A randomised comparative study of dexmedetomidine and midazolam for sedation during awake fiberoptic intubation in laproscopic cholecystectomy patients
Background: Fiberoptic nasotracheal intubation is an effective method for the management of patients with difficult airways. An ideal sedation regimen would ensure patient’s comfort, attenuation of airway reflexes, patient’s co-ordination, haemodynamic stability and amnesia. It is critical for both the surgeon and the anesthesiologist to understand the physiologic consequences of laparoscopy and to work in cooperation to achieve a good surgical outcome.
Methods: Patients were randomly allocated to midazolam (MDZ) group (group 1) and dexmedetomidine (DEX) group (group 2). DEX patients received dexmedetomidine 1μg/kg, followed by an infusion of dexmedetomidine 0.1μg/kg/hr titrated to 0.7μg/kg/hr to achieve RSS ≥2. MDZ subjects received IV midazolam 0.05mg/kg with additional doses given to achieve a RSS ≥ 2.
Measurements: Pulse rate, systolic and diastolic blood pressures and SpO2 recorded during pre-oxygenation, one minute prior to introduction of fiberscope and then every minute for the following five minutes and beginning one minute before endotracheal intubation and then every minute until the endotracheal tube was secured, patient’s tolerance assessed on 5 point fiberoptic intubation score during fiberscopy and endotracheal intubation, total comfort score values assessed during pre-oxygenation, fiberscopy and endotracheal intubation and patient’s response to 24 hour post op questionnaire assessment were measured.
Results: DEX group patients were significantly more quiet and more harmonius during awake fiberoptic intubation (AFOI) than were the MDZ group patients. The DEX group patients were found to have a lower mean Heart Rate than the MDZ patients.Conclusions: Both dexmedetomidine and midazolam are effective for fibreoptic intubation. Dexmedetomidine allows better endurance, stable haemodynamic status and a patent airway.
Bergese SD, Candiotti KA, Bokesch PM, Zura A, Wisemandle W,Bekker AY. A Phase IIIb, randomized, double-blind, placebo-controlled, multicenter study evaluating the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation. Am J Ther. 2010;17(6):586-95.
Boyd BC,Sutter SJ. Dexmedetomidine sedation for awake fiberoptic intubation of patients with difficult airways due to severe odontogenic cervicofacial infections. J Oral Maxillofac Surg. 2011;69(6):1608-12.
Madhere M, Vangura D,Saidov A. Dexmedetomidine as sole agent for awake fiberoptic intubation in a patient with local anesthetic allergy. J Anesth. 2011;25(4):592-4.
Elsayed MM, Hanoura SE, Ewieda TM, Allam ME, Abdullah AA. Intubation outcome of patients with anticipated difficult intubation: A comparative study of dexmedetomidine versus sevoflurane as a sedative. Journal of American Science. 2012; 8(9): 43-8.
Bergese SD, Patrick Bender S, McSweeney TD, Fernandez S, Dzwonczyk R,Sage K. A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation. J Clin Anesth. 2010;22(1):35-40.
Kamibayashi T,Maze M. Clinical uses of alpha2 -adrenergic agonists. Anesthesiology. 2000;93(5):1345-9.
Hall JE, Uhrich TD, Barney JA, Arain SR,Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg. 2000;90(3):699-705.
Abdelmalak B, Makary L, Hoban J,Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clin Anesth. 2007;19(5):370-3.
Maroof M, M.Khan R, Jain D,Ashraf M. Dexmedetomidine is a useful adjunct for awake intubation. Canadian Journal of Anesthesia. 2005;52(7):776-7.
Jooste EH, Ohkawa S,Sun LS. Fiberoptic intubation with dexmedetomidine in two children with spinal cord impingements. Anesth Analg. 2005;101(4):1248.
Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA,Stanley TH. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology. 1990;73(5):826-30.
Chu KS, Wang FY, Hsu HT, Lu IC, Wang HM,Tsai CJ. The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation. Eur J Anaesthesiol. 2010;27(1):36-40.
Ambuel B, Hamlett KW, Marx CM,Blumer JL. Assessing distress in pediatric intensive care
environments: the COMFORT scale. J Pediatr Psychol. 1992;17(1):95-109.
Grant SA, Breslin DS, MacLeod DB, Gleason D,Martin G. Dexmedetomidine infusion for sedation during fiberoptic intubation: a report of three cases. J Clin Anesth. 2004;16(2):124-6.
Avitsian R, Lin J, Lotto M,Ebrahim Z. Dexmedetomidine and awake fiberoptic intubation for possible cervical spine myelopathy: a clinical series. J Neurosurg Anesthesiol. 2005;17(2):97-9.
Bloor BC, Ward DS, Belleville JP,Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992;77(6):1134-42.
Martin E, Lehot JJ, Manikis P, et al. Dexmedetomidine: a novel agent for patients in the intensive care setting [abstract]. Int Care Med 1999; 25(suppl): S160..
Belleville JP, Ward DS, Bloor BC,Maze M. Effects of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology. 1992;77(6):1125-33.
Talke P, Richardson CA, Scheinin M,Fisher DM. Postoperative pharmacokinetics and sympatholytic effects of dexmedetomidine. Anesth Analg. 1997;85(5):1136-42.
Ebert T,Maze M. Dexmedetomidine: another arrow for the clinician's quiver. Anesthesiology. 2004;101(3):568-70.
Venn RM, Bradshaw CJ, Spencer R, Brealey D, Caudwell E, Naughton C, et al. Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia. 1999;54(12):1136-42.
Jorden VS, Pousman RM, Sanford MM, Thorborg PA,Hutchens MP. Dexmedetomidine overdose in the perioperative setting. Ann Pharmacother. 2004;38(5):803-7.
Venn RM,Grounds RM. Comparison between dexmedetomidine and propofol for sedation in the intensive care unit: patient and clinician perceptions. Br J Anaesth. 2001;87(5):684-90.
Peden CJ, Cloote AH, Stratford N,Prys-Roberts C. The effect of intravenous dexmedetomidine premedication on the dose requirement of propofol to induce loss of consciousness in patients receiving alfentanil. Anaesthesia. 2001;56(5):408-13.