Efficacy And Optimal Time Of Oropharyngeal Topical 10% Lignocaine Spray Before Induction Of

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1 IOSR Journl of Dentl nd Medicl Sciences (IOSR-JDMS) e-issn: , p-issn: Volume 9, Issue 6 (Sep.- Oct. 13), PP Efficcy nd Optiml Time of Orophryngel Topicl 1% Lignocine Spry Before Induction of Anesthesi in Attenuting the Pressor Response to Direct Lryngoscopy nd Endotrchel Intubtion. Dr. Fisl Mushfeen Qureshi 1, Dr. Smpthil Pdmnbh 2, Dr. Hbib Rhmn 3, Dr. Sheikh Imrn 4, Dr. Prtibh Rm Mohn 5 1 Deprtment of Anesthesi nd Criticl cre,yenepoy Medicl College, Yenepoy University, Mnglore, Krntk,Indi. 2 Professor & Hed, of Anesthesi nd Criticl cre,yenepoy Medicl College,Yenepoy University, Mnglore, Krntk,Indi. 3 Associte Professor, of Anesthesi nd Criticl cre,yenepoy Medicl College,Yenepoy University, Mnglore, Krntk,Indi. 4,5 Post grdute finl yer, of Anesthesi nd Criticl cre, Yenepoy Medicl College,Yenepoy University, Mnglore, Krntk,Indi. Abstrct: The study imed to scertin the efficcy of orophryngel topicl 1% lignocine spry pplied prior to induction of nesthesi nd lso to determine the optiml time for sprying to ttenute pressor response to lryngoscopy nd endotrchel intubtion. 8 ptients of either sex, in the ge group of -6 yers (ASA I & II) undergoing different elective surgicl procedures under generl nesthesi were tken up for the study. 1 puffs of Lignocine 1% spryed 1 min before induction in Group I, 3 min before induction in Group 2, 5 min before induction in nd norml Sline in s control. Hert rte(hr), systolic (SBP), distolic (DBP) nd men rteril pressure (MAP) were mesured t bseline, fter intubtion, fter 1min, 3 min nd 5 min following intubtion. There ws sttisticlly significnt increse in HR, systolic, distolic nd MAP in control group when compred to bseline s well s to study groups. Following lryngoscopy nd intubtion ttenution of pressor response did not show significnt difference t 1min, 3min nd 5min of 1% lignocine spry within study groups. Lignocine 1% when spryed to the orophrynx prior to induction of nesthesi ttenuted the pressor response to lryngoscopy nd intubtion irrespective of timing of the spry. Keywords: Endotrchel Intubtion, Lignocine spry (1%), Lryngoscopy, Pressor response, Systolic Blood pressure (SBP), Distolic blood pressure (DBP), rteril pressure (MAP). I. Introduction In prctice of nesthesi, lryngoscopy nd trchel intubtion forms the bsis of controlling the ptient s irwy during generl nesthesi or for rtificil ventiltion. Lryngoscopy nd endotrchel intubtion hs been chllenging procedure due to ssocited crdiovsculr chnges clled pressor response. This response includes widespred relese of norepinephrine from drenergic nerve terminls nd secretion of epinephrine from the drenl medull 1. In dults nd dolescents, the more common response to this irwy mnipultion is hypertension nd tchycrdi, medited by the crdio-ccelertor nerves nd sympthetic chin gngli. In ddition to ctivtion of the utonomic nervous system, lryngoscopy nd endotrchel intubtion result in stimultion of the centrl nervous system (C), s evidenced by increses in electroencephlogrphic ctivity, cerebrl metbolic rte, nd cerebrl blood flow (CBF) 2-5. Pressor response hs deleterious effects on ptients with preexisting hypertension, ischemic hert disese which my led to tchycrdi, rrhythmi, cerebrovsculr ccidents etc. Severl drugs like lignocine 6, clonidine 7, fentnyl 8 nd betblockers 9, hs been tried to control the pressor response to lryngoscopy nd intubtionbut it is not possible to completely bolish the response. The present study ws undertken to study the efficcy of orophryngel topicl 1% lignocine spry in ttenuting the pressor response s well s to find the optiml timing of ppliction of lignocine spry. II. Mterils And Methods: We conducted prospective, rndomized, controlled study with 8 ptients of ASA grde I & II, of either sex, ged between nd 6 yers, undergoing routine elective surgicl procedures under generl nesthesi. Study ws conducted fter getting institutionl ethicl committee pprovl nd informed consent from ll the ptients.we excluded ptients with uncontrolled hypertension, significnt heptic or renl disese, predicted difficult intubtion, history of hypersensitivity to mide locl nesthetics, seizure disorder nd ptients tking ny systemic medictions.after pre-opertive evlution nd necessry routine investigtions, premedicted with tb Rnitidine 15mg, nd tb Lorzepm 1mg 2 hour before induction. Glycopyrollte.2mg ws dministered intrmusculrly 3 min before induction. Routine monitoring ws done using 57 Pge

2 noninvsive blood pressure (NIBP), electrocrdiogrm (ECG), pulse oximeter (SPO2). Bseline vlues of hert rte(hr), systolic blood pressure(sbp), distolic blood pressure(dbp) nd men rteril pressure(map) were mesured before sprying with lignocine(1%). Ptients were rndomly llotted into one of the four groups using lottery method; ech group consisted of ptients. In, ptients were subjected to lignocine 1% spry 1 min before induction, in lignocine 1% spry ws dministered 3 min before induction, similrly in lignocine 1% spry ws dministered t 5min before induction, ptients in were dministered norml sline spry who served s control.lignocine 1% orl spry ws dministered in the sitting position by sking the ptient to fully open their mouth nd using disposble spry cnul into the mouth without using lryngoscope, totl of 1 puffs (2 puffs to soft plte, 3 puffs to posterior orophryngel wll, 2 puffs to pltophryngel rch nd 3 puffs to posterior 3 rd of tongue, ech puff delivering 1mg, resulting in totl dose of 1mg nd not exceeding the toxic dose of 3-4mg/kg. All ptients were induced with propofol 2mg/kg followed by rocuronium.9mg/kg to fcilitte endotrchel intubtion. Using Mcintosh blde lryngoscopy nd intubtion ws done by nesthesiologist hving 5 yers of experience. Ptients with difficult intubtion which require lryngoscopy more thn seconds nd who require more thn one ttempt were excluded from the study. Fentnyl 2µgs/kg ws given s n nlgesic. A second recording of HR, SBP, DBP nd MAP were noted immeditely fter lryngoscopy nd intubtion, nd then 1min, 2min, 3min nd 5min intervls fter lryngoscopy nd intubtion. The results were subjected to sttisticl nlysis using Student s unpired t test nd ANOVA ws used for overll differences. Any p vlue less thn.5 were tken s sttisticlly significnt. SPSS version 17 ws used for nlysis. III. Results: There ws no sttisticlly significnt difference in the demogrphic chrcteristics mong the 4 groups (Tble 1) There ws significnt rise of hert rte in the control groupwhen compred to the bseline hert rte.there ws lso sttisticlly very highly significnt (p<.1) difference compred to study groups 1, 2, 3. However,mong the study groups,chnge in the hert rte ws not sttisticlly significnt (Tbles 2&3). SBP, DBP nd MAP showed sttisticlly highly significnt chnge (p<.1) in control group( 4) when compred to study groups nd bseline. Moreover, there ws sttisticlly insignificnt difference in SBP, DBP nd MAP (p=.321, p=.772, p=.5) respectively between groups 1, 2, 3 (Tbles 4-9). IV. Discussion: Lryngoscopy nd intubtion is ssocited with sympthodrenl response leding to increse in rteril blood pressure, hert rte nd my lso result in rrhythmis.this bers prticulr significnce in ptients of crdic condition like hypertension, ptients with cute myocrdil infrction 1-5. The lryngoscopy nd endotrchel intubtion(et) intubtion is considered to be stronger stimulus thn surgicl incision. The mount of pressor response is relted to the force pplied to the bse of tongue, the durtion of lryngoscopy.there hve been mny different wys tried to decrese the pressor response rnging from non-phrmcologicl methods like using LMA 1, vrious types of lryngoscope bldes like McCoy 11 for doing lryngoscopy, to phrmcologicl methods like lignocine, lph-2 gonists, opioids, nitroglycerine, betblockers mong others 6-9,12. Lignocine hs been tried s intrvenous dministrtion prior to lryngoscopy, mouth grgles in vrious concentrtion, sprys. The mechnism of ction of lignocine in blunting pressor response differs ccording to the method of dministrtion. Locl dministrtion like grgles nd sprys my be effective due to its locl nesthetic property t the bse of tongue nd phryngel wlls preventing the receptor stimultion. The intrvenous dministrtion minly cts by decresing the cerebrl blood flow nd depression of myocrdil contrctility 13. Abou-Mdi etl 14 hve discussed the possible mechnisms to ccount for these observtions with IV lignocine. These include direct myocrdil depressnt effect, peripherl vsodiltion effect nd finlly n effect on synptic trnsmission. In our study we used orophryngel topicl 1% lignocine spryprior to inductionto determine the efficcy in ttenuting the pressor response nd optiml timing of sprying. Weused 1 puffs in totl, ech puffdelivering 1mg, so totl dose given ws 1 mg. This dose is well below the toxic dose of lignocine. We used glycopyrollte 15.2 mg s premediction which hs been proved to be enhncing bsorption, prolongs the nlgesic ction of lignocine nd hs nti-silgogue property. We found tht the lignocine spry ws effective in ttenuting pressor response (in terms of hert rte, systolic blood pressure, distolic blood pressure nd men rteril pressure) in ll the three groups receiving the drug in comprison to the which received norml sline nd to the bseline vlues. We performed single lryngoscopy prior to endotrchel intubtion wheres lryngoscopy ws performed twice by Mostf etl 16 becuse they dministered the spry fter induction, thus results re not 58 Pge

3 comprble. Hmill etl 17 compred topicl lignocine with I.V. lignocine. In the topicl group, fter induction of nesthesi they performed lryngoscopy to spry the orophrynx, two minutes lter, they performed nother lryngoscopy for endotrchel intubtion. While in other group they performed only one lryngoscopy nd hence noxious stimuli were given twice in the topicl group.mostf 16 nd Hmill 17 in their respective studies hd concluded tht topicl lignocine is ineffective in preventing the pressor response. Tkit etl 18 suggested tht differing intervls between trchel lignocine nd endotrchel intubtion probbly cused the inconsistent conclusion reported in other investigtions nd showed tht endotrchel intubtion performed two minutes fter trchel lignocine ttenuted the crdiovsculr responses to endotrchel intubtion M. Jin et l 19 performed study on lignocine 1 percent spry to study its efficcy in ttenuting the pressor response nd found it to be effective in ttenuting nd not bolishing the response, we hd similr findings in lignocine being ble to ttenute the pressor response, but they didn t study the optiml timing of the spry nd they didn t use glycopyrrolte s premediction. V. Conclusion We conclude tht sprying orophrynx with 1 puffs (1mg) of topicl 1% lignocine is effective in blunting the pressor response to lryngoscopy nd intubtion when it is pplied before induction of generl nesthesi irrespective of timing of the spry. Tble 1: Demogrphic chrcteristics (men ± SD) of four groups Demogrphic chrcteristics Sttisticl significnce Age.76± ± ± ± 8.1 P =.986 Sex (Mle/Femle) 11/9 1/1 11/9 8/12 X² =.973 P =.823 n = number of subjects Tble 2: Tble showing ± SD chnges in Hert rte in groups 1, 2, 3 (Study) nd (Control) = Highly significnt (p<.1) = Not significnt (p>.5) HEART RATE Groups 1,2,3 ± S.D ± S.D Bseline 86.5 ± ±11.3 After L & I * 13.± ±14.2 After 1 MIN 1.2± ±14.6 After 2 MIN 96.± ±11.5 After 3 MIN 92.2± ±9.8 After 5 MIN 88.9± ±7.8 Tble 3 Tble showing ± SD chnges in Hert rte in groups 1, 2, 3 (ANOVA) HEART RATE P Vlue # Bseline After L & I * After 1 MIN ,.989 After 2 MIN After 3 MIN After 5 MIN ,9.338 # P vlues >.5 re insignificnt 59 Pge

4 Tble 4 Tble showing ± SD chnges in Systolic blood pressure in groups 1, 2, 3 (Study) nd group 4 (Control) SYSTOLIC BLOOD Groups 1,2,3 ± S.D ± S.D Bseline ± ±7.1 After L & I * 141.6± ±5.7 After 1 MIN 138.6± ±5.6 After 2 MIN 135.8± ±5.6 After 3 MIN 132.9± ±5.1 After 5 MIN 131.8± ±6.4 = Highly significnt (p<.1) = Not significnt (p>.5) Tble 5 Tble showing ± SD chnges in Systolic blood pressure in groups 1, 2, 3 (ANOVA) SYSTOLIC BLOOD Bseline After L & I * <.1 After 1 MIN <.1 After 2 MIN <.1 After 3 MIN <.1 After 5 MIN <.1 P Vlue # # P vlues >.5 re insignificnt Tble 6 Tble showing ± SD chnges in Distolic Blood Pressure in groups 1, 2, 3 (Study) nd (Control) DIASTOLIC BLOOD Groups 1,2,3 ± S.D ± S.D Bseline 81.3± ±6.7 After L & I * 93.4± ±6.1 After 1 MIN 9.8±7. 1.6±4.7 After 2 MIN 87.6± ±4.9 After 3 MIN 85.3± ±5. After 5 MIN 82.9± ±4.9 = Highly significnt (p<.1) = Not significnt (p>.5) 6 Pge

5 Tble 7 Tble showing ± SD chnges in Distolic Blood Pressure in groups 1, 2, 3 (ANOVA) DIASTOLIC BLOOD P Vlue # Bseline After L & I * <.1 After 1 MIN <.1 After 2 MIN <.1 After 3 MIN <.1 After 5 MIN <.1 # P vlues >.5 re insignificnt Tble 8 Tble showing ± SD chnges in Arteril Pressure in groups 1, 2, 3 (Study) nd group 4 (Control) pressure = Highly significnt (p<.1) = Not significnt (p>.5) rteril Groups 1,2,3 ± S.D ± S.D Bseline 97.6 ± ±5.6 After L & I * 19.5± ±5.3 After 1 MIN 16.7± ±4. After 2 MIN 13.6± O±4.2 After 3 MIN 11.1± ±4. After 5 MIN 99.2± ±4. Tble 9 Tble showing ± SD chnges in Arteril Pressure in groups 1, 2, 3 (ANOVA) rteril pressure P Vlue # Bseline After L & I * After 1 MIN After 2 MIN After 3 MIN After 5 MIN # P vlues >.5 re insignificnt 61 Pge

6 Hert rte ± SD chnges in Hert rte in groups 1, 2, 3 (Study) nd (Control) Bseline L nd I 1 min 2 min 3 min 5 min ± SD chnges in Systolic blood pressure in groups 1, 2, 3 (Study) nd (Control) Systolic BP BASELINE L AND I 1 MIN 2 MIN 3 MIN 5 MIN ± SD chnges in Distolic Blood Pressure in groups 1, 2, 3 (Study) nd (Control) Distolic blood pressure Pge

7 ± SD chnges in Arteril Pressure in groups 1, 2, 3 (Study) nd (Control) rteril pressure References [1]. Hssn, H. G., El-Shrkwy, T. Y., Renck, H., Mnsour, G. nd Foud, A. (1991), Hemodynmic nd ctecholmine responses to lryngoscopy with vs. without endotrchel intubtion. Act Anesthesiologic Scndinvic, 35: doi: /j tb3325.x. [2]. Mi WD, Ski T, Tkhshi S, Mtsuki A,Hemodynmic nd electroencephlogrph responses to intubtion during induction with propofol or propofol/fentnyl. Cn J Anesth 1998; 45:19. [3]. Wilson IG, Meiklejohn BH, Smith G: Intrvenous lignocine nd sympthodrenl responses to lryngoscopy nd intubtion. The effect of vrying time of injection. Anesthesi Mr;46(3): [4]. Shribmn AJ, Smith G, Achol KJ: Crdiovsculr nd ctecholmine responses to lryngoscopy with nd without trchel intubtion. Br J Anesth 1987; 59:295. [5]. King BD, Hrris LC, Greifenstein FE, Elder JD, Dripps RD. Reflex circultory responses to direct lryngoscopy nd trchel intubtion performed during generl nesthesi. Anesthesiology 1951; 12: [6]. Stoelting RK. Circultory chnges during direct lryngosocpy nd trchel intubtion - influence of durtion of lryngoscopy with or without prior lidocine. Anesthesiology 1977; 47(4): [7]. RvlDipk L., Meht Mlini K. Orl clonidine pre mediction for ttenution of hemodynmic response to lryngoscopy nd intubtion.indin J. Anesth. 2; 46 (2) : [8]. Crbine UA, Allen RW, Moore J. Prtil ttenution of the pressor response to endotrchel intubtion. A comprison of the effects of intrvenous clonidine nd fentnyl. Eur J Anesthesiol Jul;9(4): [9]. Vucevic M, Purdy GM, Ellis FR. Esmolol hydrochloride for mngement of the crdiovsculr stress responses to lryngoscopy nd trchel intubtion. Br J Anesth1992; 68: [1]. Brude N, Clements EAF, Hodges UM, Andrews BP. The pressor response nd lryngel msk insertion - comprison with trchel intubtion Anesthesi, 1989; 44: [11]. S. Singhl,.Neh: Hemodynmic Response To Lryngoscopy And Intubtion: Comprison Of McCoy And Mcintosh Lryngoscope. The Internet Journl of Anesthesiology. 8 Volume 17 Number 1. DOI: 1.558/17d [12]. Fssoulki A, KnirisP.Intrnsl dministrtion of nitroglycerine ttenutes the pressor response to lryngoscopy nd intubtion of the trche.br J Anesth Jn;55(1): [13]. Lev R, Rosen P. Prophylctic lidocine use preintubtion: review. J Emerg Med. Jul-Aug 1994;12(4): [14]. Abou-Mdi MN, Keszler H, Ycoub JM. Crdiovsculr rections to lryngoscopy nd trchel intubtion following smll nd lrge intrvenous doses of lidocine. Cn AnesthSoc J 1977;24: [15]. Wtnbe H, Lindgren L, Rosenberg P, Rndell T. Glycopyrronium prolongs topicl nesthesi of orl mucos nd enhnces bsorption of lignocine. British Journl of Anesthesi 1993; 7: [16]. Mostf SM, Murthy BVS, Brrett PJ, McHugh P. Comprison of the effects of topicl Lignocine spry pplied before or fter induction of nesthesi on pressor response to direct lryngoscopy nd intubtion Eur J Anesthesiol.1999;16:7-1. [17]. Hmill JF,BedfordRF, Wever DC. Lidocine before endotrchel intubtion: Intrvenous or Lryngotrchel. Anesthesiology 1981; 55: [18]. Tkit K, Morimoto Y,Kemmotsu O. Trchel Lidocine ttenutes the crdiovsculr response to endotrchel intubtion. CJA 1:48(8): [19]. M. Jin, S.A. Gurcoo, A.N. Shor, M.S. Qzi, B.A. Dr, V.N. Buchh, S.I. Ahmd. Efficcy Of Topicl Lignocine Spry (1%) Applied Before The Induction Of Anesthesi In Attenuting The Pressor Response To Direct Lryngoscopy And Endotrchel Intubtion In Controlled Hypertensive Ptients. The Internet Journl of Anesthesiology. 9, (2) DOI: 1.558/25bc 63 Pge