Dexmedetomidine versus Remifentanil for Sedation during Awake Fiberoptic Intubation

Davide Cattano, Nicholas C Lam, Lara Ferrario, Carmen Seitan, Kash Vahdat, Darrell W Wilcox, Carin A Hagberg, Davide Cattano, Nicholas C Lam, Lara Ferrario, Carmen Seitan, Kash Vahdat, Darrell W Wilcox, Carin A Hagberg

Abstract

This study compared remifentanil and dexmedetomidine as awake fiberoptic intubation (AFOI) anesthetics. Thirty-four adult ASA I-III patients were enrolled in a double-blinded randomized pilot study to receive remifentanil (REM) or dexmedetomidine (DEX) for sedation during AFOI (nasal and oral). Thirty patients completed the study and received 2 mg midazolam IV and topical anesthesia. The REM group received a loading dose of 0.75 mcg/kg followed by an infusion of 0.075 mcg/kg/min. The DEX group received a loading dose of 0.4 mcg/kg followed by an infusion of 0.7 mcg/kg/hr. Time to sedation, number of intubation attempts, Ramsay sedation scale (RSS) score, bispectral index (BIS), and memory recall were recorded. All thirty patients were successfully intubated by AFOI (22 oral intubations/8 nasal). First attempt success rate with AFOI was higher in the REM group than the DEX group, 72% and 38% (P = 0.02), respectively. The DEX group took longer to attain RSS of ≥3 and to achieve BIS <80, as compared to the REM group. Postloading dose verbal recall was poorer in the DEX group. Dexmedetomidine seems a useful adjunct for patients undergoing AFOI but is dependent on dosage and time. Further studies in the use of dexmedetomidine for AFOI are warranted.

Figures

Figure 1
Figure 1
Mean physiologic variables from beginning to end of intubation. (a) includes oxygen saturation (SpO2) and respiratory rate (RR). (b) includes heart rate (HR) and systolic (SBP) and diastolic blood pressure (DBP). (c) includes sedation variables bispectral index (BIS) and Ramsay Sedation Scale (RSS).

References

    1. Guglielmi M, Urbaz L, Tedesco C, Pusceddu A, Sogni A, Ronzoni G. A structured training program for awake fiber optic intubation: teaching the complete package. Minerva Anestesiologica. 2010;76(9):699–706.
    1. Péan D, Floch H, Beliard C, et al. Propofol versus sevoflurane for fiberoptic intubation under spontaneous breathing anesthesia in patients difficult to intubate. Minerva Anestesiologica. 2010;76(10):780–786.
    1. Donaldson ABP, Meyer-Witting M, Roux A. Awake fibreoptic intubation under remifentanil and propofol target-controlled infusion. Anaesthesia and Intensive Care. 2002;30(1):93–95.
    1. Neidhart G, Kovács AF, Bremerich DH, Kessler P. Remifentanil/propofol for fiberoptic intubation. A case report. Anaesthesist. 2000;49(6):523–526.
    1. Machata AM, Gonano C, Holzer A, et al. Awake nasotracheal fiberoptic intubation: patient comfort, intubating conditions, and hemodynamic stability during conscious sedation with remifentanil. Anesthesia and Analgesia. 2003;97(3):904–908.
    1. Puchner W, Egger P, Pühringer F, Löckinger A, Obwegeser J, Gombotz H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiologica Scandinavica. 2002;46(4):350–354.
    1. Reusche MD, Egan TD. Remifentanil for conscious sedation and analgesia during awake fiberoptic tracheal intubation: a case report with pharmacokinetic simulations. Journal of Clinical Anesthesia. 1999;11(1):64–68.
    1. Mingo OH, Ashpole KJ, Irving CJ, Rucklidge MWM. Remifentanil sedation for awake fibreoptic intubation with limited application of local anaesthetic in patients for elective head and neck surgery. Anaesthesia. 2008;63(10):1065–1069.
    1. Rai MR, Parry TM, Dombrovskis A, Warner OJ. Remifentanil target-controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial. British Journal of Anaesthesia. 2008;100(1):125–130.
    1. Venn RM, Bradshaw CJ, Spencer R, et al. Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia. 1999;54(12):1136–1142.
    1. Venn RM, Newman PJ, Grounds RM. A phase II study to evaluate the efficacy of dexmedetomidine for sedation in the medical intensive care unit. Intensive Care Medicine. 2003;29(2):201–207.
    1. Arain SR, Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesthesia and Analgesia. 2002;95(2):461–466.
    1. Bekker AY, Kaufman B, Samir H, Doyle W. The use of dexmedetomidine infusion for awake craniotomy. Anesthesia and Analgesia. 2001;92(5):1251–1253.
    1. Tobias JD, Berkenbosch JW. Initial experience with dexmedetomidine in paediatric-aged patients. Paediatric Anaesthesia. 2002;12(2):171–175.
    1. Scher CS, Gitlin MC. Dexmedetomidine and low-dose ketamine provide adequate sedation for awake fibreoptic intubation. Canadian Journal of Anesthesia. 2003;50(6):607–610.
    1. Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. Journal of Clinical Anesthesia. 2007;19(5):370–373.
    1. Bergese SD, Khabiri B, Roberts WD, Howie MB, McSweeney TD, Gerhardt MA. Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases. Journal of Clinical Anesthesia. 2007;19(2):141–144.
    1. Grant SA, Breslin DS, MacLeod DB, Gleason D, Martin G. Dexmedetomidine infusion for sedation during fiberoptic intubation: a report of three cases. Journal of Clinical Anesthesia. 2004;16(2):124–126.
    1. Jaakola ML, Salonen M, Lehtinen R, Scheinin H. The analgesic action of dexmedetomidine—a novel α 2-adrenoceptor agonist—in healthy volunteers. Pain. 1991;46(3):281–285.
    1. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. British medical journal. 1974;2(920):656–659.
    1. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesthesia and Analgesia. 2000;90(3):699–705.
    1. Boehm CA, Carney EL, Tallarida RJ, Wilson RP. Midazolam enhances the analgesic properties of dexmedetomidine in the rat. Veterinary Anaesthesia and Analgesia. 2010;37(6):550–556.
    1. Salonen M, Reid K, Maze M. Synergistic interaction between α 2-adrenergic agonists and benzodiazepines in rats. Anesthesiology. 1992;76(6):1004–1011.
    1. Veselis RA, Reinsel RA, Feshchenko VA, Johnson R. Information loss over time defines the memory defect of propofol: a comparative response with thiopental and dexmedetomidine. Anesthesiology. 2004;101(4):831–841.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere