Dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet: a randomized, double-blinded, controlled trial

Ting Xu, Min Li, Cheng Ni, Xiang-Yang Guo, Ting Xu, Min Li, Cheng Ni, Xiang-Yang Guo

Abstract

Background: The purpose of this study was to compare the efficacy and safety of dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet (SOS).

Methods: Sixty-eight patients with cervical trauma or severe cervical spondylosis undergoing cervical spinal surgery were enrolled in this prospective study. They were randomly assigned to receive dexmedetomidine (Group D) or remifentanil (Group R). In Group D, the patients received an intravenous loading dose of dexmedetomidine 1 μg · kg(-1) over 10 min followed by a continuous infusion of 0.7 μg · kg(-1) · h(-1). In Group R, a target-controlled infusion of remifentanil was administered to achieve a plasma concentration of 2.5 ng · ml(-1), increased to 3 ng · ml(-1) 10 min later. An endotracheal tube was inserted using a SOS under dexmedetomidine or remifentanil sedation after topical anesthesia to the airway. Midazolam was given as rescue sedation. We recorded the first attempt intubation success rate, the dose of midazolam, duration of intubation, Ramsay Sedation Scale (RSS) score, tracheal tube tolerance score, duration of drug infusion, adverse events and patient satisfaction score.

Results: The RSS score was significantly higher in Group D than in Group R. First attempt success rate, rescue midazolam dose and the duration of intubation did not differ between the groups. Patients in Group R were significantly more tolerant of the tracheal tube. The incidence of hypoxia was significantly higher in Group R than Group D, but there was no significant difference in the incidence of other adverse events between the groups. The hemodynamic responses of the two groups were similar, but more patients in Group R were able to recall airway instrumentation.

Conclusions: Both dexmedetomidine and remifentanil are effective sedatives for awake intubation using an SOS. Although the first attempt success rates were similar, patients sedated with remifentanil tolerated the tracheal tube better after intubation with moderately increased risk of desaturation.

Trial registration: www.chictr.org.cn ; ChiCTR-TRC-13003052 (February 4th, 2013).

Keywords: Awake intubation; Dexmedetomidine; Remifentanil; Sedation; Shikani optical stylet.

Figures

Fig. 1
Fig. 1
Study flow diagram. Group D, group Dexmedetomidine; Group R, group remifentanil
Fig. 2
Fig. 2
Shikani Optical Stylet larygngoscope and its application in a male patient with hard plastic collar. a A Shikani Optical Stylet larygngoscope; (b) The Shikani Optical Stylet larygngoscope was inserted into an endotracheal tube; (c) Manipulation of tracheal intubation by a Shikani Optical Stylet larygngoscope

References

    1. Lin N, Li M, Shi S, Li TZ, Zhang BX. Shikani seeing optical stylet-aided tracheal intubation in patients with a large epiglottic cyst. Chin Med J (Engl) 2011;124:2795–8.
    1. Phua DS, Mah CL, Wang CF. The Shikani optical stylet as an alternative to the GlideScope® videolaryngoscope in simulated difficult intubations--a randomised controlled trial. Anaesthesia. 2012;67:402–6. doi: 10.1111/j.1365-2044.2011.07023.x.
    1. Shukry M, Hanson RD, Koveleskie JR, Ramadhyani U. Management of the difficult pediatric airway with Shikani Optical Stylet. Paediatr Anaesth. 2005;15:342–5. doi: 10.1111/j.1460-9592.2005.01435.x.
    1. Stricker P, Fiadjoe JE, McGinnis S. Intubation of an infant with Pierre Robin sequence under dexmedetomidine sedation using the Shikani Optical Stylet. Acta Anaesthesiol Scand. 2008;52:866–7. doi: 10.1111/j.1399-6576.2008.01631.x.
    1. Agro F, Cataldo R, Carassiti M, Costa F. The seeing stylet: a new device for tracheal intubation. Resuscitation. 2000;44:177–80. doi: 10.1016/S0300-9572(00)00137-4.
    1. Yang D, Tong SY, Jin JH, Tang GZ, Sui JH, Wei LX, Deng XM. Shikani optical stylet-guided intubation via the intubating laryngeal airway in patients with scar contracture of the face and neck. Chin Med Sci J. 2013;28:195–200. doi: 10.1016/S1001-9294(14)60001-8.
    1. Turkstra TP, Pelz DM, Shaikh AA, Craen RA. Cervical spine motion: a fluoroscopic comparison of Shikani Optical Stylet vs Macintosh laryngoscope. Can J Anaesth. 2007;54:441–7. doi: 10.1007/BF03022029.
    1. Kovacs G, Law AJ, Petrie D. Awake fiberoptic intubation using an optical stylet in an anticipated difficult airway. Ann Emerg Med. 2007;49:81–3. doi: 10.1016/j.annemergmed.2006.03.024.
    1. Hu R, Liu JX, Jiang H. Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial. J Anesth. 2013;27:211–7. doi: 10.1007/s00540-012-1499-y.
    1. Cattano D, Lam NC, Ferrario L, Seitan C, Vahdat K, Wilcox DW, Hagberg CA. Dexmedetomidine versus remifentanil for sedation during awake fiberoptic intubation. Anesthesiol Res Pract. 2012;2012:753107.
    1. Boyd BC, Sutter SJ. Dexmedetomidine sedation for awake fiberoptic intubation of patients with difficult airways due to severe odontogenic cervicofacial infections. J Oral Maxillofac Surg. 2011;69:1608–12. doi: 10.1016/j.joms.2010.11.004.
    1. Bergese SD, Candiotti KA, Bokesch PM, Zura A, Wisemandle W, Bekker AY, Group AS. A Phase IIIb, randomized, double-blind, placebo-controlled, multicenter study evaluating the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation. Am J Ther. 2010;17:586–95. doi: 10.1097/MJT.0b013e3181d69072.
    1. Bergese SD, Patrick Bender S, McSweeney TD, Fernandez S, Dzwonczyk R, Sage K. A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation. J Clin Anesth. 2010;22:35–40. doi: 10.1016/j.jclinane.2009.02.016.
    1. Kunisawa T, Nagashima M, Hanada S, Suzuki A, Takahata O, Iwasaki H. Awake intubation under sedation using target-controlled infusion of dexmedetomidine: five case reports. J Anesth. 2010;24:789–92. doi: 10.1007/s00540-010-0980-8.
    1. Chu KS, Wang FY, Hsu HT, Lu IC, Wang HM, Tsai CJ. The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation. Eur J Anaesthesiol. 2010;27:36–40. doi: 10.1097/EJA.0b013e32832e0d2b.
    1. Tsai CJ, Chu KS, Chen TI, Lu DV, Wang HM, Lu IC. A comparison of the effectiveness of dexmedetomidine versus propofol target-controlled infusion for sedation during fibreoptic nasotracheal intubation. Anaesthesia. 2010;65:254–9. doi: 10.1111/j.1365-2044.2009.06226.x.
    1. Shen SL, Xie Y, Wang WY, Hu SF, Zhang YL. Comparison of dexmedetomidine and sufentanil for conscious sedation in patients undergoing awake fibreoptic nasotracheal intubation: a prospective, randomised and controlled clinical trial. Clin Respir J. 2014;8:100–7. doi: 10.1111/crj.12045.
    1. Madhere M, Vangura D, Saidov A. Dexmedetomidine as sole agent for awake fiberoptic intubation in a patient with local anesthetic allergy. J Anesth. 2011;25:592–4. doi: 10.1007/s00540-011-1154-z.
    1. Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clin Anesth. 2007;19:370–3. doi: 10.1016/j.jclinane.2006.09.006.
    1. Gaszynski T, Gaszynska E, Szewczyk T. Dexmedetomidine for awake intubation and an opioid-free general anesthesia in a superobese patient with suspected difficult intubation. Drug Des Devel Ther. 2014;8:909–12. doi: 10.2147/DDDT.S64587.
    1. Bergese SD, Khabiri B, Roberts WD, Howie MB, McSweeney TD, Gerhardt MA. Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases. J Clin Anesth. 2007;19:141–4. doi: 10.1016/j.jclinane.2006.07.005.
    1. Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992;77:1134–42. doi: 10.1097/00000542-199212000-00014.
    1. Lallo A, Billard V, Bourgain JL. A comparison of propofol and remifentanil target-controlled infusions to facilitate fiberoptic nasotracheal intubation. Anesth Analg. 2009;108:852–7. doi: 10.1213/ane.0b013e318184eb31.
    1. Lee HM, Sakong J, Jee DL. The comparison of feasibility and safety on fiberoptic guided intubation under conscious sedation with remifentanil and propofol. Korean J Anesthesiol. 2013;65:215–20. doi: 10.4097/kjae.2013.65.3.215.
    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. Br J Anaesth. 2008;100:125–30. doi: 10.1093/bja/aem279.
    1. Cafiero T, Esposito F, Fraioli G, Gargiulo G, Frangiosa A, Cavallo LM, Mennella N, Cappabianca P. Remifentanil-TCI and propofol-TCI for conscious sedation during fibreoptic intubation in the acromegalic patient. Eur J Anaesthesiol. 2008;25:670–4. doi: 10.1017/S0265021508004195.
    1. Zhang X, He W, Wu X, Zhou X, Huang W, Feng X. TCI remifentanil vs. TCI propofol for awake fiber-optic intubation with limited topical anesthesia. Int J Clin Pharmacol Ther. 2012;50:10–6. doi: 10.5414/CP201580.
    1. Song JW, Kwak YL, Lee JW, Chang CH, Kim HS, Shim YH. The optimal effect site concentration of remifentanil in combination with intravenous midazolam and topical lidocaine for awake fibreoptic nasotracheal intubation in patients undergoing cervical spine surgery. Minerva Anestesiol. 2012;78:521–6.
    1. Vennila R, Hall A, Ali M, Bhuiyan N, Pirotta D, Raw DA. Remifentanil as single agent to facilitate awake fibreoptic intubation in the absence of premedication. Anaesthesia. 2011;66:368–72. doi: 10.1111/j.1365-2044.2011.06687.x.
    1. Yeganeh N, Roshani B, Azizi B, Almasi A. Target-controlled infusion of remifentanil to provide analgesia for awake nasotracheal fiberoptic intubations in cervical trauma patients. J Trauma. 2010;69:1185–90. doi: 10.1097/TA.0b013e3181cb4434.
    1. Sinha SK, Joshiraj B, Chaudhary L, Hayaran N, Kaur M, Jain A. A comparison of dexmedetomidine plus ketamine combination with dexmedetomidine alone for awake fiberoptic nasotracheal intubation: a randomized controlled study. J Anaesthesiol Clin Pharmacol. 2014;30:514. doi: 10.4103/0970-9185.142846.
    1. Ratnaraj J, Todorov A, McHugh T, Cheng MA, Lauryssen C. Effects of decreasing endotracheal tube cuff pressures during neck retraction for anterior cervical spine surgery. J Neurosurg. 2002;97:176–9.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera