Article Data

  • Views 2529
  • Dowloads 204

Original Research

Open Access

Impact of Different Stimulation Patterns of Neuromuscular Blockade Monitoring and Clinical Assessment on Intubation Time and Intensity of Hemodynamic Response During Rocuronium Induced Endotracheal Intubation

  • Radmilo J. Janković1,2
  • Milena D. Stojanović1
  • Danica Z. Marković1
  • Vladan A. Cvetanovic1
  • Anita Z.Vuković1
  • Aleksandar N.Nikolić1
  • Ines S.Veselinović1
  • Biljana S.Stošić1,2

1Clinic for Anesthesiology and Intensive care, Clinical Center Nis, Serbia

2School of Medicine, University of Nis, Serbia

DOI: 10.22514/sv.2020.16.0011 Vol.16,Issue 1,June 2020 pp.79-88

Published: 30 June 2020

*Corresponding Author(s): Milena D. Stojanović E-mail: milenastojanoviclaci@gmail.com

Abstract

Introduction and aims: Typical autonomic response to endotracheal intubation manifests itself by increasing blood pressure and heart rate. The aim of this study as to evaluate whether different stimulation patterns of neuromuscular blockade monitoring techniques may impact hemodynamic response. Materials and Methods: Randomized, prospective, double blind study involved 60 patients who underwent elective abdominal surgery. Patients were randomly allocated into 3 groups. Anesthesia was induced with propofol-remifentanil and acceleromyography at adductor pollicis was established before rocuronium (0.6 mg/kg) was given to facilitate endotracheal intubation. Endotracheal intubation was initiated after 95% suppression of 0.1 Hz single twitch (ST group), complete disappearance of responses to train-of-four stimulation (TOF group) or after clinical criteria (good relaxation of the masseter muscle and the lower jaw, easy mask ventilation and the fact that 60 secs had elapsed since rocuronium was administered) were met (control-CL group). Blood pressure and heart rate were measured in five time points: after positioning the patient (HDbas), 30 s after propofol-remifentanyl (HD1), 30 s after rocuronium (HD2), 30 s (HD3) and 2 minutes following initiation (HD4) of endotracheal intubation. Results: The interval between administration of rocuronium and initiation of endotracheal intubation was significantly shorter in CL group (66.5 s), compared to TOF group (75.44 s) and ST group (83.75 s), (p < 0.001). There was statistically significant difference in systolic blood pressure at HD3 and HD4 time point between groups (p < 0.01). Post hoc analysis shows that these values of systolic blood pressure in CL group were significantly higher compared to the other two groups (p < 0.05). Also, systolic blood pressure after the fourth and fifth measurements were significantly higher compared to initial three measurements in CL group (p < 0.01). By comparing the heart rate at HD3and HD4 time points, significant difference between the groups was noted (p < 0.01). At HD3 time heart rate was significantly higher in CL group compared to other groups (p < 0.01). Additionally, at HD4 heart rate was significantly higher in CL group than in TOF group (p < 0.05) and ST group (p < 0.01). Also, heart rate was significantly increased at HD3 time point. Conclusion: Even though objective NMB monitoring prolongs intubating time, its use prevents vacillation of the hemodynamic response associated with endotracheal intubation.

Keywords

Neuromuscular blockade monitoring, Hemodynamic response, Intubation

Cite and Share

Radmilo J. Janković,Milena D. Stojanović,Danica Z. Marković,Vladan A. Cvetanovic,Anita Z.Vuković,Aleksandar N.Nikolić,Ines S.Veselinović,Biljana S.Stošić. Impact of Different Stimulation Patterns of Neuromuscular Blockade Monitoring and Clinical Assessment on Intubation Time and Intensity of Hemodynamic Response During Rocuronium Induced Endotracheal Intubation. Signa Vitae. 2020. 16(1);79-88.

References

[1] Amin AM, Mohammad MY, Mona FI. Comparative study of neuromuscular blocking and hemodynamic effects of rocuronium and cisatracurium under sevoflurane or total intravenous anesthesia.

M.E.J Anesth. 2009; 20:39-51.

[2] Wang, Yu M, Ochani M, Ann Amella C, Tanovic M, Susarla S, Li JH, et al. Nicotinic acetylcholine receptor alpha 7 subunit is an essential regulator of inflammation. Nature. 2003;421:384-8

[3] Jonsson M, Gurley D, Dabrowski M, Larsson O, Johnson EC. Distinct pharmacologic properties of neuromuscular blocking agents on human neuronal nicotinic acethylcholine receptors: a possible explanation for the train of four fades. Anesthesiology. 2006;105:521-33

[4] Sardesai AM, Griffiths R. Monitoring techniques: neuromuscular blockade. Anesth Intensive Care Med. 2005;6: 198-200.

[5] MenckeT, Echternach M, Plinkert PK, Johann U, Afan N, Rensing H, et al. Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg. 2006;102:306–12.

[6] Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62: 806-9.

[7] Della Rocca G, Iannuccelli F, Pompei L, Pietropaoli P. Reale C, Marco

P. Di, Neuromuscular block in Italy: A survey of current management. Minerva Anestesiol. 2012;78:767-73.

[8] Gotiwale K, Lele S, Setiya S. Stress response to laryngoscopy and ease of intubation:comparison between Macintosh and (levering) McCoys type laryngoscope. Int J Res Med Sci. 2016;4:3141-5.

[9] Chien-Wei Cheng, Yi-Ming Weng, Chih-Chuan Lin, Ching-I Kuo, Chi-Chun Lin. The effects of post-intubation hypertension in severe traumatic brain injury. Signa Vitae. 2013;8: 24-9.

[10] Nandi R, Basu SR, Sarkar S, Garg R. A comparison of haemodynamic responses between clinical assessment-guided tracheal intubation and neuromuscular block monitoring-guided tracheal intubation: A prospective, randomised study. Indian J Anaesth. 2017;61:910–5.

[11] Witkowska M, Karwacki Z, Wierzchowska J, Bukowski P. Neu-romuscular block monitoring for optimisation of conditions for endotracheal intubation. Anestezjol Intens Ter. 2009;41:140–4

[12] Fuchs-Buder T, Claudius Scovgaar LT, Eriksson LI, Mirakhur LK, Viby-Mogensen J. 8th International Neuromuscular Meeting. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007;51:789-808.

[13] Mayer M, Doenicke A, Hofmann A, Peter K. Onset and recovery of rocuronium (ORG9246) and vecuronium under enflurane anesthesia. Br J Anesthesia. 1992;69:511-2.

[14] Bartowski RR, Witkowski TA, Azad S, Lesin J, Marr A. Rocuronium onset of action: A comparison with atracurium and vecuronium. Anesth Analg. 1993;77:574-8.

[15] Donati F, Meistelman C. A kinetic-dynamic model to explain the rela-tionship between high potency and slow onset time for neuromuscular blocking drugs. J Pharmacokinet Biopharm. 1991;195:537-52.

[16] Donati F. Onset of action of relaxants. Can J Anaesth. 1988;35:S52-S58.

[17] Wierda JKMH, de Wit APM, Kuizenga K, Agosoon S. Clinical observations on the neuromuscular blocking action of Org9426, a new steroidal non-depolarizing agent. Br J Anesth. 1990;64:521-3.

[18] Folders FF, Deery A. Protein binding of atracurium and other short-acting neuromuscular blocking agents and their interaction with human cholinesterases. Br J Anaesth. 1983;55:31S-34S.

[19] Bevan DR. Rocuronium. J Crit Care. 1995;14:257-63.

[20] Hans P, Brichant JF, Hubert B, Dewandre PY, Lamy M. Influence of induction of anaesthesia on intubating conditions one minute after rocuronium administration: comparison of ketamine and thiopentone. Anaesthesia. 1999;54:276-9.

[21] Fuchs-Buder T, Sparr HJ, Ziegenfuss BT. Thiopental or etomidate for rapid sequence induction with rocuronium. Br J Anaesth. 1998;80:504-6.

[22] Ganidagli S, Cengiz M, Baysal Z. Effect of ephedrine on the onset time of succinylcholine. Acta Anaesthesiol Scand. 2004;48:1306-9.

[23] Albert F, Hans P, Bitar Y, Brichant JF, De-Wandre PY, Lamy M. Effects of ephedrine on the onset time of neuromuscular block and intubating conditions after cisatracurium: preliminary results. Acta Anaesthesiol Belg. 2000;51:167-71.

[24] Harrison P, Feldman SA. Intubating conditions with ORG NC 45. Anaesthesia. 1981;36:874-7.

[25] Singh K, Singhal S, Raghove P. A study to evaluate effect of ephedrine on intubating conditions and haemodynamic parameters using low dose rocuronium with different induction agents. Int J Pharmacol Clin Sci. 2013; 2:9-13.

[26] Mirakhur RK. Dose-response and time-course of action of rocuro-nium bromide. Eur J Anaesthesiol. 1995;11: 23-5.

[27] Kayhan Z, Aldemir D, Mutlu H, Öğüş E. Which is responsible for the haemodynamic response due to laryngoscopy and endotracheal intubation? Catecholamines, vasopressin or angiotensin? Eur J Anaesthesiol. 2005;22:780-5.

[28] Stoelting RK. Circulatory changes during direct laryngoscopy and tracheal intubation. Anesthesiology. 1977;47: 381-4.

[29] Singhal SN. Haemodynamic response to laryngoscopy andintubation: Comparison Of McCoy And MacintoshLaryngoscope. The Internet Journal of Anesthesiology. 2007;17:1-5.

[30] Cozanitis DA, Nuuttila K, Merrett JD, Kala R. Influence of laryngoscope design on heart rate and rhythm changes during intubation. Can Anesth Soc. 1984;31:155-9.

[31] Singh S, Laing EF, Owiredu WKBA, Singh A. Comparison of esmolol and lidocaine for attenuation of cardiovascular stress response to laryngoscopy and endotracheal intubation in a Ghanaian population. Anesth Essays Res. 2013;7:83–8.

[32] Egan TD, Minto CF, Hermann DJ, Barr J, Muir KT, Shafer SL. Remifentanil versus alfentanil: comparative pharmackinetics and pharmacodynamics in healthy adult male volunteers. Anesthesiology. 1996;84:821–33.

[33] Cros AM, Lopez C, Kandel T, Sztark F. Determination of sevoflurane alveolar concentration for tracheal intubation with remifentanil, and no muscle relaxant. Anesthesia. 2000;55:965-9.

[34] Hogue CW, Bowdle TA, O’Leary C, Duncalf D, Miguel R, Pitts M, et al.A Multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Anesth Analg. 1996;83(2):79-85.

[35] Scott LJ, Perry CM. Remifentanil: a review of its use dur-ing the induction and maintenance of general anesthesia. Drugs. 2005;65:1793–823

[36] Ezri T, Szmuk P, Warters RD, Gebhard RE, Pivalizza EG, Katz

J. Changes in onset time of rocuronium in patients pretreated with ephedrine and esmolol—the role of cardiac output. Acta Anaesthesiol Scand. 2003;47:1067–72

[37] Tan CH, Onisong MK, Chiu WKY. The influence of induction technique on intubating conditions 1 minute after rocuronium administration: a comparison of propofol-ephedrine combination and propofol. Anaesthesia. 2002;57:223–6.

[38] Stevens JB, Hecker RB, Talbot JC, Walker SC. Haemodynamic effects of rocuronium and vecuronium are different during balanced anaesthesia. Acta Anaesthesiol Scand. 1997;41:502-5.

[39] Hudson ME, Rothfield KP, Tullock WC, Firestone LL. Hemo-dynamic effects of rocuronium bromide in adult cardiac surgical patients. Canadian J Anaesth. 1998;45:139-43.

[40] Rao U. Comparison of hemodynamic and neuromuscular properties of rocuronium versus vecuronium in anesthesia. Int J Med Sci Public Health. 2016;5:1617-20.

[41] Levy JH, Davis GK, Duggan J, Szlam F. Determination of the hemodynamics and histamine release of rocuronium (Org 9426) when administered in increased doses under N2O/O2-sufentanil anesthesia. Anesth Analg. 1994;78:318–21.

[42] Savargaonkar AP, Ruparel DH, Patil RS. Comparison of effects of rocuronium bromide versus vecuronium bromide on hemodynamic parameters during anaesthesia for elective surgical procedures. Int J Basic Clin Pharmcol. 2016;5:317-23.

[43] Naguib M, Kopman A, Cynthia AL, Hunter J, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111:110–9.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.3 (2023) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time

Conferences

Top