Intubating conditions and hemodynamic changes during awake fiberoptic intubation using fentanyl with ketamine versus dexmedetomidine for anticipated difficult airway: a randomized clinical trial
Condições para intubação traqueal e alterações hemodinâmicas durante intubação com fibroscopia. Estudo clínico randomizado versus dexmedetomidina
Background and objectives
: Awake fiberoptic intubation (AFOI) is usually performed in patients with an anticipated difficult airway. Various sedation regimens are used during AFOI, however, most of them cause respiratory depression. The present study aims to compare the effectiveness of fentanyl with ketamine versus dexmedetomidine in search of a better sedation regimen which would achieve desirable intubating conditions and hemodynamic stability without causing respiratory depression.
This is a single centered randomized, double-blind clinical trial. Patients of both sexes between age 18-55 years and ASA class I-II with an anticipated difficult airway were randomly divided into two groups of thirty each. Group FK patients received intravenous fentanyl and ketamine, and group DX patients received dexmedetomidine, until Ramsay sedation scale ≥ 2. Heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO2), respiratory rate (RR), endoscopy time, intubation time, first end-tidal carbon dioxide (ETCO2) after intubation, endoscopist satisfaction score, and patient discomfort score were recorded during the study period. The level of recall was assessed on the next postoperative day.
Endoscopist satisfaction score was better in group DX patients (p < 0.05). There was a smaller variation in HR and MBP from baseline with dexmedetomidine compared to fentanyl with ketamine. First ETCO2 after intubation was higher in group FK patients (p < 0.05). No significant difference was found in patient discomfort score, intubation time, RR, SpO2, and level of recall of the event.
The use of dexmedetomidine in AFOI provides better intubating conditions and hemodynamic stability compared to fentanyl with ketamine.
1 M. Popat Practical Fiberoptic Intubation (1st edition), Butterworth-Heinemann Publishers, Oxford (2001), pp. 75-95
2 L. Mildh, M. Taittonen, K. Leino, et al. The effect of low-dose Ketamine on Fentanyl-induced respiratory depression. A double blinded randomized controlled trial J Clin Anesth, 53 (1998), pp. 965-970
3 C.C. Yeh, C.T. Wu, B.K. Huh, et al. Premedication with intravenous low-dose ketamine suppresses fentanyl-induced cough J Clin Anesth, 19 (2007), pp. 53-56
4 S.D. Bergese, B. Khabiri, W.D. Roberts, et al. Dexmedetomidine for conscious sedation in difficult awake fibre optic intubation cases J Clin Anesth, 19 (2007), pp. 141-146
5 S.D. Bergese, S. Patrick Bender, T.D. McSweeney, et al. A comparative study of Dexmedetomidine with Midazolam and Midazolam alone for sedation during elective awake fibre optic intubation J Clin Anesth, 22 (2010), pp. 35-40
6 T. Kamibayashi, M. Maze Clinical uses of alpha2-adrenergic agonists Anesthesiol, 93 (2000), pp. 1345-1349
7 T.J. Ebert, J.E. Hall, J.A. Barney, et al. The effects of increasing plasma concentrations of Dexmedetomidine in humans Anesthesiol, 93 (2000), pp. 382-394
8 Sc. Dhasmana Nasotracheal fiberoptic intubation: Patient comfort, intubating conditions and hemodynamic stability during conscious sedation with different doses of Dexmedetomidine J Maxillofac Oral Surg, 13 (2014), pp. 53-58
9 M.A. Ramsay, T.M. Savege, B.R. Simpson, et al. Controlled sedation with alphaxalone-alphadolone Br Med J, 2 (1974), pp. 656-659
10 S. Masoud, S. El-Tohamy, A. Amin Dexmedetomidine versus midazolam/propofol or midazolam/Fentanyl for conscious sedation during awake fiberoptic intubation Ain-Shams J Anaesthesiol, 6 (2013) 30–30
11 S.K. Sinha, B. Joshiraj, L. Chaudhary, et al. A comparison of Dexmedetomidine plus Ketamine combination with Dexmedetomidine alone for awake fiberoptic nasotracheal intubation: A randomized controlled study J Anaesthesiol Clin Pharmacol, 30 (2014), pp. 514-519
12 A. Ovassapian, M. Tuncbilek, E.K. Weitzel, et al. Airway management in adult patients with deep neck infections: a case series and review of the literature Anesth Analg, 100 (2005), pp. 585-589
13 J.L. Apfelbaum, C.A. Hagberg, R.A. Caplan, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway Anesthesiology, 118 (2013), pp. 251-270
14 J.E. Hall, T.D. Uhrich, J.A. Barney, et al. Sedative, amnestic, and analgesic properties of small – dose dexmedetomidine infusions Anesth Analg, 90 (2000), pp. 699-705
15 H.H. Liu, T. Zhou, J.Q. Wei, et al. Comparison between remifentanil and Dexmedetomidine for sedation during modified awake fiberoptic intubation Exp Ther Med, 9 (2015), pp. 1259-1264
16 S.D. Bergese, R. Dzwonczyk A comparative study of Dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fibre optic intubation J Clin Anesth, 22 (2010), pp. 35-40
17 B. Abdelmalak, L. Makary, J. Hoban, et al. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway J Clin Anesth, 19 (2007), pp. 370-373
18 S. Rajan, R. Talukdar, P. Tosh, et al. Hemodynamic Responses and Safety of Sedation Following Premedication with Dexmedetomidine and Fentanyl during Fiberoptic-assisted Intubation in Patients with Predicted Difficult Airway Anesth Essays Res, 12 (2018), pp. 11-15
19 R. Hu, J.X. Liu, H. Jiang Dexmedetomidine versus remifentanil sedation during awake fibre optic nasotracheal intubation: A double – blinded randomized controlled trial J Anesth, 27 (2013), pp. 211-217
20 C.R. Patel, S.R. Engineer, B.J. Shah, et al. Effect of intravenous infusion of Dexmedetomidine on perioperative hemodynamic changes and post-operative recovery Indian J Anaesth, 56 (2012), pp. 542-546