Comparative Study of Safety and Efficacy of Three Different Doses of Fentanyl on Hemodynamic Response to Laryngoscopy and Tracheal Intubation in Patients under General Anaesthesia

Aim of Study: Laryngoscopy and endotracheal intubation are the commonest method for securing a definitive airway for general anaesthesia. It is one of the most invasive and painful stimuli in anaesthesia producing clinically relevant changes in the hemodynamic variables. This study has been designed to compare the safety and efficacy of three different doses of fentanyl (2µg/kg, 3µg/kg and 4µg/kg) in attenuating hemodynamic response, following laryngoscopy and endotracheal intubation. Materials and Methods: In this observational study, three groups of 90 patients belonging to ASA grade I and II, aged between 18 to 65 years, including either gender, posted for elective surgery under GA with informed consent. Baseline vital hemodynamic parameters and the serial heart rate, arterial pressures, SpO2 and respiratory rate were noted at five minutes after intravenous fentanyl administration, during laryngoscopy & intubation and at 1-, 3-, 5-, 10- and 20-minutes after laryngoscopy. Ramsay sedation scores were also noted at five minutes after intravenous fentanyl administration, during extubation and at 10-, 20- and 30-minutes after extubation. Results: There was substantial difference in mean HR, SBP, DBP & MAP values post 5 minutes after intravenous fentanyl administration, during laryngoscopy, at 1, 3-, 5-, 10- and 20-minutes following laryngoscopy and intubation between the three groups. Patients’ behaviour belonging to group C (IV fentanyl 4µg/kg), followed by the patients of group B (IV fentanyl 3µg/kg) presented considerable amount of attenuation of all the hemodynamic stress parameters effectively, with statistically significant results when compared to group A (IV fentanyl 2µg/kg). Conclusion: Intravenous fentanyl 4µg/kg and 3µg/kg are better at attenuating the laryngo-tracheal stress response, in comparison to intravenous fentanyl 2µg/kg.

‘NOPAIN-ROP’ trial: Intravenous fentanyl and intravenous ketamine for pain relief during laser photocoagulation for retinopathy of prematurity (ROP) in preterm infants: A randomised trial

ObjectivesTo investigate if intravenous fentanyl or intravenous ketamine can provide adequate analgesia in preterm infants undergoing laser photocoagulation for retinopathy of prematurity (ROP).DesignOpen-label randomised trial.SettingTertiary care institution.ParticipantsPreterm infants who underwent laser photocoagulation for ROP.InterventionsInfants were randomised to receive fentanyl as intravenous bolus dose of 2 µg/kg, followed by an intravenous infusion of 1 µg/kg/hour increased to a maximum of 3 µg/kg/hour or intravenous ketamine as bolus dose of 0.5 mg/kg, followed by further intermittent intravenous bolus doses of 0.5 mg/kg to a maximum of 2 mg/kg in the initial phase and intravenous fentanyl (bolus of 2 µg/kg followed by infusion of 2 µg/kg/hour to a maximum of 5 µg/kg/hour) or intravenous ketamine (bolus dose of 1 mg/kg followed by intermittent bolus doses of 0.5 mg/kg to a maximum of 4 mg/kg) in the revised regimen phase.Main outcome measuresProportion of infants with adequate analgesia defined as the presence of both: (1) all the Premature Infant Pain Profile-Revised scores measured every 15 min less than seven and (2) proportion of the procedure time the infant spent crying less than 5%.Secondary outcomes included apnoea, cardiorespiratory or haemodynamic instability, feed intolerance and urinary retention requiring catheterisation during and within 24 hours following the procedure.ResultsA total of 97 infants were randomised (fentanyl=51, ketamine=46). The proportions of infants with adequate analgesia were 16.3% (95% CI 8.5% to 29%) with fentanyl and 4.5% (95% CI 1.3% to 15.1%) with ketamine. Ten infants (19.6%) in the fentanyl group and seven infants (15.2%) in the ketamine group had one or more side effects. In view of inadequate analgesia with both the regimens, the study steering committee recommended using a higher dose of intravenous fentanyl and intravenous ketamine. Consequently, we enrolled 27 infants (fentanyl=13, ketamine=14). With revised regimens, the proportions of infants with adequate analgesia were higher: 23.1% (95% CI 8.2% to 50.2%) with fentanyl and 7.1% (95% CI 1.3% to 31.5%) with ketamine. However, higher proportions of infants developed apnoea (n=4; 30.7%), need for supplemental oxygen (n=5, 38.4%) and change in cardiorespiratory scores (n=7; 53.8%) with fentanyl but none with ketamine.ConclusionsFentanyl-based and ketamine-based drug regimens provided adequate analgesia only in a minority of infants undergoing laser photocoagulation for ROP. More research is needed to find safe and effective regimens that can be employed in resource constrained settings.Trial registration numberCTRI/2018/03/012878.

A comparison of high thoracic epidural anaesthesia versus conventional intravenous opioids in pediatric patients undergoing corrective open heart surgery for ventricular septal defect

Background: We compared high thoracic epidural anaesthesia with a combination of morphine and bupivacaine versus IV fentanyl as an alternative for perioperative pain management.Methods: Group-E: Injection Morphine 75-100 mcg/kg and Injection 0.25 % Bupivacaine 0.5 ml/kg was given via epidural catheter at insertion, Injection 0.25% Bupivacaine 0.5 ml/kg just before skin incision, and continuous infusion of Injection 0.125% Bupivacaine at 0.2 ml/kg/hr intra-operatively. Post-operative 0.1 ml/kg/hr infusion. Group F- intravenous fentanyl 2-3 mcg/Kg IV bolus given just before skin incision, followed by 1-2 mcg/Kg/hr IV fentanyl started after weaning from cardiopulmonary bypass.Results: The mean ScvO2 was comparable between the two groups during induction period but became higher in group E during bypass and post bypass period intraoperatively, and the difference in rise in ScvO2 is statistically significant with a p<0.05. The mean rSo2- C was comparable between the two groups in the first postoperative hour but group F shows higher rSo2-C postoperatively which was statistically significant. The postoperative pain was significantly lower in group E in the postoperative period (except for 4,5,6 and 40 and 48th hour).Conclusions: HTEA to paediatric patients prior to sternotomy for cardiac surgeries resulted in a much better control of haemodynamic parameters. Produces better central venous and regional tissue oxygenation during bypass and post bypass intraoperatively as compared to the patients that received only intravenous fentanyl. There was lower amount of postoperative bleeding in the HTEA group with significant reduction in requirement of post-operative ventilation and time to extubation after surgery, better post-operative pain control and overall outcome.

Evaluation of anesthesia manual for strabismus correction surgeries in outpatient practice among children and impact of anesthesia on early recovery after surgery

The majority of strabismus correction surgeries are performed in outpatient conditions. Improving the quality of pain management is essential to avoid undesirable events, especially among children after general anesthesia during strabismus surgery. The use of opioid analgesia during surgery may be accompanied by a higher risk of postoperative nausea and vomiting, as well as longer sedation leading to delayed discharge from hospital. The local 0.4% hydrochloride oxybuprocaine anesthetic has a local pro-active analgesic effect on the operated eye prior to the surgical incision, and later the additional use of drops in the surgical field eliminates the need for further analgesic administration in the perioperative and postoperative period without any subsequent sedation or significant nausea and vomiting episodes that are observed with intravenous fentanyl injection. The results of the study showed that the local application of 0.4% oxybuprocaine is comparable in the effect with intravenous fentanyl injection in achieving the desired optimal effect in the perioperative and postoperative periods and contributes to discharge from hospital in the near future.

Preoperative regional scalp block versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia

During brain tumour resection a lot of noxious stimuli are released resulting in a significant hemodynamic and stress response, its control is challenging during anaesthesia, and can be evaluated by monitoring blood pressure (BP), heart rate (HR) Attenuating autonomic cardiovascular responses to pain resulting from skull pinning, skin incision, and craniotomy are considered significant benefits of Regional Scalp Block (RSB) in addition to reducing postoperative analgesic requirements. This study aims to evaluate the effect of preoperative regional scalp block (RSB) versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia. The study included 30 patients randomly distributed into two equal groups with 15 patients in each, Group A: Preoperative RSB was done after induction of general anaesthesia and before skull pinning, Group C: Control group: patients were given conventional intraoperative analgesia in the form of intravenous fentanyl with no block. This study included patients with Supratentorial brain tumours were admitted to Zagazig University Hospitals. Patients have been gathered over two years duration from march 2018 to march 2020. The results showed that there were highly significant differences between RSB group and control group. Preoperative RSB showed advantages over Standard analgesia in terms of better attenuation of stress response to pain in the form of heart rate and blood pressure intraoperatively, decrease opioid consumption, lower Visual Analogue Score (VAS), Preoperative RSB can be performed easily in a short time with very high success rate allowing better intraoperative control of haemodynamics, less postoperative pain. We recommend using preoperative RSB in supratentorial craniotomy as a gold standard in our hospital to get the advantages mentioned above.