 2. Miller CD, Warren SJ: IV lignocaine fails to attenuate the cardiovascular response to laryngoscopy and tracheal intubation. BrJ Anaesth 1990;65:216-9. 3. Smith I, Van Hemelrijck J, White PF: Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia. An&h Analg 1991;73:540-6. 4. Parnass SM, Rothenberg DM, Kerchberger JP, lvankovich AD: A single bolus dose of esmolol in the prevention of intubation-induced tachycardia and hypertension in an ambulatory surgery unit. J Clin An&h 1990;2:232-7. of blood pressure response to laryn5 Stoelting RK: Attenuation goscopy and tracheal intubation with sodium nitroprusside. Anesth Analg 1979;58:116-9. 6. Hatano Y, lmai R, Komatsu K, Mori K: Intravenous administration of isosorbide dinitrate attenuates the pressor response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Stand 1989;33:214-8. Mikawa K, Hasegawa M, Suzuki T, et al: Attenuation of hypertensive response to tracheal intubation with nitrog1ycerin.J Clin Anesth 1992;4:367-71. Nishikawa T, Namiki A: Attenuation of the pressor response to laryngoscopy and tracheal intubation with intravenous verapamil. Acta Anaesthesiol Stand 1989;33:232-5. Ghignone M, Calvillo 0, Quintin L: Anesthesia and hypertension: the effect of clonidine on perioperative hemodynamics and isoflurane requirements. Anesthesiology 1987;67:3-10.
8
J. Clin.
Anesth.,
vol. 7, January/February
1995
10. Pathak D, Slater RM, Ping SS, From RP: Effects of alfentanil and lidocaine on the hemodynamic responses to laryngoscopy and tracheal intubation. J Clin Anesth 1990;2:81-5. 11 Liu J, Latson TW, Wu G, White PF: Effects of IV and/or aerosolized lidocaine on the hemodynamic and EEG responses to laryngoscopy and tracheal intubation [Abstract]. Anesthesiology 1993;79:A157. 12 lnada E, Cullen DJ, Nemeskal AR, Teplick R: Effect of labetalol or lidocaine on the hemodynamic response to intubation: a controlled randomized double-blind study. J Clin Anesth 1989;1:207-13. 13. Fox EJ, Sklar GS, Hill CH, Villanueva R, King BD: Complications related to the pressor response to endotracheal intubation. Anesthesiology 1977;47:524-5. 14. Tam S, Chung F, Campbell M: Intravenous lidocaine: optimal time of injection before tracheal intubation. An&h Analg 1987; 66: 1036-8. 15. Sklar BZ, Lurie S, Ezri T, Krichelli D, Savir I, Soroker D: Lidocaine inhalation attenuates the circulatory response to laryngoscopy and endotracheal intubation. J Clin Anesth 1992;4: 382-5. 16. Longmire S, Leduc L, Jones MM, Hawkins JL, Joyce TH 3d, Cotton DB: The hemodynamic effects of intubation during nitroglycerin infusion in severe preeclampsia. Am J Obstet Gynecol 1991;164:551-6. 17. Newsome LR, Roth JV, Hug CC Jr, Nagle D: Esmolol attenuates the hemodynamic responses during fentanyl-pancuronium anesthesia for aortocoronary bypass surgery. Anesth Analg 1986;65:451-6. M, Purdy GM, Ellis FR: Esmolol hydrochloride for 18. Vucevic management of the cardiovascular stress responses to laryngoscopy and tracheal intubation. BrJ Anaesth 1992;68:529-30. 19. Miller DR, Martineau RJ, Wynands JE, Hill J: Bolus administration of esmolol for controlling the haemodynamic response to tracheal intubation: the Canadian Multicentre Trial. CanJ Anaesth 1991;38:849-58.
PhD,
Department of Anesthesiology and Pain Management, Southwestern Medical Center at Dallas, Dallas, TX.
MD8
University
of Texas,
Study Objective: To compare the safety and eff icac y of 1i d ocaine, esmolol, and nitroglycerin in modifying the hemodynamic response to laryngoscopy and intubation. Design: Randomized, placebo-controlled, double-blind study. Setting: University-affiliated VA medical center.
*Fellow tvisiting
Assistant
Professor
$Associate
Clinical
Professor
PProfessor thesiology
and McDermott
Chair
in Anes-
Address reprint requests to Dr. White at the Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75235 9068, USA. Received for publication November 10, 1993; revised manuscript accepted for publication February 8, 1994.
Journal of Clinical Anesthesia 7:5-S, 1995 0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY
Patients: 40 ASA physical status I and II patients undergoing elective surgery with general endotracheal anesthesia. Interventions: Anesthesia was induced with thiopental sodium5 mglkg, and intubation was facilitated with vecuronium 0.15 mglkg. Isoflurane (0.5% to I %) and 50% nitrous oxide in oxygen were used for maintenance of anesthesia. In addition, patients received one of the following four study drugs intravenously (IV) prior to laryngoscopy: Group 1 (control) = saline 5 ml; Group 2 = lidocaine 1.5 mglkg; Group 3 = esmolol 1.4 mglkg; Group 4 = nitroglycerin 2 pglkg. Measurements and Main Results: Mean arterial pressure (MAP) and heart rate (HR) were recorded every minute for 20 minutes following induction of anesthesia. Following laryngoscofi and intubation, MAP increased significantly in all four treatment groups (control 49% + 19%, lidocaine 55% + 26%, esmolol 25% 2 ll%, nitroglycerin 45Yo +- 21%) compared with preinduction baseline values. In the esmololpretreated patients, the increase in HR was significantly lower (20% + 3 %) compared with the nitroglycerin (37% * 8%), lidocaine (52% + 8%), and control (29% 2 4%) groups. Conclusions: Lidocaine 1.5 mglkg IV and nitroglycerin 2 kglkg IV were ineffective in controlling the acute hemodynamic response following laryngoscopy and intubation. Esmolol 1.4 mglkg IV was significantly moreeffective than either lidocaine or nitroglycerin in controlling the HR response to laryngoscopyand intubation (p < 0.05). Esmolol also was significantly more effective than lidocaine in minimizing the increase in MAP (25% vs. 55%).
10010
SSDI
0952-8180195/$10.00 0952-8180(94)00013-T
Original Contributions
Keywords: Esmolol; hypertension; intubation, intratracheal-cardiovascular responses; laryngoscopy; lidocaine; nitroglycerin; tachycardia.
Introduction Transient tachycardia and hypertension are common cardiovascular responses to laryngoscopy and intubation.’ Several different cardiovascular drugs-including lidocaine,’ esmolo1,3x4 nitroprusside,’ isosorbide,6 nitroglycerin,’ verapamil,’ and clonidineg-have been evaluated with respect to their ability to blunt the acute hemodynamic response to tracheal intubation. Intravenous (IV) lidocaine is still used for this purpose, even thou h published studies have questioned its efficacy.B‘*11 Beta-adrenergic-receptor blocking drugs appear to be more effective in preventing the increase in heart rate (HR) than the rise in blood pressure (BP).4Z’2 Nitroglycerin infusion also has been used to control the acute hypertensive responsesduring surgery. However, the safety and efficacy of IV bolus administration of nitroglycerin for control of the hyperdynamic response to tracheal intubation requires further evaluation. Although verapamil and clonidine are effective, they have failed to gain widespread clinical acceptance becauseof their variable onsets and relatively long durations of action. Therefore, we designed a randomized, double-blind, placebo-controlled study to compare the safety and efficacy of standard IV bolus dosesof lidocaine, esmolol, and nitroglycerin in modifying the acute hemodynamic response to laryngoscopy and tracheal intubation.
Materials
and Methods
After obtaining University of Texas, Southwestern Medical Center Institutional Review Board approval, 40 consenting, normotensive ASA physical status I and II adult malesundergoing elective surgery with general endotracheal anesthesia were randomized via a computergenerated table to one of four treatment groups according to a double-blind, placebo-controlled protocol. Patients with clinically significant cardiovascular disease were excluded from the study. Anesthesia was induced with thiopental 5 mglkg IV and vecuronium 0.15 mg/kg IV (at time 0 minutes). Anesthesia was maintained with 0.5% to 1% isoflurane and 50% nitrous oxide in oxygen (0,). Opioid analgesics and other adjunctive drugs were administered after the 20-minute study period. Patients received one of four standardized treatment regimens prior to laryngoscopy: Group 1 = saline 5 ml IV at time 0 minutes; Group 2 = lidocaine 1.5 mgikg IV at time 1 minute; Group 3 = esmolol 1.4 mglkg IV at time 2 minutes; Group 4 = nitroglycerin 2 kg/kg IV at time 3 minutes. Laryngoscopy wasinitiated 3.5 minutes after the thiopental induction by the same anesthesiologist, and tracheal intubation was accomplished within 30 seconds. Mean arterial pressure (MAP) and HR were subse6
J. Clin. Anesth.,vol. 7, January/February1995
quently recorded at 1 minute intervals for 20 minutes. In addition, hemoglobin O2 saturation and ECG lead Vj were monitored continuously for 20 minutes. Data were analyzed using repeated-measures of analysisof variance and Student’s paired t-test for evaluating changes within groups; an unpaired t-test with Bonferroni’s correction was used for comparisons between treatment groups. A p-value less than 0.05 was considered statistically significant.
Results The four treatment groups were comparable with respect to age, weight, and ASA physical status (Table I). MAP increased significantly following tracheal intubation in all four treatment groups (control 49% * 19%, lidocaine 55% 2 26%, esmolol 25% * ll%, nitroglycerin 45% +- 21%) compared with preinduction baseline values. In the saline (control) group, the maximum pressor response was observed 1 minute following intubation, with the value returning to baseline 5 minutes later. In the esmolol, nitroglycerin, and lidocaine groups, the maximum pressor response was observed at the time of tracheal intubation, with the values returning to baseline 3 minutes, 5 minutes, and 6 minutes, respectively, after intubation (Figure I). HR increased significantly in the control (29% * 4%), nitroglycerin (37% + 8%), and lidocaine (52% + 8%) groups. In the esmolol group, the increase in HR was significantly lower than in the other three groups (20% + 3%). The maximum increase in HR occurred 1 minute, 1 minute, 0 minutes, and 1 minute after intubation and returned to preinduction baseline by 10 minutes, 6 minutes, 8 minutes, and 7 minutes following tracheal intubation in the control, lidocaine, nitroglycerin, and esmolol groups, respectively (Figure 2). During the study period, no patient developed cardiac arrhythmias or evidence of ischemic changes on ECG lead Vs. One esmolol-pretreated patient developed transient hypotension (MAP lessthan 70 mmHg), which was treated with ephedrine 10 mg IV.
Discussion The magnitude (MAP 49% 2 19% and HR 29% -C 4%) and duration (MAP 6 minutes and HR 10 minutes) of 1. DemographicCharacteristicsof the Four Drug Treatment Groups
Table
Saline
Lidocaine
W-) 53 k 11 48 ? 15 Weight (kg) 78 ?I 8 82 5 14 ASA-PS I (n) 5 4 ASA-PS II (n) 5 6 Age
Note: Somedata are means* SD. = ASA physicalstatus.
ASA-PS
Esmolol 53 + 15 84 k 18 6 4
Nitroglycerin 56-+ 15 14 6 4
90 -t
Lidocaine,
0
1
2
3
4
5
6
7
8
--t
Control Lidocaine
-
Esmolol Nitroglycerin
9
10
11
12
13
14
15
Time (min)
1. Changes in mean arterial pressure (MAP) as a function of time following induction of anesthesia.Note: Data are means? SEM. Figure
-
Control
-t
Lidocaine
-
Esmolol
-
Nitroglycerin
-_ 0
1
2
3
4
5
6
7 8 Time(min)
9
10
11
12
13
14
15
2. Changesin heart rate (HR) asa function of time following induction of anesthesia.Note: Data are means+SEM. Figure
the acute hemodynamic responsesto tracheal intubation in our study population are consistent with other published values.’ Although transient hemodynamic changes may not be of any clinical importance in healthy patients, these changes are undesirable in patients with hypertension, myocardial insufficiency, or cerebrovascular disease.I3 Tam et al. l4 reported that lidocaine 1.5 mg/kg IV administered 3 minutes prior to intubation was highly effective in blunting the hyperdynamic response to intubation. They also demonstrated that lidocaine administered 1 minute, 2 minutes, or 5 minutes prior to intubation failed to attenuate the increase in HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), or MAP. Although it was administered 3 minutes prior to intubation, we found lidocaine 1.5 mg/kg IV ineffective in blunting the acute hemodynamic response to laryn-
esmolol, and nitroglycerin
and hemodynamic
response:
Singh et
al.
goscopy and intubation. Our findings are consistent with those of other studies that failed to show that IV lidocaine was effective for this purpose.“,” In a 1992 study, Sklar et al. l5 demonstrated that inhalational lidocaine 120 mg was effective in attenuating the hemodynamic response to laryngoscopy and tracheal intubation, whereas IV lidocaine 1 mg/kg failed to attenuate this response. These investigators suggested that topical analgesia, rather than a central action of lidocaine, was responsible for attenuating the hemodynamic response. Longmire et al. l6 studied the effectiveness of an IV infusion of nitroglycerin 0.1 kg/kg/min for controlling the hemodynamic response to endotracheal intubation in primigravid women with severe preeclampsia. HOWever; they observed that HR, MAP, and systemic vascular resistance still increased 28%, 22.5%, and 7.5%, respectively, following intubation. Mikawa et al.’ reported that an IV bolus of nitroglycerin 1.5 or 2.5 pg/kg administered at the start of laryngoscopy and intubation was effective in attenuating the hypertensive response. They reported that MAP began to decrease 30 seconds after IV nitroglycerin administration, was maximal after 45 seconds, and returned to baseline values within 2 minutes. When nitroglycerin 2 pg/kg IV was administered 30 secondsprior to laryngoscopy, we found it to be ineffective in preventing the hyperdynamic response to tracheal intubation. This finding could be due to the shorter duration of action of nitroglycerin compared with the untreated hyperdynamic response (1 to 2 minutes vs. 6 to 10 minutes). The pharmacokinetic profile of esmolol makes it well suited for controlling the cardiovascular response to tracheal intubation when it is administered as a continuous infusion. ” For example, Vucevic et al.” demonstrated that the pressor response to laryngoscopy was significantly less marked in patients receiving a continuous infusion of esmolol 500 kglkgimin for 2 minutes followed by an infusion of esmolol 100 pg/kg/min. Furthermore, Parnass et d4 reported that an IV bolus of esmolol 1.4 t 0.3 or 2.6 2 0.7 mg/kg administered 2.5 to 3 minutes prior to intubation significantly blunted increasesin HR and MAP following intubation. However, the frequency of hypotension was greater in patients receiving the higher dose of esmolol. We found that esmolol 1.4 mg/kg IV administered 2 minutes prior to intubation was only partially effective in blunting the tachycardic response to laryngoscopy and intubation. Miller et al. lg demonstrated that esmolol 1.4 ? 0.4 mgikg IV, in combination with low-dose fentanyl 2 to 3 *g/kg IV, suppressed the acute hypertensive response to tracheal intubation while avoiding hypotension. In conclusion, lidocaine 1.5 mg/kg IV and nitroglycerin 2 pg/kg IV were ineffective in controlling the acute hemodynamic response following laryngoscopy and intubation. Esmolol 1.4 mg/kg IV was significantly more effective than either lidocaine or nitroglycerin in controlling the increase in HR, and it was also more effective than lidocaine in minimizing the increase in MAP following tracheal intubation. In situations where opioid analgesicsare contraindicated, esmolol would appear to J. Clin. Anesth., vol. 7, February 1995
7
Original
Contributions
be the cardiovascular modynamic stability tion.
drug of choice in maintaining heduring laryngoscopy and intuba-
References 1. Bruder N, Ortega D, Granthil C: Consequences and prevention methods of hemodynamic changes during laryngoscopy and intratracheal intubation. Ann Fr An&h Reanim 1992; 11: 57-71. 2. Miller CD, Warren SJ: IV lignocaine fails to attenuate the cardiovascular response to laryngoscopy and tracheal intubation. BrJ Anaesth 1990;65:216-9. 3. Smith I, Van Hemelrijck J, White PF: Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia. An&h Analg 1991;73:540-6. 4. Parnass SM, Rothenberg DM, Kerchberger JP, lvankovich AD: A single bolus dose of esmolol in the prevention of intubation-induced tachycardia and hypertension in an ambulatory surgery unit. J Clin An&h 1990;2:232-7. of blood pressure response to laryn5 Stoelting RK: Attenuation goscopy and tracheal intubation with sodium nitroprusside. Anesth Analg 1979;58:116-9. 6. Hatano Y, lmai R, Komatsu K, Mori K: Intravenous administration of isosorbide dinitrate attenuates the pressor response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Stand 1989;33:214-8. Mikawa K, Hasegawa M, Suzuki T, et al: Attenuation of hypertensive response to tracheal intubation with nitrog1ycerin.J Clin Anesth 1992;4:367-71. Nishikawa T, Namiki A: Attenuation of the pressor response to laryngoscopy and tracheal intubation with intravenous verapamil. Acta Anaesthesiol Stand 1989;33:232-5. Ghignone M, Calvillo 0, Quintin L: Anesthesia and hypertension: the effect of clonidine on perioperative hemodynamics and isoflurane requirements. Anesthesiology 1987;67:3-10.
8
J. Clin.
Anesth.,
vol. 7, January/February
1995
10. Pathak D, Slater RM, Ping SS, From RP: Effects of alfentanil and lidocaine on the hemodynamic responses to laryngoscopy and tracheal intubation. J Clin Anesth 1990;2:81-5. 11 Liu J, Latson TW, Wu G, White PF: Effects of IV and/or aerosolized lidocaine on the hemodynamic and EEG responses to laryngoscopy and tracheal intubation [Abstract]. Anesthesiology 1993;79:A157. 12 lnada E, Cullen DJ, Nemeskal AR, Teplick R: Effect of labetalol or lidocaine on the hemodynamic response to intubation: a controlled randomized double-blind study. J Clin Anesth 1989;1:207-13. 13. Fox EJ, Sklar GS, Hill CH, Villanueva R, King BD: Complications related to the pressor response to endotracheal intubation. Anesthesiology 1977;47:524-5. 14. Tam S, Chung F, Campbell M: Intravenous lidocaine: optimal time of injection before tracheal intubation. An&h Analg 1987; 66: 1036-8. 15. Sklar BZ, Lurie S, Ezri T, Krichelli D, Savir I, Soroker D: Lidocaine inhalation attenuates the circulatory response to laryngoscopy and endotracheal intubation. J Clin Anesth 1992;4: 382-5. 16. Longmire S, Leduc L, Jones MM, Hawkins JL, Joyce TH 3d, Cotton DB: The hemodynamic effects of intubation during nitroglycerin infusion in severe preeclampsia. Am J Obstet Gynecol 1991;164:551-6. 17. Newsome LR, Roth JV, Hug CC Jr, Nagle D: Esmolol attenuates the hemodynamic responses during fentanyl-pancuronium anesthesia for aortocoronary bypass surgery. Anesth Analg 1986;65:451-6. M, Purdy GM, Ellis FR: Esmolol hydrochloride for 18. Vucevic management of the cardiovascular stress responses to laryngoscopy and tracheal intubation. BrJ Anaesth 1992;68:529-30. 19. Miller DR, Martineau RJ, Wynands JE, Hill J: Bolus administration of esmolol for controlling the haemodynamic response to tracheal intubation: the Canadian Multicentre Trial. CanJ Anaesth 1991;38:849-58.