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Comparison of the Hemodynamic Responses with Laryngeal Mask Airway Vs Endotracheal Intubation in Adults Undergoing General Anes

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Comparison of the Hemodynamic Responses with Laryngeal Mask Airway Vs Endotracheal Intubation in Adults Undergoing General Anes JMEDS Comparison of the Hemodynamic Responses10.5005/jp-journals-10045-0060 with LMA vs Endotracheal Intubation ORIGINAL ARTICLE Comparison of the Hemodynamic Responses with Laryngeal Mask Airway vs Endotracheal Intubation in Adults undergoing General Anesthesia for Elective Surgeries 1Jithumol T Thomas, 2Sathyanarayana P Sankaranarayana, 3Muninarasimhiah Manjuladevi ABSTRACT How to cite this article: Thomas JT, Sankaranarayana SP, Manjuladevi M. Comparison of the Hemodynamic Responses Aim: The aim of this study was to compare the hemodynamic with Laryngeal Mask Airway vs Endotracheal Intubation in response between laryngoscopy with endotracheal intubation Adults undergoing General Anesthesia for Elective Surgeries. and laryngeal mask insertion. The study also compared imme- J Med Sci 2017;3(3):69-75. diate postoperative complications between laryngeal mask airway (LMA) and endotracheal intubation. Source of support: Nil Materials and methods: Fifty-five American Society of Conflict of interest: None Anesthesiologists (ASA) physical status I and II adult patients who underwent elective surgeries under general anesthesia were included in either group I—LMA or group II—endotracheal INTRODUCTION tube (ETT). Patients were induced with intravenous (IV) propofol, The choice of securing the airway during general anes- fentanyl, and atracurium. After intubation/insertion, patients were thesia often lies between endotracheal intubation and mechanically ventilated and isoflurane was used to maintain ade- insertion of the LMA. Though intubation has many quate level of anesthesia with N2O/oxygen mixture. Hemodynamic parameters were measured before induction and after insertion advantages including provision of a reliable airway and of the airway device every minute for the first 10 minutes and prevention of aspiration, it is not without complications. every 5 minutes after that for the first half hour following insertion These include airway trauma, physiological reflexes like of the airway device. hypoxia, tachycardia and hypertension, malposition, Results: A significant and longer increase in heart rate (HR) laryngospasm, narrowing, and increased airway resis- was noted after ETT intubation as compared with LMA group. tance as well as negative pressure pulmonary edema.1,2 However, a decrease in systolic, diastolic, and mean arterial The LMA offers a much less invasive way of main- pressures (SBP, DBP, and MAP) was noted after both LMA insertion and ETT intubation. The decrease was significantly taining the airway as it does not pass through the more in LMA group (p < 0.001). Complications of postoperative glottis but is placed over the glottis. It does not require sore throat and hoarseness of voice were also significantly instrumentation, i.e., use of the laryngoscope. It acts as more in ETT group. an intermediate between the ETT and the oropharyngeal Conclusion: Pressor responses might be of no clinical airway and offers some of the advantages of the ETT importance in the healthy, normotensive patients, but might while overcoming the disadvantages like stimulation of be harmful in patients with hypertension, aortic or cerebral the laryngopharyngeal reflex.2 This study aimed to deter- aneurysm, raised intracranial pressure, or other cardiovascular mine and compare the hemodynamic responses elicited diseases. In such cases, the attenuated response of the LMA might be desirable. Therefore, where appropriate, the use of by laryngoscopy and endotracheal intubation with that the LMA would be recommended in such patients to avoid the elicited by laryngeal mask insertion. The study also com- marked response produced by the ETT. pared the immediate postoperative complications of LMA Keywords: Endotracheal tube, Hemodynamic responses, and endotracheal intubation (laryngospasm, dental/ Intubation, Laryngeal mask airway, Randomized controlled airway trauma, postoperative sore throat, hoarseness of study. voice, dysphonia, dysarthria, dysphagia, postoperative nausea, and vomiting). 1 2 3 Resident, Professor, Associate Professor MATERIALS AND METHODS 1-3Department of Anesthesiology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India A prospective randomized controlled study was con- ducted on 110 ASA physical status I and II patients from Corresponding Author: Jithumol T Thomas, Resident Department of Anesthesiology, St. John's Medical College and both genders in the age group 18 to 50 years, scheduled Hospital, Bengaluru, Karnataka, India, Phone: +919632094554 for elective surgical procedures, of duration 1 to 2 hours e-mail: [email protected] under general anesthesia. Ethical clearance was sought The Journal of Medical Sciences, July-September 2017;3(3):69-75 69 Jithumol T Thomas et al from the Ethical and Research Committee of St. John’s bpm, an SBP and DBP increase of ≥15 mm Hg. Duration Medical College and Hospital and was granted. of intubation/insertion was defined as the time from the Exclusion criteria included patients who were obese, start of laryngoscopy/LMA insertion, until cuff inflation. pregnant, difficult intubation (Mallampati III and IV), h/o chronic obstructive pulmonary disease, h/o autonomic Monitoring neuropathy, patients undergoing head and neck surger- Heart rate and noninvasive blood pressure which ies, surgeries where prone positioning was required, and included SBP, DBP, and MAP were monitored throughout patients in whom more than one attempt at insertion of the study and recorded at the following time points. airway device was required • Preinsertion/intubation The patients were randomized via computer- • One minute after intubation or insertion of laryngeal generated table: mask Group I • : Airway was secured using LMA • Every minute after that for the first 10 minutes Group II • : Airway was secured using ETT • Every 5 minutes after that for the first half hour. Oxygen saturation and end-tidal CO were also Preoperative Assessment 2 monitored. All data were collected by the principal Preoperative evaluation of all the patients was performed investigator. with detailed history, physical examination including The data collected were coded and entered into height, weight, airway examination, and systemic exami- Statistical Package for the Social Sciences (SPSS) software nation. The basal HR and blood pressure were recorded version 17. prior to surgery. All the patients were kept nil per oral for Continuous variables were described using mean ± 8 hours. All patients were premedicated which includes standard deviation or median and interquartile range as ranitidine 150 mg on the night before surgery and also appropriate. Categorical variables were reported using 2 hours prior to surgery and Alprazolam 0.25 mg on the frequency and percentage. Changes in SBP, DBP, HR, and night before surgery with sips of water. Informed valid MAP over time in groups and by group were analyzed written consent for participation in the study was taken using repeated-measures analysis of variance. All the from all the patients. analyses were done using SPSS version 17. A p-value of < 0.05 was considered statistically significant. Intraoperative Assessment RESULTS Patients were randomly allocated into either group I (LMA) or group II (endotracheal intubation). Intravenous This study was done at St John’s Medical College over a access was obtained in all patients. In all selected patients, period of 2 years. All the patients who met the inclusion preinduction (baseline) SBP, DBP, MAP, pulse rate (HR), criteria were included in the study. In the LMA group, and oxygen saturation (SpO2) were recorded. Patients three patients were excluded, two patients who needed were preoxygenated with 100% O2 for at least 3 minutes. two attempts at insertion and one patient in whom Anesthesia induced with IV propofol 2 mg/kg, fentanyl LMA got displaced. In the ETT group, three patients 2 µg/kg, and atracurium 0.6 mg/kg was administered for were excluded as they needed more than one attempt mechanical ventilation. Patients were then ventilated for at intubation. Each group had a total of 55 participants 3 minutes before intubation/insertion. In the ETT group, for analysis. intubation of the trachea was attempted with a cuffed The two groups were comparable in terms of demo- tracheal tube (internal diameter 7.5 mm for women and graphic data as there were no significant differences 8.5 mm for men) using direct laryngoscopy. In the LMA between the two groups in terms of age, sex, and ASA group, the size 3/4 for women and size 4/5 for men were classification (p > 0.001; Table 1). chosen. Patients’ lungs were mechanically ventilated and Table 1: Demographic data minute volume set to maintain end-tidal CO2 at 30 to 35 mm Hg. Isoflurane was used to maintain adequate level LMA (n = 55) ETT (n = 55) p-value Mean age (years) 35.35 35.85 0.820 of anesthesia with N2O/oxygen mixture in 50%; 50% Sex volume ratio. The SBP, DBP, MAP, HR, and SpO2 were Male 34 32 0.697 measured before induction and after insertion of the Female 21 23 airway device every minute for the first 10 minutes and ASA 0.101 every 5 minutes for the first half hour following insertion I 40 47 of the airway device. Heart rate, SBP, and DBP responses II 15 8 were prospectively defined as an HR increase of ≥10 p-value < 0.05 is significant 70 JMEDS Comparison of the Hemodynamic Responses with LMA vs Endotracheal Intubation Graph 1: Comparison of HR between the two groups over Graph 2: Comparison of SBP between the two groups over 30 minutes after insertion 30 minutes after insertion
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