Emergence times and airway reactions during general anaesthesia with remifentanil and a laryngeal mask airway: A multicentre randomised controlled trial

Ana Kowark, Rolf Rossaint, Friedrich Pühringer, András P Keszei, Harald Fritz, Gebhard Fröba, Christopher Rex, Hansjörg Haas, Volker Otto, Mark Coburn, Study Collaborators, Ana Kowark, Rolf Rossaint, Friedrich Pühringer, András P Keszei, Harald Fritz, Gebhard Fröba, Christopher Rex, Hansjörg Haas, Volker Otto, Mark Coburn, Study Collaborators

Abstract

Background: Avoidance of airway complications and rapid emergence from anaesthesia are indispensable for the use of a laryngeal mask airway (LMA). Evidence from adequately powered randomised studies with a low risk of bias for the optimal anaesthetic in this context is limited.

Objective: We tested the hypothesis that when using remifentanil-based intra-operative analgesia, desflurane would be the most suitable anaesthetic: with noninferiority in the occurrence of upper airway complications and superiority in emergence times compared with sevoflurane or propofol.

Design: A randomised, multicentre, partially double-blinded, three-arm, parallel-group study.

Setting: Two university and two regional German hospitals, from February to October 2015.

Patients: A total of 352 patients (age 18 to 75 years, ASA physical status I to III, BMI less than 35 kg m and fluent in German) were enrolled in this study. All surgery was elective with a duration of 0.5 to 2 h, and general anaesthesia with a LMA was feasible.

Intervention: The patients were randomised to receive desflurane, sevoflurane or propofol anaesthesia.

Main outcome measures: This study was powered for the primary outcome 'time to state date of birth' and the secondary outcome 'intra-operative cough'. Time to emergence from anaesthesia and the incidence of upper airway complications were assessed on the day of surgery.

Results: The primary outcome was analysed for 343 patients: desflurane (n=114), sevoflurane (n=111) and propofol (n=118). The desflurane group had the fastest emergence. The mean (± SD) times to state the date of birth following desflurane, sevoflurane and propofol were 8.1 ± 3.6, 10.1 ± 4.0 and 9.8 ± 5.1 min, respectively (P < 0.01). There was no difference in upper airway complications (cough and laryngospasm) across the groups, but these complications were less frequent than in previous studies.

Conclusion: When using a remifentanil infusion for intra-operative analgesia in association with a LMA, desflurane was associated with a significantly faster emergence and noninferiority in the incidence of intra-operative cough than either sevoflurane or Propofol.

Trial registration: ClinicalTrials.gov identifier: NCT02322502; EudraCT identifier: 2014-003810-96.

Figures

Fig. 1
Fig. 1
CONSORT-Flow chart. After screening of 536 patients, we recruited and randomised 352 patients into this study. §The particular reasons for exclusion of 121 patients, who did not meet the inclusion criteria, are drug abuse (n=26), nonfluency in German language (n=52), pre-operatively the feasibility of a laryngeal mask airway technique for the respective surgery was unclear (n=21), pre-operatively the duration of surgery was unclear (n=22). ITT, intention to treat analysis; TSB, time to state the date of birth.

References

    1. Yu SH, Beirne OR. Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review. J Oral Maxillofac Surg 2010; 68:2359–2376.
    1. Jakobsson J. Desflurane: a clinical update of a third-generation inhaled anaesthetic. Acta Anaesthesiol Scand 2012; 56:420–432.
    1. Nyktari V, Papaioannou A, Volakakis N, et al. Respiratory resistance during anaesthesia with isoflurane, sevoflurane, and desflurane: a randomized clinical trial. Br J Anaesth 2011; 107:454–461.
    1. Klock PA, Czeslick EG, Klafta JM, et al. The effect of sevoflurane and desflurane on upper airway reactivity. Anesthesiology 2001; 94:963–967.
    1. Stevanovic A, Rossaint R, Fritz HG, et al. Airway reactions and emergence times in general laryngeal mask airway anaesthesia: a meta-analysis. Eur J Anaesthesiol 2015; 32:106–116.
    1. Ashworth J, Smith I. Comparison of desflurane with isoflurane or propofol in spontaneously breathing ambulatory patients. Anesth Analg 1998; 87:312–318.
    1. Dolk A, Cannerfelt R, Anderson RE, et al. Inhalation anaesthesia is cost-effective for ambulatory surgery: a clinical comparison with propofol during elective knee arthroscopy. Eur J Anaesthesiol 2002; 19:88–92.
    1. Gupta A, Kullander M, Ekberg K, et al. Anaesthesia for day-care arthroscopy. A comparison between desflurane and isoflurane. Anaesthesia 1996; 51:56–62.
    1. Naidu-Sjösvärd K, Sjöberg F, Gupta A. Anaesthesia for videoarthroscopy of the knee. A comparison between desflurane and sevoflurane. Acta Anaesthesiol Scand 1998; 42:464–471.
    1. Saros GB, Doolke A, Anderson RE, et al. Desflurane vs. sevoflurane as the main inhaled anaesthetic for spontaneous breathing via a laryngeal mask for varicose vein day surgery: a prospective randomized study. Acta Anaesthesiol Scand 2006; 50:549–552.
    1. De Oliveira GS, Fitzgerald PC, Ahmad S, et al. Desflurane/fentanyl compared with sevoflurane/fentanyl on awakening and quality of recovery in outpatient surgery using a laryngeal mask airway: a randomized, double-blinded controlled trial. J Clin Anesth 2013; 25:651–658.
    1. Mahmoud NA, Rose DJ, Laurence AS. Desflurane or sevoflurane for gynaecological day-case anaesthesia with spontaneous respiration? Anaesthesia 2001; 56:171–174.
    1. Green MS, Green P, Neubert L, et al. Recovery following desflurane versus sevoflurane anesthesia for outpatient urologic surgery in elderly females. Anesth Pain Med 2015; 5:e22271.
    1. Werner JG, Castellon-Larios K, Thongrong C, et al. Desflurane allows for a faster emergence when compared to sevoflurane without affecting the baseline cognitive recovery time. Front Med 2015; 2:75.
    1. Stevanovic A, Rossaint R, Keszei AP, et al. Emergence times and airway reactions in general laryngeal mask airway anesthesia: study protocol for a randomized controlled trial. Trials 2015; 16:316.
    1. R Development Core Team. R: A language and environment for statistical computing. 2011; Vienna, Austria: R Foundation for Statistical Computing, 2013.
    1. Euasobhon P, Dej-Arkom S, Siriussawakul A, et al. Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults. Cochrane Database Syst Rev 2016; 2:CD007874.
    1. Brodner G, Gogarten W, Van Aken H, et al. Efficacy of intravenous paracetamol compared to dipyrone and parecoxib for postoperative pain management after minor-to-intermediate surgery: a randomised, double-blind trial. Eur J Anaesthesiol 2011; 28:125–132.
    1. Lassen CL, Link F, Lindenberg N, et al. Anesthesiological acute pain therapy in Germany: telephone-based survey. Der Anaesthesist 2013; 62:355–364.
    1. Pogatzki-Zahn E, Chandrasena C, Schug SA. Nonopioid analgesics for postoperative pain management. Curr Opin Anaesthesiol 2014; 27:513–519.
    1. Rossaint R, Reyle-Hahn M, Schulte Am Esch J, et al. Multicenter randomized comparison of the efficacy and safety of xenon and isoflurane in patients undergoing elective surgery. Anesthesiology 2003; 98:6–13.
    1. Royse CF, Newman S, Chung F, et al. Development and feasibility of a scale to assess postoperative recovery: the postoperative quality recovery scale. Anesthesiology 2010; 113:892–905.
    1. Yan X, Su XG. Stratified Wilson and Newcombe confidence intervals for multiple binomial proportions. Stat Biopharm Res 2010; 2:329–335.
    1. White IR, Carlin JB. Bias and efficiency of multiple imputation compared with complete-case analysis for missing covariate values. Stat Med 2010; 29:2920–2931.
    1. Kelly RE, Hartman GS, Embree PB, et al. Inhaled induction and emergence from desflurane anesthesia in the ambulatory surgical patient: the effect of premedication. Anesth Analg 1993; 77:540–543.
    1. Kong CF, Chew ST, Ip-Yam PC. Intravenous opioids reduce airway irritation during induction of anaesthesia with desflurane in adults. Br J Anaesth 2000; 85:364–367.
    1. Lee MG, Chang YJ, Park JM, et al. The clinical effective dose of alfentanil for suppressing cough during emergence from desflurane anesthesia. Korean J Anesthesiol 2011; 61:292–296.
    1. Tanaka M, Nishikawa T. Propofol requirement for insertion of cuffed oropharyngeal airway versus laryngeal mask airway with and without fentanyl: a dose-finding study. Br J Anaesth 2003; 90:14–20.
    1. White PF, Elvir-Lazo OL, Zaentz AS, et al. Does small-dose fentanyl improve perioperative outcomes in the ambulatory setting? A randomized, double-blind, placebo-controlled study. Acta Anaesthesiol Scand 2015; 59:56–64.
    1. Zöllner C, Schäfer M. Opioids in anesthesia. Anaesthesist 2008; 57:729–740.
    1. McKay RE, Hall KT, Hills N. The effect of anesthetic choice (sevoflurane versus desflurane) and neuromuscular management on speed of airway reflex recovery. Anesth Analg 2016; 122:393–401.
    1. Eshima RW, Maurer A, King T, et al. A comparison of airway responses during desflurane and sevoflurane administration via a laryngeal mask airway for maintenance of anesthesia. Anesth Analg 2003; 96:701–705.
    1. Lema FE, Tafur LA, Giraldo C, et al. Incidence of cough after desflurane and sevoflurane administration through a laryngeal mask: a controlled clinical trial. Rev Esp Anestesiol Reanim 2010; 57:141–146.
    1. McKay RE, Large MJC, Balea MC, et al. Airway reflexes return more rapidly after desflurane anesthesia than after sevoflurane anesthesia. Anesth Analg 2005; 100:697–700.
    1. McKay RE, Bostrom A, Balea MC, et al. Airway responses during desflurane versus sevoflurane administration via a laryngeal mask airway in smokers. Anesth Analg 2006; 103:1147–1154.
    1. McKay RE, Malhotra A, Cakmakkaya OS, et al. Effect of increased body mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. Br J Anaesth 2010; 104:175–182.
    1. White PF, Tang J, Wender RH, et al. Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing. Anesth Analg 2009; 109:387–393.
    1. Sun L, Guo R, Sun L. The impact of prophylactic intravenous lidocaine on opioid-induced cough: a meta-analysis of randomized controlled trials. J Anesth 2014; 28:325–333.
    1. Poulton TJ, James FM. Cough suppression by lidocaine. Anesthesiology 1979; 50:470–472.
    1. Lev R, Rosen P. Prophylactic lidocaine use preintubation: a review. J Emerg Med 1994; 12:499–506.
    1. Pandey CK, Raza M, Ranjan R, et al. Intravenous lidocaine 0.5 mg kg−1 effectively suppresses fentanyl-induced cough. Can J Anaesth 2005; 52:172–175.
    1. Nickalls RWD, Mapleson WW. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. Br J Anaesth 2003; 91:170–174.
    1. van den Berg JP, Vereecke HEM, Proost JH, et al. Pharmacokinetic and pharmacodynamic interactions in anaesthesia. A review of current knowledge and how it can be used to optimize anaesthetic drug administration. Br J Anaesth 2017; 118:44–57.
    1. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the American Society of Anesthesiologists task force on intraoperative awareness. Anesthesiology 2006; 104:847–864.
    1. Richardson MG, Wu CL, Hussain A. Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization. Anesth Analg 1997; 85:301–305.
    1. Brattwall M, Warrén-Stomberg M, Hesselvik F, et al. Brief review: theory and practice of minimal fresh gas flow anesthesia. Can J Anaesth 2012; 59:785–797.
    1. Rörtgen D, Kloos J, Fries M, et al. Comparison of early cognitive function and recovery after desflurane or sevoflurane anaesthesia in the elderly: a double-blinded randomized controlled trial. Br J Anaesth 2010; 104:167–174.
    1. Kristensen MS, Teoh WH, Asai T. Which supraglottic airway will serve my patient best? Anaesthesia 2014; 69:1189–1192.

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