- Email: [email protected]
Propofol permits tracheal intubation but does not affect postoperative myalgias
ELSEVIER
Propofol Permits Tracheal Intubation But Does Not Affect Postoperative Myalgias Melinda L. Mingus, MD,* Adiba K. Shamsi, MD,* Jane F. Recant, MD,? James B. Eisenkraft, MDS Department of Anesthesiology, New York, New York
Mount Sinai School of Medicine,
Study Objective: To determine the effect ofpropofol without succinylcholine on intubating conditions and postoperative myalgias in ambulatory surgical patients undergoing general anesthesia. Design: Prospective, double-blind, randomized study. Setting: Ambulatory surgq adult patients. Patients: 56 ASA physical status I and II adult patients undergoing general endotracheal anesthesia. Interventions: Group 1 patients received thiamylal plus succinylcholine, Group 2 patients received propofol plus succinylcholine; and Group 3 patients received propofol plus saline. All patients received fentanyl, lidocaine, and nitrous oxide plus isoflumne in oxygen. Measurements and Main Results: Incidence and severity of fasciculations, tracheal intubating renditions, and myalgias on the first and third postoperative days were measured. Propofol did not affect the incidence or severity offasciculations following succinylcholine, or the incidence of myalgias. Of patients who received propofol without succinylcholine, intubation was successful in 85 96. Conclusions: Propofol did not affect the incidence or severity of postoperative myalgias following succinylcholine.
Keywords: Anesthesia, complications, succinylcholine
outpatient; anesthetics, intravenous, propofol; muscle pain; intubation, tracheal; neuromuscular relaxants,
*Assistant Professor
Introduction
tResident
The administration of succinylcholine may result in postoperative myalgias, especially in ambulatory patients in whom the avoidance of succinylcholine may be desirable.‘-” Propofol may depress pharyngeal and laryngeal reflexes sufficiently to permit successful tracheal intubation in most patients.§3”34*5 The administration of propofol with or without the use of succinylcholine to facilitate tracheal intubation may decrease or prevent postoperative myalgias in patients following ambulatory surgery.§‘i343”
$Professor Address reprint requests to Dr. Mingus at the Department of Anesthesiology, Box 1010, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574. Received for publication January 20, 1995; revised manuscript accepted for publication June 8, 1995. An abstract of this work was presented at the Annual Meeting of the American Society of Anesthesiologists, Washington, D.C., in October 1993.
SKallar SK: Propofol allows intubation without relaxants [Abstract]. Anesthesiology 1990;73:A22. qacque9, Gold MI, deLisser EA: Is propofol a muscle relaxant? [Abstract]. An&h Analg 1990;7O:S172.
Journal of Clinical Anesthesia 8:220-224, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0952-8180/96/$15.00 SSDI 0952-8180(95)00234-O
The purpose of this study was to determine the efficacy of propofol without succinylcholine to provide adequate intubating conditions, and the effect of propofol on postoperative myalgias in ambulatory surgical patients undergoing general anesthesia.
Materials
and Methods
Following Mount Sinai Medical Center Institutional Review Board approval, written informed consent was ob tained from 56 ASA physical status I and II adult patients to participate in this randomized, double-blind study. All patients were scheduled to undergo general anesthesia for outpatient surgery, for which tracheal intubation was indicated. The patients received no premeditation. Routine monitors were placed including blood pressure (BP) cuff, ECG, precordial stethoscope, and pulse oximeter; and an intravenous (IV) catheter was inserted. Following preoxygenation, and three minutes prior to induction, all patients received fentanyl 2 mcg/kg IV and lidocaine 1.5 mg/kg IV. Patients were randomly assigned, via computergenerated numbers table, to one of three treatment groups. Group 1 received thiamylal sulfate 4 mg/kg IV until loss of eyelid reflex, immediately followed by succinylcholine 1 mg/kg IV. Group 2 received propofol 2.5 mg/kg IV until loss of eyelid reflex, immediately followed by succinylcholine 1 mg/kg IV to facilitate tracheal intubation. Group 3 received propofol 2.5 mg/kg IV until loss of eyelid reflex, immediately followed by 0.9% saline (5 ml) IV. Additional thiamylal sulfate or propofol was given, if necessary, to produce loss of consciousness. Anesthesia was maintained with isoflurane 0.2% to 1.0% in 70% nitrous oxide/30% oxygen. An anesthesiologist who was blinded to the treatment group rated fasciculations on a scale of 0 to 3, where 0 = none, 1 = mild, 2 = moderate, and 3 = severe and widespread, requiring restraint.’ Tracheal intubating conditions were rated by an investigator who performed the intubation, on a scale of 1 to 3, where 1 =
Table
1.
smooth and easy, 2 = coughing or bucking on intubation, and 3 = intubation was impossible.’ On postoperative days 1 and 3 (POD 1, POD 3) patients were telephoned by a research nurse who was blinded to the patient’s group assignment and asked to rate any myalgias on a scale of 0 to 3, where 0 = none, 1 = mild muscle stiffness or pains, 2 = moderate muscle stiffness and pain spontaneously complained of by the patient, and 3 = severe, incapacitating generalized muscle stiffness and pains requiring analgesics.’ Fasciculations (incidence and severity), tracheal intubating conditions, and postoperative myalgias on POD 1 and POD 3 were compared among the treatment groups using chi-square tests, and the Mantel-Haenzel test to control for differences among groups in factors such as smoking, gender, and type of procedure. A p-value less than 0.05 was considered statistically significant.
Results We found no significant differences among the groups with respect to age, weight, gender, dose of propofol used, or type of surgery (7’nbk 1). Group 1 included fewer females than did Groups 2 or 3, but the differences were not significant. The percentage of smokers in Group 3 was significantly lower than in Group 2, and was less compared with Group 1. Patients underwent a variety of surgical procedures, the most common being head and neck, followed by gynecologic (nonlaparoscopic) and orthopedic (Y.&k I). The median dose of propofol was similar in Groups 2 and 3. The amount of analgesics taken by patients for postsurgical pain, including acetaminophen, acetaminophen with codeine, acetaminophen with oxycodone, and hydrocodone on PODS 1 and 3, were similar. Only two patients (one from Group 2 and one from Group 3) required analgesics for myalgias. Patients in Group 3 did not demonstrate any fasciculations. The incidence and severity of fasciculations did not differ significantly between Groups 1 and 2 (Table 2).
Demographics
Group Treatment
1 Thiamylal/Succinylcboline
2
3
Propofol/Succinylcholine
Propofol/Saliie
11 Femate/Matr 5%Female Median Age (y-s) Median Wt (kg) Median Propofot (mg) 76 Smokers 5%ENT Surgeq % Gy~ecotogic Surger) 5%Orthoprdic Surgery % Analgesics POD 1 5%Analgesics POD 3 +p < O.OJ, Group :3 II\. Group 2. POD = txNopcrativr day.
,J. Clin. Anestlr., vol. 8, May 1996
221
Original
Contributions
Significantly fewer patients in Group 3 received an intubation score of 1 compared with Groups 1 or 2 (Table 3). Two patients assigned to Group 3 could not be tracheally intubated and subsequently required succinylcholine for a successful intubation. There was a significantly greater incidence of coughing (70%) in Group 3 compared with Groups 1 and 2. Tracheal intubation was successfully accomplished in all patients in Groups 1 and 2 but in only S5% of patients in Group 3 (Tuble 3). The incidence of postoperative myalgias on PODS 1 and 3 did not differ significantly among the groups. The incidence of postoperative myalgias (Table 2) is calculated based on the presence or absence of postoperative myalgias described by the patient in the postoperative telephone calls. The severity of postoperative myalgias (as graded on the scale 0 to 3 but not shown in Table 3) did not differ significantly among the groups. There was a trend for a postoperative myalgias score greater than 1 in Group 2 for both POD 1 and POD 3, but the difference was not statistically significant (Tuble 2). There was no association between the incidence and severity of fasciculations and postoperative myalgias for any of the three groups considered one at a time, nor for all three groups, as determined by the Mantel-Haenzel test.2 The number of patients per group gave this study a power of 0.8 to detect a 40% change in the incidence of postoperative myalgias with a p-value of 0.05.
Discussion Propofol, which is a short-acting IV hypnotic drug, may obtund pharyngeal and laryngeal reflexes sufficiently to permit tracheal intubation.*%4X5 Kallar et al.,* using a propofol bolus of 2.5 mg/kg, preceded by fentany14 mcg/kg and lidocaine 1 mg/kg, were able to tracheally intubate 28 (93.3%) of 30 patients. McKeating et uL5 achieved a rapid and smooth tracheal intubation in 18 (60%) of 30 patients using propofol 2.5 mg/kg without lidocaine or an opioid. Even though a propofol-based technique seems to produce adequate intubating conditions, its effect on muscle relaxation is unclear. Examining the effect of propofol on
Table 2.
Fasciculations and Postoperative Myalgias
Group
n % Fasciculation % postoperative myalgias POD 1 (score 3 1)
% postoperative myalgias POD 3 (score 2 1) *Significance of difference: NS = not significant. POD = postoperative day.
1
2
3
p-value
18 94
18 72
20 0*
0.0001*
33
50
30
NS
22
28
15
NS
Group 3 us. Groups 1 and 2 (by Fisher’s exact test), respectively.
*Kallar SK: Propofol allows intubation Anesthesiology 1990;73:A22.
222
the neuromuscular junction, Jacque et al.? failed to find a decrease in the total amount of vecuronium needed for neuromuscular blockade when propofol was given as a 2 to 2.5 mg/kg bolus followed by an infusion. Other hypnotic drugs may also facilitate tracheal intubation without the aid of muscle relaxants; the success rate following thiopental sodium varies between 3.3% and 36%.*,4,“,y In our study, tracheal intubation was achieved in 92.5% of patients (average of Groups 2 and 3) using a propofolbased anesthetic technique, and in 85% of patients using propofol without a muscle relaxant (Group 3), but with the majority of patients (70%) exhibiting some coughing or bucking on placement of the tracheal tube. Only 15% of patients in Group 3 were judged as having a smooth and “easy” intubation, and two were rated as impossible intubations, subsequently requiring succinylcholine. Smokers may exhibit more airway irritability than nonsmokers,‘” which may contribute to problems during tracheal intubation. In our study, however, smoking did not appear to contribute significantly to coughing or bucking on placement of the tracheal tube. This finding is probably explained because there were fewest smokers in the group in which there was the greatest number of problems during intubation. McKeating et al.,” using the same dose of propofol in larger patient groups (30 vs. our 18 to 20 patients per group), found a much higher rate of successful intubations. They assessed intubation at 45, 90, and 120 seconds and found the greatest success rate at 45 seconds. Even though we did not precisely time our intubations, all patients had loss of eyelid reflex, apnea, and relaxed jaw muscles prior to laryngoscopy. It is possible that some of our intubations were performed between 20 and 30 seconds after propofol administration; however, in the two patients who eventually required succinylcholine, two attempts were made to intubate following propofol, a process that took more than 45 seconds. Our intubation results are more similar to those of Keaveny et al.,* who, using the same dose of propofol in 20 patients, found intubation easy in 60%, coughing or bucking in 35%, and one “impossible” intubation in a patient with previously
without
J. Clin. Anesth., vol. 8, May 1996
relaxants
[Abstract].
tJacque JJ, Gold MI, deLisser EA: Is propofol [Abstract]. An&h Analg 1990;7O:S172.
a muscle relaxant?
Table 3.
Intubating Conditions
Group
1
2
3
p-value
n % Easy Intubation (Score 1) % Successful Intubation (Score 1 or 2) % Coughing/Bucking
18 94
18 94
20 15%
0.0000
100 6
100 0
85 70”
NS 0.0001
*Significant difference: Group 3 us. Groups 1 and 2 (by Fisher’s exact test). NS‘= not significant.
undiagnosed upper airway abnormality. Kallar,* using the same dose of propofol and lidocaine as in our study but a larger dose of fentanyl (4 mcg/kg vs. 2 mcg/kg) in 30 patients per group, showed a 93.3% success rate with two “impossible” intubations secondary to severe coughing. Whether more patients exhibited coughing and bucking on intubation was not discussed in her report.* The technique that we used in this study (propofol 2.5 mg/kg preceded by fentanyl 2 mcg/kg and lidocaine 1.5 mg/kg) resulted in a relaxed jaw and vocal cords sufficient to permit an 85% success rate for tracheal intubation, but with 70% of patients exhibiting some degree of coughing or bucking when the tube was passed. The overall incidence of postoperative myalgias following succinylcholine varies from 5% to 83%.” The occurrence of postoperative myalgias following succinylcholine may be greatest after ambulatory surgery,“,‘,” minor surgical procedures,” and in females.‘“,” Methods to decrease the incidence of postoperative myalgias include pretreatment with a small dose of nondepolarizing z’,“’ a “self-taming” dose of succinylcholine,‘“~‘” and ZZZaine.t7 Because lidocaine may affect the incidence of postoperative myalgias, it was administered to all patients. In ambulatory patients undergoing laparoscopy, postoperative myalgias may occur following the use of atracurium or vecurollillm,‘~.7.‘X-20 even when muscle relaxants have not been used.“’ At least for the female patient following outpatient laparoscopy, several studies have shown that the incidence of postoperative myalgias is unrelated to the administration of succinylcholine, with or without pretreatment, and with or without fasciculations.‘,‘“-“” Myalgias may be more related to the laparoscopic surgical procedure itself that to the medications and or the techniques employed,‘~.‘“‘,“.~’ In contrast to previous studies, our patient population underwent a variety of surgical procedures (gynecologic laparoscopic procedures were excluded from the treatment groups), and included males and females (52% to 78% female among the three groups). Our study methods also differed from those of a recent study by Smith et a1.2” and McClymont,’ in that we included a group who did not receive any muscle relaxant. In the study by Smith et a1.,‘” and McClymont,” all patients received a muscle relaxant
*Kallar SK: Propofol allows intubation Anesthc&locg 1990;73:A22.
without
relaxants
[Abstract],
(either succinylcholine or atracurium), one group received d-tubocurarine as pretreatment, but no group received propofol without a muscle relaxant. Our study design included a group who received fentanyl and lidocaine followed by propofol without neuromuscular blockade to examine the effects of propofol on tracheal intubating conditions and on postoperative myalgias. We did not find any attenuation of succinylcholineinduced fasciculations by propofol. The incidence and severity of fasciculations in Group 1 was not significantly different from that in Group 2 (94% US. 72%). Smith et n1.“’ similarly failed to fmd an effect of propofol on the incidence and severity of fasciculations. Our results show that the administration of propofol without succinylcholine did not affect the incidence of postoperative myalgias, either on POD 1 or POD 3. The use of propofol prior to succinylcholine also did not decrease the incidence of postoperative myalgias associated with succinylcholine. These results are in agreement with those of others reported for patients following laparoscopic procedures.‘8-20 McClymont,” however, found a reduction in succinylcholine-induced postoperative myalgias following propofol in patients undergoing laparoscopic surgery. Because postlaparoscopic gas pains may be confused with postoperative myalgias2”,24 our study excluded laparoscopy and included patients undergoing several different types of surgery. However, even with a variety of surgical procedures, we were unable to find a difference between the groups in the incidence and/or the severity of postoperative myalgias. In contrast to the scoring system used by Smith et n1.,“’ our scoring system for postoperative myalgias was not specific to the neck and shoulder. The most common complaint associated with the muscle pain was a “flu-like” feeling in which the pain was not localized to any body part. This description of myalgias as being similar to the “flu” was first reported in 1961 by Burtles and Tunstall.“’ Postoperative myalgias continued to be present on POD 3 although they were decreased for all groups compared with POD 1. This finding has also been previously reported.‘“-‘” However, in McClymont’s study,” the severity of myalgia pain increased after 24 hours. Like those of other studies, our results showed no association between the incidence and severity of fasciculations and the occurrence of postoperative myalgias.‘~‘i,‘H-“O In summary, the use of propofol, even without muscle relaxants, did not affect the incidence or severity of postoperative myalgias on POD 1 and POD 3 following a variety of nonJ. Clin. Anesth., vol. 8. Mav 1996
223
originnl Co?ltributions
laparoscopic surgical procedures undergone by both males and females on an ambulatory basis. A propofolfentanyl-lidocaine anesthesia induction resulted in an 85% success rate for tracheal intubation even though the majority of patients reacted to placement of the tube. Most patients showed some degree of coughing or bucking on placement of the tracheal tube. In spite of these less-thanideal conditions, the ability to tracheally intubate a patient without the use of a muscle relaxant may be beneficial, particularly for procedures of short duration, while avoiding the potential side effects of neuromuscular blockade.
References 1. Brodsky JB, Ehrenwerth J: Postoperative muscle pains and suxamethonium. BrJAnaesth 1980;52:215-8. 2. Churchill-Davidson HC: Suxamethonium chloride and muscle pains. BMJ 1954;1:74-5. 3. Trepanier CA, Brousseau C, Lacerte L: Myalgia in outpatient surgery: comparison of atracurium and succinylcholine. Can J Am&h 1988;35(3 (Pt 1)):255-8. 4. Scheller MS, Zornow MH, Saidman LJ: Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil. An&h Annlg 1992;75:788-93. 5. McKeating K, Bali IM, Dundee JW: The effects of thiopentone and propofol on upper airway integrity. Anaesthesia 1988;43:63840. 6. McClymont C: A comparison of the effect of propofol or thiopentone on the incidence and severity of suxamethoniuminduced myalgia. Ann&h Intmsiw Care 1994;22:147-9. 7. Sosis M, Broad T, Larijani GE, Marr AT: Comparison of atracurium and d-tubocurarine for prevention of succinylcholine myalgia. Anrsth Ancclg 1987;66:657-9. 8. Keaveny JP, Knell PJ: Intubation under induction doses of propofol. Ames//mm 1988;43 Suppl:HO-1. 9, Lewis CB: Endotracheal intubation under thiopentone: an analysis of 200 cases. Ann&he.& 1948;3:113-5.
224
J. Clin. Anesth., vol. 8, May 1996
10. Jones RM: Smoking before surgery: the case for stopping. BMJ 1985;290:1763-4. 1. Pace NL: Prevention of succinylcholine myalgias: a meta-analysis. An&h Annlg 1990;70:477-83. 12. Brindle GF, Soliman MC: Anaesthetic complications in surgical outpatients. Can Ann&h Sot J 1975;22:613-9. 13. Burtles R, Tunstall ME: Suxamethonium chloride and muscle pains. BrJArmusth 1961;33:24-8. 14. Bennetts FE, Khalil KI: Reduction of post-suxamethonium pain by pretreatment with four non-depolarising agents. BrJ Ann&h 1981;53:531-6. 15. Verma RS: “Self-taming” with succinylcholine and muscle pain [Letter]. An&h&logy 1983;58:487. 16. Durant NN, Katz RL: Suxamethonium. BrJAnaecth 1982;54:195208. 17. Chatterji S, Thind SS, Daga SR: Lignocaine pretreatment for s11xamethonium. A clinicobiochemical study. Anuectherin 1983;38: X67-70. 18. Zahl K, Apfelbaum JL: Muscle pain occurs after outpatient laparoscopy despite the substitution of vecuronium for succinylcholine. Anesthesiology 1989;70:408-II. 19. Mingus ML, Herlich A, Eisenkraft JB: Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium. Ana~.du~in 1990;45:834-7. 20. Smith I, Ding Y, White PF: Muscle pain after outpatient laparoscopy-influence of propofol vers11s thiopental and enflurane. Anesth Annlg 1993;76:1181-4. 21. Kenefick JP, Leader A, Maltby JR, Taylor PJ: Laparoscopy: bloodgas values and minor sequelae associated with three techniques based on isoflurane. Br JAna&h 1987;59:189-94. 22. Clark RS, Dundee JW, Daw RH: Clinical studies of induction agents. XI. The influence of some intravenous anaesthetics on the respiratory effects and sequelae of suxamethonium. Br J Anarrth 1964;36:307-13. 23. Laurence AS, Smith SO: Attenuation of suxamethonium myalgias [I.etter]. Anwsth&n 1991;46:588-9. 24. Mingus ML, Herlich A, Eisenkraft JB: Attenuation of suxamethonium myalgias. A Reply. Annrcthesin 1991;46:.589.
Propofol Permits Tracheal Intubation But Does Not Affect Postoperative Myalgias Melinda L. Mingus, MD,* Adiba K. Shamsi, MD,* Jane F. Recant, MD,? James B. Eisenkraft, MDS Department of Anesthesiology, New York, New York
Mount Sinai School of Medicine,
Study Objective: To determine the effect ofpropofol without succinylcholine on intubating conditions and postoperative myalgias in ambulatory surgical patients undergoing general anesthesia. Design: Prospective, double-blind, randomized study. Setting: Ambulatory surgq adult patients. Patients: 56 ASA physical status I and II adult patients undergoing general endotracheal anesthesia. Interventions: Group 1 patients received thiamylal plus succinylcholine, Group 2 patients received propofol plus succinylcholine; and Group 3 patients received propofol plus saline. All patients received fentanyl, lidocaine, and nitrous oxide plus isoflumne in oxygen. Measurements and Main Results: Incidence and severity of fasciculations, tracheal intubating renditions, and myalgias on the first and third postoperative days were measured. Propofol did not affect the incidence or severity offasciculations following succinylcholine, or the incidence of myalgias. Of patients who received propofol without succinylcholine, intubation was successful in 85 96. Conclusions: Propofol did not affect the incidence or severity of postoperative myalgias following succinylcholine.
Keywords: Anesthesia, complications, succinylcholine
outpatient; anesthetics, intravenous, propofol; muscle pain; intubation, tracheal; neuromuscular relaxants,
*Assistant Professor
Introduction
tResident
The administration of succinylcholine may result in postoperative myalgias, especially in ambulatory patients in whom the avoidance of succinylcholine may be desirable.‘-” Propofol may depress pharyngeal and laryngeal reflexes sufficiently to permit successful tracheal intubation in most patients.§3”34*5 The administration of propofol with or without the use of succinylcholine to facilitate tracheal intubation may decrease or prevent postoperative myalgias in patients following ambulatory surgery.§‘i343”
$Professor Address reprint requests to Dr. Mingus at the Department of Anesthesiology, Box 1010, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574. Received for publication January 20, 1995; revised manuscript accepted for publication June 8, 1995. An abstract of this work was presented at the Annual Meeting of the American Society of Anesthesiologists, Washington, D.C., in October 1993.
SKallar SK: Propofol allows intubation without relaxants [Abstract]. Anesthesiology 1990;73:A22. qacque9, Gold MI, deLisser EA: Is propofol a muscle relaxant? [Abstract]. An&h Analg 1990;7O:S172.
Journal of Clinical Anesthesia 8:220-224, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0952-8180/96/$15.00 SSDI 0952-8180(95)00234-O
The purpose of this study was to determine the efficacy of propofol without succinylcholine to provide adequate intubating conditions, and the effect of propofol on postoperative myalgias in ambulatory surgical patients undergoing general anesthesia.
Materials
and Methods
Following Mount Sinai Medical Center Institutional Review Board approval, written informed consent was ob tained from 56 ASA physical status I and II adult patients to participate in this randomized, double-blind study. All patients were scheduled to undergo general anesthesia for outpatient surgery, for which tracheal intubation was indicated. The patients received no premeditation. Routine monitors were placed including blood pressure (BP) cuff, ECG, precordial stethoscope, and pulse oximeter; and an intravenous (IV) catheter was inserted. Following preoxygenation, and three minutes prior to induction, all patients received fentanyl 2 mcg/kg IV and lidocaine 1.5 mg/kg IV. Patients were randomly assigned, via computergenerated numbers table, to one of three treatment groups. Group 1 received thiamylal sulfate 4 mg/kg IV until loss of eyelid reflex, immediately followed by succinylcholine 1 mg/kg IV. Group 2 received propofol 2.5 mg/kg IV until loss of eyelid reflex, immediately followed by succinylcholine 1 mg/kg IV to facilitate tracheal intubation. Group 3 received propofol 2.5 mg/kg IV until loss of eyelid reflex, immediately followed by 0.9% saline (5 ml) IV. Additional thiamylal sulfate or propofol was given, if necessary, to produce loss of consciousness. Anesthesia was maintained with isoflurane 0.2% to 1.0% in 70% nitrous oxide/30% oxygen. An anesthesiologist who was blinded to the treatment group rated fasciculations on a scale of 0 to 3, where 0 = none, 1 = mild, 2 = moderate, and 3 = severe and widespread, requiring restraint.’ Tracheal intubating conditions were rated by an investigator who performed the intubation, on a scale of 1 to 3, where 1 =
Table
1.
smooth and easy, 2 = coughing or bucking on intubation, and 3 = intubation was impossible.’ On postoperative days 1 and 3 (POD 1, POD 3) patients were telephoned by a research nurse who was blinded to the patient’s group assignment and asked to rate any myalgias on a scale of 0 to 3, where 0 = none, 1 = mild muscle stiffness or pains, 2 = moderate muscle stiffness and pain spontaneously complained of by the patient, and 3 = severe, incapacitating generalized muscle stiffness and pains requiring analgesics.’ Fasciculations (incidence and severity), tracheal intubating conditions, and postoperative myalgias on POD 1 and POD 3 were compared among the treatment groups using chi-square tests, and the Mantel-Haenzel test to control for differences among groups in factors such as smoking, gender, and type of procedure. A p-value less than 0.05 was considered statistically significant.
Results We found no significant differences among the groups with respect to age, weight, gender, dose of propofol used, or type of surgery (7’nbk 1). Group 1 included fewer females than did Groups 2 or 3, but the differences were not significant. The percentage of smokers in Group 3 was significantly lower than in Group 2, and was less compared with Group 1. Patients underwent a variety of surgical procedures, the most common being head and neck, followed by gynecologic (nonlaparoscopic) and orthopedic (Y.&k I). The median dose of propofol was similar in Groups 2 and 3. The amount of analgesics taken by patients for postsurgical pain, including acetaminophen, acetaminophen with codeine, acetaminophen with oxycodone, and hydrocodone on PODS 1 and 3, were similar. Only two patients (one from Group 2 and one from Group 3) required analgesics for myalgias. Patients in Group 3 did not demonstrate any fasciculations. The incidence and severity of fasciculations did not differ significantly between Groups 1 and 2 (Table 2).
Demographics
Group Treatment
1 Thiamylal/Succinylcboline
2
3
Propofol/Succinylcholine
Propofol/Saliie
11 Femate/Matr 5%Female Median Age (y-s) Median Wt (kg) Median Propofot (mg) 76 Smokers 5%ENT Surgeq % Gy~ecotogic Surger) 5%Orthoprdic Surgery % Analgesics POD 1 5%Analgesics POD 3 +p < O.OJ, Group :3 II\. Group 2. POD = txNopcrativr day.
,J. Clin. Anestlr., vol. 8, May 1996
221
Original
Contributions
Significantly fewer patients in Group 3 received an intubation score of 1 compared with Groups 1 or 2 (Table 3). Two patients assigned to Group 3 could not be tracheally intubated and subsequently required succinylcholine for a successful intubation. There was a significantly greater incidence of coughing (70%) in Group 3 compared with Groups 1 and 2. Tracheal intubation was successfully accomplished in all patients in Groups 1 and 2 but in only S5% of patients in Group 3 (Tuble 3). The incidence of postoperative myalgias on PODS 1 and 3 did not differ significantly among the groups. The incidence of postoperative myalgias (Table 2) is calculated based on the presence or absence of postoperative myalgias described by the patient in the postoperative telephone calls. The severity of postoperative myalgias (as graded on the scale 0 to 3 but not shown in Table 3) did not differ significantly among the groups. There was a trend for a postoperative myalgias score greater than 1 in Group 2 for both POD 1 and POD 3, but the difference was not statistically significant (Tuble 2). There was no association between the incidence and severity of fasciculations and postoperative myalgias for any of the three groups considered one at a time, nor for all three groups, as determined by the Mantel-Haenzel test.2 The number of patients per group gave this study a power of 0.8 to detect a 40% change in the incidence of postoperative myalgias with a p-value of 0.05.
Discussion Propofol, which is a short-acting IV hypnotic drug, may obtund pharyngeal and laryngeal reflexes sufficiently to permit tracheal intubation.*%4X5 Kallar et al.,* using a propofol bolus of 2.5 mg/kg, preceded by fentany14 mcg/kg and lidocaine 1 mg/kg, were able to tracheally intubate 28 (93.3%) of 30 patients. McKeating et uL5 achieved a rapid and smooth tracheal intubation in 18 (60%) of 30 patients using propofol 2.5 mg/kg without lidocaine or an opioid. Even though a propofol-based technique seems to produce adequate intubating conditions, its effect on muscle relaxation is unclear. Examining the effect of propofol on
Table 2.
Fasciculations and Postoperative Myalgias
Group
n % Fasciculation % postoperative myalgias POD 1 (score 3 1)
% postoperative myalgias POD 3 (score 2 1) *Significance of difference: NS = not significant. POD = postoperative day.
1
2
3
p-value
18 94
18 72
20 0*
0.0001*
33
50
30
NS
22
28
15
NS
Group 3 us. Groups 1 and 2 (by Fisher’s exact test), respectively.
*Kallar SK: Propofol allows intubation Anesthesiology 1990;73:A22.
222
the neuromuscular junction, Jacque et al.? failed to find a decrease in the total amount of vecuronium needed for neuromuscular blockade when propofol was given as a 2 to 2.5 mg/kg bolus followed by an infusion. Other hypnotic drugs may also facilitate tracheal intubation without the aid of muscle relaxants; the success rate following thiopental sodium varies between 3.3% and 36%.*,4,“,y In our study, tracheal intubation was achieved in 92.5% of patients (average of Groups 2 and 3) using a propofolbased anesthetic technique, and in 85% of patients using propofol without a muscle relaxant (Group 3), but with the majority of patients (70%) exhibiting some coughing or bucking on placement of the tracheal tube. Only 15% of patients in Group 3 were judged as having a smooth and “easy” intubation, and two were rated as impossible intubations, subsequently requiring succinylcholine. Smokers may exhibit more airway irritability than nonsmokers,‘” which may contribute to problems during tracheal intubation. In our study, however, smoking did not appear to contribute significantly to coughing or bucking on placement of the tracheal tube. This finding is probably explained because there were fewest smokers in the group in which there was the greatest number of problems during intubation. McKeating et al.,” using the same dose of propofol in larger patient groups (30 vs. our 18 to 20 patients per group), found a much higher rate of successful intubations. They assessed intubation at 45, 90, and 120 seconds and found the greatest success rate at 45 seconds. Even though we did not precisely time our intubations, all patients had loss of eyelid reflex, apnea, and relaxed jaw muscles prior to laryngoscopy. It is possible that some of our intubations were performed between 20 and 30 seconds after propofol administration; however, in the two patients who eventually required succinylcholine, two attempts were made to intubate following propofol, a process that took more than 45 seconds. Our intubation results are more similar to those of Keaveny et al.,* who, using the same dose of propofol in 20 patients, found intubation easy in 60%, coughing or bucking in 35%, and one “impossible” intubation in a patient with previously
without
J. Clin. Anesth., vol. 8, May 1996
relaxants
[Abstract].
tJacque JJ, Gold MI, deLisser EA: Is propofol [Abstract]. An&h Analg 1990;7O:S172.
a muscle relaxant?
Table 3.
Intubating Conditions
Group
1
2
3
p-value
n % Easy Intubation (Score 1) % Successful Intubation (Score 1 or 2) % Coughing/Bucking
18 94
18 94
20 15%
0.0000
100 6
100 0
85 70”
NS 0.0001
*Significant difference: Group 3 us. Groups 1 and 2 (by Fisher’s exact test). NS‘= not significant.
undiagnosed upper airway abnormality. Kallar,* using the same dose of propofol and lidocaine as in our study but a larger dose of fentanyl (4 mcg/kg vs. 2 mcg/kg) in 30 patients per group, showed a 93.3% success rate with two “impossible” intubations secondary to severe coughing. Whether more patients exhibited coughing and bucking on intubation was not discussed in her report.* The technique that we used in this study (propofol 2.5 mg/kg preceded by fentanyl 2 mcg/kg and lidocaine 1.5 mg/kg) resulted in a relaxed jaw and vocal cords sufficient to permit an 85% success rate for tracheal intubation, but with 70% of patients exhibiting some degree of coughing or bucking when the tube was passed. The overall incidence of postoperative myalgias following succinylcholine varies from 5% to 83%.” The occurrence of postoperative myalgias following succinylcholine may be greatest after ambulatory surgery,“,‘,” minor surgical procedures,” and in females.‘“,” Methods to decrease the incidence of postoperative myalgias include pretreatment with a small dose of nondepolarizing z’,“’ a “self-taming” dose of succinylcholine,‘“~‘” and ZZZaine.t7 Because lidocaine may affect the incidence of postoperative myalgias, it was administered to all patients. In ambulatory patients undergoing laparoscopy, postoperative myalgias may occur following the use of atracurium or vecurollillm,‘~.7.‘X-20 even when muscle relaxants have not been used.“’ At least for the female patient following outpatient laparoscopy, several studies have shown that the incidence of postoperative myalgias is unrelated to the administration of succinylcholine, with or without pretreatment, and with or without fasciculations.‘,‘“-“” Myalgias may be more related to the laparoscopic surgical procedure itself that to the medications and or the techniques employed,‘~.‘“‘,“.~’ In contrast to previous studies, our patient population underwent a variety of surgical procedures (gynecologic laparoscopic procedures were excluded from the treatment groups), and included males and females (52% to 78% female among the three groups). Our study methods also differed from those of a recent study by Smith et a1.2” and McClymont,’ in that we included a group who did not receive any muscle relaxant. In the study by Smith et a1.,‘” and McClymont,” all patients received a muscle relaxant
*Kallar SK: Propofol allows intubation Anesthc&locg 1990;73:A22.
without
relaxants
[Abstract],
(either succinylcholine or atracurium), one group received d-tubocurarine as pretreatment, but no group received propofol without a muscle relaxant. Our study design included a group who received fentanyl and lidocaine followed by propofol without neuromuscular blockade to examine the effects of propofol on tracheal intubating conditions and on postoperative myalgias. We did not find any attenuation of succinylcholineinduced fasciculations by propofol. The incidence and severity of fasciculations in Group 1 was not significantly different from that in Group 2 (94% US. 72%). Smith et n1.“’ similarly failed to fmd an effect of propofol on the incidence and severity of fasciculations. Our results show that the administration of propofol without succinylcholine did not affect the incidence of postoperative myalgias, either on POD 1 or POD 3. The use of propofol prior to succinylcholine also did not decrease the incidence of postoperative myalgias associated with succinylcholine. These results are in agreement with those of others reported for patients following laparoscopic procedures.‘8-20 McClymont,” however, found a reduction in succinylcholine-induced postoperative myalgias following propofol in patients undergoing laparoscopic surgery. Because postlaparoscopic gas pains may be confused with postoperative myalgias2”,24 our study excluded laparoscopy and included patients undergoing several different types of surgery. However, even with a variety of surgical procedures, we were unable to find a difference between the groups in the incidence and/or the severity of postoperative myalgias. In contrast to the scoring system used by Smith et n1.,“’ our scoring system for postoperative myalgias was not specific to the neck and shoulder. The most common complaint associated with the muscle pain was a “flu-like” feeling in which the pain was not localized to any body part. This description of myalgias as being similar to the “flu” was first reported in 1961 by Burtles and Tunstall.“’ Postoperative myalgias continued to be present on POD 3 although they were decreased for all groups compared with POD 1. This finding has also been previously reported.‘“-‘” However, in McClymont’s study,” the severity of myalgia pain increased after 24 hours. Like those of other studies, our results showed no association between the incidence and severity of fasciculations and the occurrence of postoperative myalgias.‘~‘i,‘H-“O In summary, the use of propofol, even without muscle relaxants, did not affect the incidence or severity of postoperative myalgias on POD 1 and POD 3 following a variety of nonJ. Clin. Anesth., vol. 8. Mav 1996
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originnl Co?ltributions
laparoscopic surgical procedures undergone by both males and females on an ambulatory basis. A propofolfentanyl-lidocaine anesthesia induction resulted in an 85% success rate for tracheal intubation even though the majority of patients reacted to placement of the tube. Most patients showed some degree of coughing or bucking on placement of the tracheal tube. In spite of these less-thanideal conditions, the ability to tracheally intubate a patient without the use of a muscle relaxant may be beneficial, particularly for procedures of short duration, while avoiding the potential side effects of neuromuscular blockade.
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