A comparative study of the effect of low-dose epinephrine and ketamine on rapid-sequence endotracheal intubation by the priming dose method of cisatracurium in patients under general anesthesia

Saryazdi, Hamid Hajigholam; Honarmand, Azim; Nazemroaya, Behzad; Afshar, Pouyan Naderi

A comparative study of the effect of low-dose epinephrine and ketamine on rapid-sequence endotracheal intubation by the priming dose method of cisatracurium in patients under general anesthesia

Authors

¹ Department of Anesthesiology, School of Medicine, Anesthesiology and Critical Care Research Center, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

² Department of Anesthesiology, School of Medicine, Anesthesiology and Critical Care Research Center, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

³ Department of Anesthesiology, School of Medicine, Anesthesiology and Critical Care Research Center, Al-Zahra Hospital, Feiz Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

⁴ Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: Low-dose ephedrine and ketamine may accelerate the onset time of action of neuromuscular blocking agents. We studied the effect of ephedrine and ketamine and cisatracurium priming on endotracheal intubation conditions and the onset time of action of cisatracurium.
Materials and Methods: The study was a double-blind clinical trial performed on American Society of Anesthesiologists (ASA) class 1 and 2 patients, who were candidates for general anesthesia. In total, 120 patients were entered into the study and were divided into 4 groups, E, K, E + K, and N. The first group was given 70 mcg/kg ephedrine (E group), the second group was given 0.5 ml/kg ketamine (K group), the third group was given the same amount of ketamine plus ephedrine (E + K group), and the fourth group was given the same volume of normal saline (control group); a single dose of 0.1 mg/kg cisatracurium was given, and intubating conditions were evaluated at 60 seconds after cisatracurium administration.
Results: The mean Cooper score based on the response to laryngoscopy, the position of the vocal cords, and the movement of the diaphragm of patients in the control group with a mean of 2.53 ± 1.07 was significantly lower than in the three groups of E, K, and E + K with the means of 4.47. 1.17, 4.53 ± 1.14, and 7.63 ± 1.42, respectively (P value < 0.001). In the (E + K) group, it was significantly higher than in the two other drugs alone (P value < 0.001). The two groups of E and K alone were not significantly different from each other (P value = 0.997). The means of hemodynamic parameters were not significantly different in any of the groups (P value > 0.05).
Conclusion: According to the results of the present study, the use of low-dose ephedrine and ketamine alone can improve intubation conditions. In addition, the combined use of these drugs not only had any Positive effect on patients' hemodynamic parameters but also greatly improved intubation conditions.

Keywords

References

1.	Ibrahim L, Diazgranados N, Luckenbaugh DA, Machado-Vieira R, Baumann J, Mallinger AG, et al. Rapid decrease in depressive symptoms with an N-methyl-d-aspartate antagonist in ECT-resistant major depression. Prog Neuropsychopharmacol Biol Psychiatry 2011;35:1155-9.
2.	Hegazy MA, Hegazi RA, Hendawy SR, Hussein MS, Abdellateef A, Awad G, et al. Cardiac preconditioning effect of ketamine–dexmedetomidine versus fentanyl–propofol during arrested heart revascularization. Anesth Essays Res 2020;14:312-20. [Full text]
3.	Shiroma PR, Velit-Salazar MR, Vorobyov Y. A systematic review of neurocognitive effects of subanesthetic doses of intravenous ketamine in major depressive disorder, post-traumatic stress disorder, and healthy population. Clin Drug Investig 2022;42:549-66.
4.	Abram SV, Roach BJ, Fryer SL, Calhoun VD, Preda A, van Erp TG, et al. Validation of ketamine as a pharmacological model of thalamic dysconnectivity across the illness course of schizophrenia. Mol Psychiatry 2022;27:2448-56.
5.	5. Girish K, Gangadhar BN, Janakiramaiah N. Ect in neurological counditions. Indian J Psychiatry 2002;44:228-239.
6.	Andrade C, Shah N, Tharyan P, Reddy MS, Thirunavukarasu M, Kallivayalil RA, et al. Position statement and guidelines on unmodified electroconvulsive therapy. Indian J Psychiatry 2012;54:119-33. [Full text]
7.	Anderson TA, Fuzaylov G. Perioperative anesthesia management of the burn patient. Surg Clin North Am 2014;94:851-61.
8.	Hovgaard HL, Juhl-Olsen P. Suxamethonium-induced hyperkalemia: A short review of causes and recommendations for clinical applications. Crit Care Res Pract 2021;2021:6613118.
9.	Palmer BF. Regulation of potassium homeostasis. Clin J Am Soc Nephrol 2015;10:1050-60.
10.	Stone WA, Beach TP, Hamelberg W. Succinylcholine-danger in the spinal cord injured patient. Anesthesiology 1970;32:168-9.
11.	Tobey RE. Paraplegia succinylcholine and cardiac arrest. Anesthesiology 1970;32:359-64.
12.	Mortada H, Altuawijri I, Alhumsi T. The use of a single-piece bone flap for cranial reshaping in anterior craniosynostosis patients: Clinical experience and a description of a novel technique. Maxillofac Plast Reconstr Surg 2022;44:2.
13.	Kachaeva EV, Ushakov IB, Shenkman BS. [Activity of the skeletal muscle proteolytic systems during functional unloading]. Usp Fiziol Nauk 2012;43:3-20.
14.	Andel H, Markstaller K. Rapid-sequence-Narkoseeinleitung und Intubation – das Timing-Prinzip [Rapid sequence induction and intubation-the timing principle]. Anaesthesist 2019;68:46-7.
15.	Consensus Conference. Electroconvulsive therapy. JAMA 1958;254:2103-8.
16.	Thomas ET. Circulatory collapse following succinylcholine: Report of a case. Anesthesia Analg 1969;48:333-7.
17.	Marco LA, Randels PM. Succinylcholine drug interaction electroconvulsive therapy. Biol Psychiatry 1979;14:433-45.
18.	Kisor DF, Schmith VD. Clinical pharmacokinetics of cisatracurium besilate. Clin Pharmacokinet 1999;36:27-40.
19.	Bryson HM, Faulds D. Cisatracurium besilate. A review of its pharmacology and clinical potential in anaesthetic practice. Drugs 1997;53:848-66.
20.	Belmont MR, Lien CA, Quessy S, Abou-Donia MM, Abalos A, Eppich L, et al. The clinical neuromuscular pharmacology of 51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology 1995;82:1139-45.
21.	Pinard AM, Donati F, Martineau R, Denault AY, Taillefer J, Carrier M. Magnesium potentiates neuromuscular blockade with cisatracurium during cardiac surgery. Can J Anaesth 2003;50:172-8.
22.	Brull SJ, Meistelman C. Pharmacology of neuromuscular blocking drugs. In: Gropper MA, editor. Miller's Anesthesia. 9^th ed. Philadelphia, PA: Elsevier; 2020. p. 2751-93.
23.	Mirinejad M, Azarfarin R, Asl AA. Cisatracurium in cardiac surgery--continuous infusion vs. bolus administration. Middle East J Anaesthesiol 2007;19:563-72.
24.	Dear GJ, Harrelson JC, Jones AE, Johnson TE, Pleasance S. Identification of urinary and biliary conjugated metabolites of the neuromuscular blocker 51W89 by liquid chromatography/mass spectrometry. Rapid Commun Mass Spectrom 1995;9:1457-64.
25.	Welch RM, Brown A, Ravitch J, Dahl R. The in vitro degradation of cisatracurium, the R, cis-R'-isomer of atracurium, in human and rat plasma. Clin Pharmacol Ther 1995;58:132-42.
26.	Weindlmayr-Goettel M, Kress HG, Hammerschmidt F, Nigrovic V. In vitro degradation of atracurium and cisatracurium at pH 7.4 and 37 degrees C depends on the composition of the incubating solutions. Br J Anaesth 1998;81:409-14.
27.	Kisor DF, Schmith VD, Wargin WA, Lien CA, Ornstein E, Cook DR. Importance of the organ-independent elimination of cisatracurium. Anesth Analg 1996;83:1065-71.
28.	Cooper R, Mirakhur RK, Clarke RSJ, Boules Z. Comparison of intubating condition after administration of ORG – 9426 (Rocuronium) and suxamethonium. Br J Anaesth 1992;69:269-73.
29.	Labrada DA, Vanegas GD, Costa OG. Rocuronium versus succinylcholine in the obese patient treated with laparoscopic bariatric surgery. Rev Cubana Anestesiol Reanimación 2019;18:1-14.
30.	Shahryari H, Alavi S M, Ferasat Kish R, Motamed N, Karimi M. Comparison of propofol effect with Ketamine for sedation induction in pediatric patients who underwent cardiol catheterization. Iran South Med J 2010;13:16-23.
31.	Deepika K, Kenaan CA, Bikhazi GB, Martineau DB. Influence of the priming technique on pharmacodynamics and intubating conditions of cisatracurium. J Clin Anesth 1999;11:572-5.
32.	Mak PH, Irwin MG. The effect of cisatracurium and rocuronium on cisatracurium precurarization and the priming principle. J Clin Anesth 2004;16:83-7.
33.	Yusuf AH, Okeke CI, Merah NA, Olatosi JO, Desalu IS, Kushimo OT. Comparison of suxamethonium and priming with atracurium for rapid sequence orotracheal intubation in a Nigerian adult population. Niger Postgrad Med J 2006;13:313-8.

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