|Year : 2017 | Volume
| Issue : 1 | Page : 34-40
Propofol, remifentanil, and low-dose atracurium besylate versus sevoflurane and fentanyl for bronchoscopy in children: a randomized-controlled trial
Amr Ahmed Kasem, Fekry Elbokl, Hany Elzahaby, Hisham Elazzazy, Ahmed Elsayed, Amr Ahmed Kasem
ICU & Pain Management, Ain Shams University, Cairo, Egypt
|Date of Web Publication||3-Aug-2018|
Amr Ahmed Kasem
Masr Elgedida, Lecturer of Anesthesia, ICU & Pain ManagementAin Shams University, Cairo
Source of Support: None, Conflict of Interest: None
Objective The aim of this study was to compare the use of remifentanil and propofol infusion plus low-dose atracurium besylate technique with the commonly used inhalational technique using sevoflurane with fentanyl for children undergoing bronchoscopy for foreign body (FB) removal.
Patients and methods This prospective randomized-controlled trial was conducted at Ain Shams University Hospitals. Sixty children aged 1–5 years planned for elective or emergency FB removal by bronchoscopy were included in the current study. The recruited children were assigned randomly into two groups: group I: total intravenous anesthesia (TIVA group) (remifentanil, propofol, and low-dose atracurium besylate); group II: volatile induction and maintenance of anesthesia (VIMA) (sevoflurane and fentanyl). Intraoperative and postoperative measurements and complications were recorded.
Results There was no statistically significant difference between both groups in induction time, bronchoscopy time, time for discharge from the recovery room, and emergence time between both groups. The number of bronchoscopy attempts, interruptions of bronchoscopy, and body movements were significantly higher in the VIMA group than the TIVA group; satisfaction with surgery was greater in the TIVA group than the VIMA group. There was no difference between groups in the incidence of complications, except for postoperative agitation, with a higher incidence in the VIMA group compared with the TIVA group.
Conclusion The use of 0.1 µg/kg/min remifentanil-propofol TIVA, plus a small dose (0.25 mg/kg) of atracurium besylate at induction, provided stable hemodynamics, better surgeon satisfaction, and less postoperative agitation compared with sevoflurane 2% in 100% oxygen plus fentanyl 1 µg/kg in children undergoing tracheobronchial FB removal during rigid bronchoscopy.
Keywords: atracurium, bronchoscopy, children, propofol, sevoflurane
|How to cite this article:|
Kasem AA, Elbokl F, Elzahaby H, Elazzazy H, Elsayed A, Kasem AA. Propofol, remifentanil, and low-dose atracurium besylate versus sevoflurane and fentanyl for bronchoscopy in children: a randomized-controlled trial. Ain-Shams J Anaesthesiol 2017;10:34-40
|How to cite this URL:|
Kasem AA, Elbokl F, Elzahaby H, Elazzazy H, Elsayed A, Kasem AA. Propofol, remifentanil, and low-dose atracurium besylate versus sevoflurane and fentanyl for bronchoscopy in children: a randomized-controlled trial. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2019 Jun 18];10:34-40. Available from: http://www.asja.eg.net/text.asp?2017/10/1/34/238452
| Introduction|| |
Foreign body (FB) aspiration is a life-threatening situation, with children younger than 5 years of age being at greater risk. Early recognition and rapid intervention for FB aspiration are imperative to decrease the possibly severe and occasionally fatal complications . Under general anesthesia, otorhinolaryngologists or thoracic surgeons use rigid bronchoscopy as the first-choice management for tracheal or bronchial FB removal. As a result of sharing the airway with the surgeon, the anesthetic management is perplexing as satisfactory depth of anesthesia and adequate ventilation are required in spite of repeated trials of bronchoscopy . Fentanyl, alfentanil, sufentanil, and remifentanil are powerful opioids commonly used to reduce the pressor reaction to intubation and bronchoscopy. Newly administered opioid, remifentanil, is a 4-amiliodopiperidine derivative that possesses specific μ-opioid receptor agonist properties, with effectiveness similar to that of fentanyl. However, unlike any other opioid, remifentanil has an ester linkage in its molecular structure. Therefore, it has a very short duration of action because of the rapid breakdown of the ester linkage by nonspecific plasma and tissue esterases into inactive metabolites . Total intravenous anesthesia (TIVA) using opioids combinds with propofol is a striking anesthetic technique in pediatric procedures because of their properties and synergistic effects . Low-dose atracurium besylate 0.25 mg/kg is used to enable airway instrumentation, manual ventilation and to reduce the occurrence of intraoperative complications such as laryngospasm, at the same time not significantly adding to the procedure time . The aim of this study was to compare the use of remifentanil and propofol infusion plus low-dose atracurium besylate technique with the commonly used inhalational technique using sevoflurane with fentanyl for children undergoing bronchoscopy for FB removal.
| Patients and methods|| |
This prospective randomized-controlled trial was conducted at Ain Shams University Hospitals from February 2012 to May 2014, after being approved by the local hospital ethics and research committee. Sixty children aged between 1 and 5 years planned for elective or emergency FB removal by bronchoscopy were included in the current study. The purpose and procedures of this study were explained to all parents and a written informed parental consent was obtained before the procedure. All participants were admitted to the Otorhinolaryngology or the Thoracic Surgery Department for the bronchoscopy procedure in Ain Shams University Hospitals. All recruited children had a physical status of I or II as classified by the American Society of Anesthesiologists (ASA). Children with heart and lung disease, airway abnormalities, neurological disorders, allergies to the study drugs, and coagulopathy were excluded from the study. Before induction of anesthesia and under complete aseptic conditions using 70% alcohol, a 22- or a 24-G venous cannula was inserted using EMLA cream 5% (EMLA cream; AstraZeneca, Cambridge, UK) 20 min before insertion. All children were administered intravenous atropine 0.01 mg/kg and intravenous dexamethasone 0.2 mg/kg as a prophylactic step to minimize postoperative nausea, vomiting, and airway edema. Randomization was performed using a computer-generated system. The random categorization was written on duplicate sheets of paper, placed in closed opaque envelopes, and given to an individual who is not involved in the study. Group distribution was determined preoperatively if the participant fulfilled the study criteria. The recruited children were assigned randomly into two groups using a computer-generated random numbers table: group I: TIVA group (remifentanil, propofol, and low-dose atracurium besylate): remifentanil infusion (Ultiva; GlaxoSmithKline Manufacturing, Parma, Italy) was started 8 min before induction of anesthesia at a dose of 0.05–0.1 μg/kg/min and was maintained throughout the procedure . Propofol 1% 2.5 mg/kg (Propofol; Fresenius Kabi, Bad Homburg, Germany) was started slowly, preceded by lidocaine 1% 1 ml (Lidocaine 2%; Adco, Cairo, Egypt), which was administered to decrease the pain caused by propofol injection . Propofol infusion was continued at a dose of 10 mg/kg/h in the first 10 min, 8 mg/kg/h in the next 10 min, and 6 mg/kg/h until the end of the procedure. Atracurium besylate 10 mg/ml ampoules (Tracrium; GlaxoSmithKline Manufacturing) 0.25 mg/kg were administered before intubation. Top-up doses of 0.1 mg/kg were administered if the train of four (TOF) ratio was at least 0.5 . Group II: volatile induction and maintenance of anesthesia (VIMA) (sevoflurane and fentanyl). Sevoflurane (Sevorane; Abbott Laboratories, Illinois, USA) was used to induce anesthesia with a vital capacity breath of 8% sevoflurane from a primed circle circuit with 8% sevoflurane in 100% oxygen; maintenance in this group was performed with sevoflurane value of 2% in 100% oxygen. Fentanyl (Fentanyl; Hameln Pharmaceuticals Ltd, Gloucester, UK) 1 μg/kg intravenously was administered after induction of anesthesia. In both groups, ventilation was sustained manually through the side port of the bronchoscope to maintain visible chest expansion. Interruption of the procedure for ventilation was performed if SpO2 was less than 80% or bradycardia was less than 20% of the starting heart rate (HR). Ventilation was performed using mask ventilation to increase SpO2 to 98–100%. At the end of the procedure, an appropriate-size endotracheal tube was inserted and the children were ventilated manually until extubating criteria were fulfilled. Extubation was performed when there was: (a) spontaneous breathing after reversal using neostigmine 0.05 mg/kg and atropine 0.0.1 mg/kg when the TOF ratio was greater than 0.5; (b) vigorous movement of all limbs; (c) facial grimacing. (d) hemodynamic stability; (e) presence of the gagging reflex.
The mean arterial blood pressure (MAP), HR, peripheral oxygen saturation (SpO2), temperature, and respiratory rate were monitored continuously and recorded at 5-min intervals during the study period, along with recording of events such as body movement, numbers of interruptions for ventilation (if SpO2 was <80% or HR was <20% of baseline HR). These were all measured using DragerDatascope Mindray DPM4 Patient Monitorm (Mindray, Shenzhen, China). Degree of neuromuscular blockade by the TOF ratio using TOF-Watch SX acceleromyography (Organon Ltd, Dublin, Ireland), induction time, surgical time, emergence time (time from stoppage of anesthetics to extubation), and time to discharge from the recovery room were recorded. Number of bronchoscopy attempts, number of interruption of bronchoscopy for ventilation, and types of FBs were all recorded. Surgeon satisfaction was measured on a scale of 1 to 10. Complications such as laryngospasm, hypoxemia (SpO2<92%), postoperative agitation, and ICU admission were recorded if any.
Children were observed for recovery criteria using Modified Aldrete Postanesthetic Recovery Score and were discharged when a score of 9 or more was reached . Any complications such as nausea and vomiting were also recorded. Pain control was achieved using paracetamol 30–40 mg/kg suppository 1–2 times/day and additional intravenous doses of morphine 0.05–0.1 mg/kg were administered in case of inadequate analgesia, especially in the recovery room.
Microsoft Access was used for statistical analysis, interpretation, dissemination of the results, and data entry, and then an analysis was carried out using the Statistical Package for the Social Sciences (SPSS) for Windows (version 13.0; SPSS Inc., Chicago, Illinois, USA). Numerical data were presented as mean (SD), whereas categorical data were presented as number of cases (%). Variables with a normal distribution were analyzed using Student’s t-test, whereas non-normally distributed variables were analyzed using the Mann–Whitney rank sum test. Categorical data were analyzed using Fisher’s exact test. Hemodynamic responses were measured by the repeated analysis of variance test to detect differences in the same patient over more than 2 measurements. A P-value of less than 0.05 was considered statistically significant.
| Results|| |
There was no significant difference among both groups in age, sex, weight, and ASA status ([Table 1]). There was no statistically significant difference in induction time, bronchoscopy time, time for discharge from the recovery room, and emergence time between both groups ([Table 2]).
|Table 2 Induction time, emergence time, recovery time, and bronchoscopy duration|
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The number of bronchoscopy attempts (11 in the VIMA group vs. six in the TIVA group), interruptions of bronchoscopy (nine in the VIMA group vs. four in the TIVA group), and body movements (eight in the VIMA group vs. 0 in the TIVA group) were significantly higher in the VIMA group than the TIVA group. (P=0.286, 0.157, and 0.063, respectively).
Surgeon satisfaction was greater in the TIVA group than the VIMA group (P<0.001) ([Table 3]). There was no statistically significant difference between groups in the types of FB ([Table 4]). There was no difference between groups in the incidence of complications, except for postoperative agitation, with a higher incidence in the VIMA group (four cases) compared with the TIVA group (0 cases) (P=0.038) ([Table 5]).
Analysis of variance showed significant differences between both groups in HR across all time intervals (P<0.001), with the TIVA group showing lower values than the VIMA group, except at baseline. However, at baseline, 1, 3, and 5 min after induction, HR was significantly higher than at 10, 20, and 25 min after induction within each group. MAP was significantly lower in the TIVA group than the VIMA group at 1, 3, 5, 10, and 25 min ([Table 6]) (P=0.042, 0.011, 0.016, 0.017, and 0.013, respectively), with no difference at baseline, immediately after induction, and at 20 min. Within each group, the values for MAP were higher at baseline, immediately after induction, and 10, 20, and 25 min than at 1, 3, and 5 min ([Table 7]).
SpO2 was maintained uneventfully throughout the procedure, with no statistically significant difference between both groups. The lowest recorded value was at 10 min and the mean SpO2 for groups I and II was 89.00±7.30 and 87.21±6.51, respectively ([Table 8]). There was no significant change in temperature between and within both groups throughout the procedure ([Table 9]). Degree of neuromuscular blockade as measured by the T4/T1 ratio was significantly lower in the TIVA group than the VIMA group at all time points ([Table 10]).
| Discussion|| |
This study shows that TIVA provided better surgeon satisfaction with less postoperative agitation, better values of HR, MAP, and degree of muscle relaxation compared with the VIMA technique. The incidence of postoperative nausea and vomiting was higher in the VIMA group than the TIVA group despite the fact that all children had received 0.2 mg/kg dexamethasone intravenously before induction; one possible explanation for this could be the combined antiemetic effect of propofol and dexamethasone in the TIVA group. Also, the incidence of postoperative agitation was higher in the VIMA group compared with the TIVA group.
Shen and colleagues reported that there is no proof for the superiority of any specific anesthetic procedure during rigid bronchoscopy for FB removal in children. Although inhalation induction has been used in children for many years, leakages around the rigid bronchoscope and obstruction by a FB may cause inadequate depth of anesthesia and protraction of anesthesia induction . Moreover, They stated that the use of inhalation agents causes pollution in the operation room and requires high gas flow to achieve adequate ventilation. In the same study, they stated that contamination in the operation room and the need for high gas flows for ventilation are undesirable side effects of inhaled anesthetics. Liao et al. , in their study of tracheobronchial FB removal in children, used propofol and remifentanil infusion at a dose of 0.05–0.1 µg/kg/min for rigid bronchoscopy with spontaneous breathing; they found a high incidence of breath-holding, excitement, and desaturation. Similarly, Chen et al. , reported breath-holding and extra intraoperative body movement and a high incidence of disastrous FB removal in children who received TIVA with propofol and remifentanil at a dose of 0.1 µg/kg/min. One possible explanation for these poor results could be the use of remifentanil without a muscle relaxant; in our study, we administered a low dose 0.25 mg/kg atracurium besylate. Our study showed that marked hemodynamic instability was detected possibly because of the use of a more balanced anesthesia technique and a lower dose (0.1 µg/kg/min) of remifentanil. In contrast to our results, other investigators reported that with remifentanil infusion at a dose 0.2 µg/kg/min, hemodynamic stability was not achieved immediately after the bronchoscope was introduced . Fidkowski and colleagues found that even though spontaneous ventilation has certain advantages, including continuous ventilation during the technique, general anesthesia with muscle relaxation has characteristic advantages. As spontaneous respiration increases the risk of FB dislodgement and airway trauma during FB removal by the rigid bronchoscope, some otorhinolaryngologists and anesthesiologists favor controlled ventilation with a neuromuscular blocker .
Soodan and colleagues in a prospective clinical trial, compared spontaneous and controlled ventilation for removal of FB in children, one with suxamethonium and one with halothane; in their study, all children in the spontaneous ventilation group had to be converted to assisted ventilation because of either desaturation or inadequate depth of anesthesia. They also reported a higher frequency of coughing and clasping in the spontaneous ventilation group .
Ozturk et al.  reported that with the use of remifentanil and sevoflurane, there is no reduction in cough frequency in children undergoing fiberoptic bronchoscopy for bronchoalveolar lavage.
Park and colleagues noted that the high rate of agitation and excitement during induction and emergence from sevoflurane can be attributed to the central nervous system effects of sevoflurane or to the speedy emergence from anesthesia with sevoflurane. In the current study, we observed a statistically significant difference between both groups, with a higher incidence in the VIMA group than the TIVA group .
Limitations of our study included the lack of adequate muscle relaxation in the VIMA group, which can be overcome by adding a small dose of a nondepolarizing muscle relaxant. Also, There is a difficulty to maintain adequate therapeutic level of total intravenous agents propofol and remifentanil; this is because target-controlled infusion systems for the pediatric population are still in the experimental stage. Another limitation was that this study was carried out on patients classified as ASA I or II and between the ages of 1 and 5 years; thus, we cannot reliably extrapolate our conclusions to other subgroups. Finally, the small sample size may not have enabled the detection of adverse events that could occur with a low frequency.
Future study designs should include other patient groups such as ASA III and IV patients. Also, modifications should be made to the anesthetic technique, should they become available in the future, such as the addition of a nondepolarizing muscle relaxant to the volatile anesthetic technique, addition of a sedative-hypnotic to decrease postoperative agitation in patients anesthetized with sevoflurane, and utilizing target-controlled infusion systems.
| Conclusion|| |
The use of 0.1 µg/kg/min remifentanil-propofol TIVA, plus a small dose (0.25 mg/kg) of atracurium besylate at induction, provided stable hemodynamics, better surgeon satisfaction, and less postoperative agitation compared with sevoflurane 2% in 100% oxygen, plus fentanyl 1 µg/kg in children undergoing tracheobronchial FB removal during rigid bronchoscopy.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]