Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 39-44

Induction of anesthesia and endotracheal intubation in children without muscle relaxant: a comparative study on addition of fentanyl or propofol to sevoflurane


Department of Anesthesia, Critical Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission19-May-2013
Date of Acceptance15-Jul-2013
Date of Web Publication17-Mar-2016

Correspondence Address:
Hazem M Fawzi
179 El Hegaz Street, Heliopolis, Cairo, 11471
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.178878

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  Abstract 

Background
Intubation without the need of muscle relaxant is a common practice in pediatric patients. Many drugs are used with inhalational induction to improve the intubation score and to decrease the induction time; of these drugs are propofol and narcotics. The aim of this study was to compare the effect of adding propofol or fentanyl to sevoflurane on the intubating conditions in pediatric patients undergoing adenotonsillectomy.
Patients and methods
A randomized controlled study was conducted on 90 patients aged 4-8 years and with ASA physical status I and II scheduled for elective adenotonsillectomy. Patients were divided by opening a sealed envelope into three equal groups, each consisting of 30 patients. Group S patients received inhalational induction alone using sevoflurane. Group SF received 3 mcg/kg fentanyl intravenously followed by inhalational induction using sevoflurane. Group SP received 3 mg/kg propofol intravenously followed by inhalational induction using sevoflurane. The intubation conditions, hemodynamic parameters (heart rate and systolic blood pressure), oxygen saturation, operative time, induction time, and recovery time, were all recorded and statistically analyzed.
Results
With respect to the intubating condition, no patient in any of the three groups needed rescue muscle relaxant for intubation. Group SP showed more acceptable and excellent intubating conditions compared with the other two groups (90 and 83.3%, respectively). After 6 min, the heart rate was slower, 106.5 (100-110.5) beats/min, and the systolic blood pressure was lower, 110 (110-115) mmHg, in group SF than in the other two groups. Induction time was faster, 107 (99.8-117) min, in group SP than in the other two groups. The recovery time was shorter in group S than in group SF and slightly longer in group SP, with median and interquartile range of 265 (249.5-280) s, 337 (320-360) s, and 500 (496.8-510) s, respectively.
Conclusion
Endotracheal intubation without neuromuscular blocking agents in pediatric patients undergoing adenotonsillectomy can be achieved with no serious respiratory or hemodynamic adverse events by adding propofol (3 mg/kg) or fentanyl (3 mcg/kg) to sevoflurane. Propofol is suitable for rapid induction as it offers the shortest induction time with 83.3% excellent intubating conditions, whereas fentanyl blunts the stress response to intubation with 46.7% excellent intubating conditions.

Keywords: fentanyl, intubation in children, intubation score, propofol, sevoflurane


How to cite this article:
Fawzi HM, Samir GM. Induction of anesthesia and endotracheal intubation in children without muscle relaxant: a comparative study on addition of fentanyl or propofol to sevoflurane. Ain-Shams J Anaesthesiol 2016;9:39-44

How to cite this URL:
Fawzi HM, Samir GM. Induction of anesthesia and endotracheal intubation in children without muscle relaxant: a comparative study on addition of fentanyl or propofol to sevoflurane. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2019 Sep 20];9:39-44. Available from: http://www.asja.eg.net/text.asp?2016/9/1/39/178878


  Introduction Top


Sevoflurane for induction of anesthesia is frequently used in pediatrics. Sevoflurane is a volatile anesthetic with properties suitable for day-case anesthesia, as it allows rapid recovery and is associated with an acceptably low incidence of postoperative nausea and vomiting (PONV) [1] . It allows loss of consciousness, which is comparably as rapid as propofol, especially when a single-breath induction technique is used [2] . Some anesthesiologists question the need for muscle relaxants in the pediatric induction protocols and argue that tracheal intubation without muscle relaxants has been a common practice since anesthesia began [3] . Reasons for omitting muscle relaxants are numerous; of them are brief procedures or great interindividual variability in the recovery time [4] . Anesthesiologists who defend the use of muscle relaxants for tracheal intubation argue that omitting these agents from the induction regimen may lead to potential risks and complications, which include difficult tracheal intubation [5] . Opioids suppress respiration thus establishing appropriate conditions for endotracheal intubation; they are therefore good substitutes for muscle relaxants when used along with intravenous or inhaled hypnotics during intubation [6] . This study was designed to assess the conditions for endotracheal intubation in pediatric patients undergoing adenotonsillectomy following an inhalational induction with sevoflurane alone and when used in combination with propofol (3 mg/kg) or fentanyl (3 mcg/kg) without the use of muscle relaxants. The conditions for endotracheal intubation as well as the hemodynamic changes were recorded. The induction time and the recovery time were also measured.


  Patients and methods Top


After obtaining consent from guardians, we recruited 90 patients with ASA physical status I and II, aged 4-8 years, scheduled to perform elective adenotonsillectomy in this randomized controlled study. We chose this tight age group, as the induction time differs at different age groups [7] . Any patient with stigmata of difficult airway, bleeding disorder, cardiac or chest problem contraindicating any of the used drugs, or history of allergy to any of the studied drugs were excluded.

Patients were divided by opening a sealed envelope into three equal groups, each consisting of 30 patients.

Group S patients received 0.3 ml/kg saline, intravenous, and lignocaine (Sigmatec Pharmaceutical Industry-A.R.E. Co.) 0.2 mg/kg followed by inhalational induction with sevoflurane (Abbott).

Group SF patients received 3 mcg/kg fentanyl intravenously [Sunny Pharmaceutical (Egypt) under license of Hamelin Pharmaceuticals (Germany)] and lignocaine 0.2 mg/kg followed by inhalational induction with sevoflurane.

Group SP patients received 3 mg/kg propofol intravenously (propofol 1%; Fresenius Kabi Austria GmbH, Graz, Austria) and 0.2 mg/kg lignocaine 100 mg, 5 ml (Sigma-Tec Pharmaceutical Idust-A.R.E.) (which was added to propofol solution to abolish pain on injection) followed by inhalational induction with sevoflurane.

The study was conducted using three sets of syringes; the first contained saline, the second contained fentanyl 10 mcg/ml, and the third contained propofol 10 mg/ml. All syringes were covered by opaque tape to hide the color of the solution and patients received 0.3 ml/kg of the selected syringe according to the group; all syringes had lignocaine as mentioned before. Syringes were prepared by a different doctor according to the weight of each patient and the drug was given by another anesthetist blinded for the prepared drug; also, this doctor was the one who recorded the data.

Anesthetic technique: a total of 90 patients had intravenous cannula inserted before admission to the operating room using Elma cream 5% (AstraZeneca, UK Ltd), which was applied to the skin over a chosen visible vein 45 min before its cannulation. All patients received premedication with midazolam (0.05 mg/kg intravenous), 10 min before induction. Intraoperatively, the patients were monitored using three-lead ECG, pediatric pulse oximetry, capnography, and NIBP (Dash5000; General Electric, Medical Systems Information Technologies, Inc. Tower Ave., Milwaukee, WI, USA). Before induction, all patients received atropine (0.02 mg/kg, intravenous). Patients were given 0.3 ml/kg of the studied solution followed by inhalational induction with sevoflurane 8% (volume%). Anesthesia was administered using the pediatric circle systems and appropriately sized pediatric masks with total flows maintained at 10 l/min throughout induction, applying assisted ventilation as soon as possible with a pressure less than 20 cm H 2 O; airway of appropriate size was inserted when needed. Anesthetic machine used was from Datex-Ohmeda Inc. (3030 Ohmeda Drive Madison, WI 53707-7550, USA). When the pupils became small and centered and the patient became relaxed, intubation was performed orally using a Macintosh laryngoscope blade and an uncuffed endotracheal tube of appropriate size without the use of any muscle relaxant; the duration from injection of the drug until insertion of the tube was calculated as the induction time. Intubation conditions were assessed using a scoring system for intubation condition [Table 1], where excellent condition means all criteria scoring 1, acceptable condition means all criteria equal or less than 2, whereas any parameter scoring more than 2 makes the intubating condition unacceptable [8] . Single laryngoscopy attempt was allowed; inadequate intubation condition and the need for rescue drug was declared if the patient failed to be intubated after 30 s or oxygen saturation decreased below 90%. In this case, suxamethonium 1 mg/kg was given as rescue drug and then intubation was performed, and no data were recorded from this patient after this. All patients received Abimol (GlaxoSmithKline, S.p.A, Parma, Italy) rectal suppository 15 mg/kg as analgesia after intubation and before surgery. Hemodynamic parameters [heart rate (HR), systolic blood pressure (SBP), and oxygen saturation] were recorded at 1 min after atropine as baseline data, during intubation, and 6 min after intubation, intubation time (which is the time from drug injection until intubation), the ease of intubation (intubation score), and the recovery time (which is the time from closing inhalational anesthesia until eye opening to command), together with the demographic data were recorded. Thereafter, all data were statistically analyzed.
Table 1 Scoring system for intubating conditions [8]

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Statistical analysis

The required sample size was calculated using G*Power software version 3.1.0 (Institut für Experimentelle Psychologie, Heinrich Heine Universität, Düsseldorf, Germany). The primary outcome measure was acceptability of intubating conditions. It was estimated that a sample of 30 patients in each study group would have a power of 80% to detect a medium effect size (w) of 0.33. The χ2 -test was used for sample size calculation and significance was targeted at a two-sided type I error of 0.05 assuming two degrees of freedom.

Statistical analysis was performed on a personal computer using IBM SPSS Statistics version 21 (IBM Corp., Armonk, New York, USA). The Shapiro-Wilk test was used to test the normality of numerical data distribution. As these data were skewed, they were presented as median and interquartile range, and between-group differences were compared nonparametrically using the Kruskal-Wallis test, with application of the Mann-Whitney U-test for post-hoc pairwise comparisons whenever a statistically significant difference was detected with the Kruskal-Wallis test. The Bonferroni method was applied to correct for multiple post-hoc comparisons with the Mann-Whitney U-test. This indicated that, to maintain a final type I error of 0.05, significance should be targeted at P value less than 0.017 (two-sided).

Categorical data were presented as number and percentage, and differences between the two groups were compared using the Pearson χ2 -test or the χ2 -test for trends for nominal or ordinal data, respectively. Fisher's exact test was used in place of the χ2 -test if more than 20% of cells in any contingency table had an expected count of less than 5.

All P values were two-sided. P value less than 0.05 was considered statistically significant.


  Results Top


All groups were comparable according to the demographic data (age, weight, and sex) [Table 2]. According to the hemodynamic parameters, there were no statistical differences between the three groups at the baseline HR (1 min after atropine) and also during intubation, but after 6 min the HR was slower in the second group (group SF) than in the other two groups, with no differences between the first (group S) and the third (group SP) groups and with median and interquartile range of 125 (119.3-125.3) beats/min, 106.5 (100-110.5) beats/min, and 120 (120-125) beats/min, respectively [Table 3]. In addition, there were no statistical differences between the three groups with respect to the baseline SBP (1 min after atropine), whereas during intubation the third group (group SP) showed higher blood pressure, which was statistically significant but clinically insignificant with median and interquartile range of 110 (110-115) mmHg, 110 (110-115) mmHg, and 115 (110-119.3) mmHg, respectively. However, after 6 min, the second group (group SF) showed lower SBP than the other two groups, with median and interquartile range of 115 (110-115) mmHg, 101 (100-105) mmHg, and 115 (113.5-117) mmHg, respectively. In addition, there were no statistical differences between the groups with respect to the oxygen saturation at any time [Table 3].
Table 2 Demographic data

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Table 3 Cardiorespiratory variables

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With respect to the intubating condition, no patient in any of the three groups needed rescue muscle relaxant for intubation; the third group (group SP) showed more acceptable intubating condition than the other two groups, with number and percentage of acceptable to nonacceptable being 20 (66.7%), 19 (63.3%), and 27 (90%), respectively. In addition, the number of excellent intubating condition was higher in the third group (group SP) than in the other two groups, with number and percentage of 15 (50.0%), 14 (46.7%), and 25 (83.3%), respectively [Figure 1] and [Figure 2].
Figure 1: Intubation score in the three study groups

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Figure 2: Acceptability of intubating conditions in the three study groups

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The operative time showed no statistical differences between the three groups [Table 4]. Induction time was shorter in the third group (group SP) than in the other two groups, with median and interquartile range of 107 (99.8-117) min, 105.5 (100-109.5) min, and 74 (59-92) min, respectively. With respect to the recovery time, it was shorter in the first group (group S) than in the second group (group SF) and slightly longer in the third group (group SP), with median and interquartile range of 265 (249.5-280) min, 337 (320-360) min, and 500 (496.8-510) min, respectively [Table 4].
Table 4 Induction, operative, and recovery times

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  Discussion Top


Adenotonsillectomy remains one of the most common surgical procedures carried out in children. Successful and safe implementation of day-case adenotonsillectomy requires careful patient selection. An extended observation period of 4-6 h before discharge is recommended [9] . The goals of anesthesiologists are to provide stable patient hemodynamic, rapid patient emergence, and rapid patient readiness for home discharge with minimal unpleasant side effects, especially pain and PONV [10] . Inhalation induction remains a widely used technique in pediatric outpatient anesthesia; sevoflurane has potential to be the inhalation induction agent of choice in children. Its relatively low blood-gas solubility, nonpungent odor, and lack of irritation to the airway passages makes it a very useful anesthetic for rapid induction and a more predictable emergence from anesthesia in pediatric outpatients, thereby facilitating patients' turnover [11] . Propofol is the most commonly used induction and maintenance anesthetic agent for day-case anesthesia because it allows rapid recovery and a low incidence of PONV [12] . However, the use of propofol is associated with pain on injection and cardiovascular and respiratory depression [13] .

In the current study, the use of propofol resulted in higher incidence of acceptable and excellent intubating conditions, 90 and 83.3%, respectively. This was in agreement with the study by Lerman et al. [14] and Taha et al. [15] ; they reported the incidence of excellent intubating conditions of 90%. In 2005, Oberer et al. [16] mentioned that propofol decreases laryngotracheal reactivity and muscle tone thus allowing ease in intubation, but the intubating conditions are not optimal because of the expiration reflexes and cough, which are most frequently reported during propofol anesthesia, whereas laryngospasm is more frequent with sevoflurane. The success of the combination of both drugs may be explained by their complementary effects on laryngeal responsiveness [16] . In 2002, Politis et al. [7] reported that induction using propofol at doses ranging between 2.5 and 4 mg/kg yielded ideal intubating conditions than those obtained using sevoflurane with other adjuvants.

In the present study, the use of sevoflurane alone resulted in 66.7% incidence of acceptable intubating conditions, of which 50% being excellent conditions. Weber et al. [17] , Aouad et al. [18] , Verghese et al. [19] , Lerman et al. [14] , and Devys et al. [20] evaluated sevoflurane alone for intubation. The weighted average of acceptable and excellent intubating conditions was 49 and 41%, respectively. The addition of fentanyl to sevoflurane did not yield much improvement in the intubating conditions as the incidence of acceptable and excellent conditions was 63.3 and 46.7%, respectively, and this was in agreement with the findings of Plastow et al. [21] , who reported that fentanyl has no significant influence over the speed and quality of sevoflurane induction.

Deciding when to perform laryngoscopy can be based on induction time, end-tidal anesthetic concentration, physical examination, or changes in the blood pressure, HR, or respiratory pattern. Longer exposure time of a high inspired sevoflurane concentration results in a higher concentration of the agent in the brain and subsequently a deeper level of anesthesia. Although the presence of physical examination end points, such as constricted centralized pupils, may frequently result in successful tracheal intubation, such end points are considerably more subjective than induction time, and many patients may be ready for laryngoscopy before the clinical criteria are met [7] . With respect to the induction time, there was a statistically significant reduction in group 3 (group SP) than in group 1 (group S) and group 2 (group SF), with P value less than 0.001. Our results are in agreement with those by Hwaites et al. [22] ; they found that the induction time with sevoflurane was shorter compared with that with propofol. This difference was not of great clinical significance [22] . In addition, Kamal et al. [23] found that the time to complete induction with the use of propofol was more rapid with statistically significant differences when compared with the sevoflurane induction time, 42.9 ± 5.1 and 133.3 ± 25.8s, respectively. However, Politis et al. [7] found that the induction time of sevoflurane to achieve 80% successful intubation was 187 (153-230) s, but excellent intubating conditions (≥ 80%) were achieved only when adequate adjuvant was added. In 1997, Paris et al. [24] explained why sevoflurane induction times were not so rapid, despite of its low solubility. The maximum concentration of the agent that could be delivered by various vaporizers was sevoflurane 8%. This corresponds to ~4 minimum alveolar concentration (MAC), which suggests that part of the limitation of induction time with sevoflurane may be a function of the vaporizer. In addition, sevoflurane is a respiratory depressant at concentrations greater than 1.4 MAC; hence, at deeper planes of anesthesia, uptake of the vapor may be slow, which may make the induction relatively slow [24] . In 2002, Politis et al. [7] showed that the persistence of spontaneous ventilation at the time of laryngoscopy was associated with poor intubating conditions. In nearly all the regimens recommended for intubation without muscle relaxants, assisted ventilation was used. The continuous delivery of sevoflurane through assisted ventilation provided a greater depth of anesthesia at the time of intubation [7] .

In the present study, the shortest recovery time was in group 1 (group S), whereas the longest was in group 3 (group SP). These readings were statistically significant with P value less than 0.001. Our results are in agreement with those by Smith et al. [25] , Sury et al. [26] , Hwaites et al. [22] , Tang et al. [27] , and Kamal et al. [23] . Intravenous propofol was found to have a highly significant and more prolonged time to respond to commands and eye-opening compared with the sevoflurane group (268.8 ± 86.8s) in the study by Kamal et al. [23] .

In 1995, Smith et al. [25] concluded that the rapid recovery with sevoflurane can be attributed to its low blood-gas solubility. In 1997, Hwaites et al. [22] related the difference in the recovery time to the residual sedative effect of propofol; however, this difference of only 2 min was probably of little, if any, clinical significance. In 2002, Kamal et al. [23] concluded that, although induction times with sevoflurane were shorter compared with propofol, this difference was not of great clinical significance as it was compensated by the rapid recovery characteristics of sevoflurane.

With respect to the hemodynamic changes in the present study, there was a statistically significant reduction in the HR and SBP recorded 6 min after endotracheal intubation in group 2 (group SF) than in group 3 (group SP) and group 1 (group S), with P value less than 0.001. Increasing the depth of anesthesia by administering increments of fentanyl improves the hemodynamic response to endotracheal intubation, with fentanyl effect lasting up to 6 min after endotracheal intubation provided atropine is given at induction. Dahlgren and Messeter [28] , Billard et al. [29] , and Srivastava et al. [30] reported that fentanyl effectively blunts the hemodynamic response to intubation and reduces some aspects of the stress response to induction of anesthesia. Because increasing anesthetic depth correlates poorly with decreasing hemodynamic variables in the sevoflurane and propofol study groups. In 1994, Lerman et al. [31] concluded that it was difficult to use alterations in HR or SBP to decide when a patient has reached adequate depth for intubation. In addition, Kern et al. [32] concluded that the hemodynamic markers of readiness for endotracheal intubation may not be useful with sevoflurane because HR and SBP change minimally and may even increase during sevoflurane induction.


  Conclusion Top


Endotracheal intubation without neuromuscular blocking agents in pediatric patients undergoing adenotonsillectomy can be achieved with no serious respiratory or hemodynamic adverse events by adding propofol (3 mg/kg) or fentanyl (3 mcg/kg) to sevoflurane. Propofol is suitable for rapid induction as it offers the shortest induction time with 83.3% excellent intubating conditions, whereas fentanyl blunts the stress response to intubation with 46.7% excellent intubating conditions.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

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Taha SK, Siddik-Sayyid SM, Aouad MT, Abdallah FW, Al Alami AA, Kanazi GE. Propofol 2 mg/kg is superior to propofol 1 mg/kg for tracheal intubation in children during sevoflurane induction. Acta Anaesthesiol Scand 2011; 55:535-538.  Back to cited text no. 15
    
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