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ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 5  |  Page : 622-626  

Comparison between nalbuphine propofol and dexmedetomidine propofol for laryngeal mask airway insertion


Department of Anaesthesiology, S.R.T.R. Rural Government Medical College, Ambajogai, Maharashtra, India

Date of Web Publication13-Oct-2016

Correspondence Address:
Aparna Gundeshwar Kulkarni
Godavari Apt., Flat No. 6, Near Kapil Ganesh Temple, Aadarsh Colony, Ambajogai, Beed - 431  517, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.192170

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  Abstract 


Aims and Objectives: The aim of the present study was to compare the laryngeal mask airway (LMA) insertion conditions using either nalbuphine - propofol or dexmedetomidine - propofol. Materials and Methods: Sixty female patients aged 25–35 years posted for interval tubal ligation were randomly allocated in two groups of 30 each. Group N received intravenous injection nalbuphine 0.2 mg/kg over 5 min, and Group D received injection dexmedetomidine 1 μg/kg over 5 min. Later, all the patients were induced with injection propofol 2 mg/kg and 90 s after induction, classic LMA of number 3 was inserted in all the patients. LMA insertion conditions were assessed using various parameters. Heart rate, mean arterial pressure, respiratory rate, and SpO2were recorded before induction and at 1, 3, 5, and 10 min after LMA insertion. Incidence and duration of apnea were also recorded. Observations and Results: Demographic data were comparable in both the groups. LMA insertion conditions were comparable in both the groups (P = 0.15), and both the groups had excellent LMA insertion conditions. The apnea duration was slightly more in dexmedetomidine group (140 s) as against nalbuphine group (120 s). The reduction in heart rate was more in Group D and the difference was statistically significant at 1 and 3 min after induction (P < 0.001). Conclusion: Nalbuphine combined with propofol provides similar conditions of LMA insertion as that of dexmedetomidine - propofol combination with advantage of better maintenance of hemodynamic stability.

Keywords: Dexmedetomidine, laryngeal mask airway, nalbuphine, propofol


How to cite this article:
Kulkarni AG, Rani B D, Tarkase AS, Barsagde WS. Comparison between nalbuphine propofol and dexmedetomidine propofol for laryngeal mask airway insertion. Med J DY Patil Univ 2016;9:622-6

How to cite this URL:
Kulkarni AG, Rani B D, Tarkase AS, Barsagde WS. Comparison between nalbuphine propofol and dexmedetomidine propofol for laryngeal mask airway insertion. Med J DY Patil Univ [serial online] 2016 [cited 2022 Jul 6];9:622-6. Available from: https://www.mjdrdypu.org/text.asp?2016/9/5/622/192170




  Introduction Top


Supraglottic airway devices are alternative to endotracheal intubation for securing airway, among which laryngeal mask airway (LMA) is the most preferred one.[1]

Safe insertion of LMA requires deep level of anesthesia with obtundation of airway reflexes as, inadequate anesthesia can cause coughing, laryngospasm, and may lead to desaturation, regurgitation, and aspiration.[2],[3],[4] Propofol is the most commonly used induction agent for LMA insertion due to its depressant action on upper airway reflexes.[5],[6]

Various adjuvants such as fentanyl, dexmedetomidine, and nalbuphine were used along with propofol for LMA insertion though an ideal adjuvant is yet to be found.[8],[9] Opioids such as fentanyl when used along with propofol provide good LMA insertion conditions but has its own disadvantage of causing respiratory depression, apnea, and chest rigidity.[10],[11] Newer drugs such as dexmedetomidine and nalbuphine have less risk of respiratory depression.[12],[13]

The present study was undertaken to compare the LMA insertion conditions provided by nalbuphine - propofol combination with dexmedetomidine - propofol combination in minor surgical procedures.


  Materials and Methods Top


After approval from the Institutional Ethical Committee, this prospective, randomized, double-blind, comparative study was carried on sixty female patients of American Society of Anesthesiologists Grade I and II. The study period was 6 months. Patients aged 25–35 years undergoing interval tubal ligation under general anesthesia with spontaneous ventilation using classic LMA were included in the study. Those patients who had suspected difficult intubation, known allergy to propofol or any allergic condition, neuromuscular disorder, cardiovascular pathology, and hepatic or renal disease were excluded from the study.

Written informed consent was obtained from each patient, and patients were randomly assigned into two groups of 30 each using computerized randomization table.

On the operating table, intravenous access was obtained, and Ringer's lactate infusion started. Standard monitors such as pulse oximeter and noninvasive blood pressure were connected to the patients. Patients were then premedicated with intravenous injection ranitidine 50 mg injection metoclopramide 10 mg, injection glycopyrrolate 0.2 mg, and injection midazolam 1 mg. While preoxygenating the patients with 100% oxygen, Group N patients received intravenous injection nalbuphine 0.2 mg/kg over 5 min in 50 ml of normal saline and Group D received injection dexmedetomidine 1 µg/kg over 5 min in 50 ml of normal saline. One minute after administration of the study drug, all the patients were induced with intravenous injection of propofol 2 mg/kg over 30 s. Ninety seconds after induction, classic LMA number 3 was inserted in each patient by an anesthesiologist who was blinded to the choice of induction agent and the adjuvant used. In case of any resistance to insertion, additional 0.5 mg/kg propofol was administered to facilitate LMA insertion. Conditions of LMA insertion were assessed using various parameters such as patient's response to LMA insertion such as coughing, gagging, or any movement and scored according to scoring system modified by Muzi et al.[14] Jaw mobility was graded as: 1 - fully relaxed, 2 - mild resistance, 3 - tight but opens, and 4 - close. Scores <2 were considered as acceptable for LMA insertion. Incidence of breath holding and apnea duration was recorded in both the groups. After ensuring proper placement of LMA, it was connected to Bain's circuit, and anesthesia was maintained with 50% O2 and 50% N2O. In case of apnea, the patient was ventilated with 100% oxygen till spontaneous breathing was restored. Heart rate, mean arterial pressure (MAP), and SpO2 were recorded before induction and at 1, 3, 5, and 10 min after insertion of LMA.

Statistical analysis

The sample size was calculated using statistical package software statistical analysis system with an alpha error of 0.05, confidence of 95% for an infinite population. Statistical analysis of data was performed using the Student's t-test for parametric data and Chi-square test for nonparametric data. Analysis was performed using statistical product for social sciences (SPSS) software version 15.0 (International Business Machines (IBM) Corporation, Armonk, New York, USA). P < 0.05 was considered statistically significant.


  Results Top


Demographic data such as age, weight, and duration of surgery were comparable in both the groups and the difference was not statistically significant [Table 1].
Table  1: Demographic distribution of patients

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Insertion conditions with respect to jaw mobility were almost similar in both the groups [Table 2]. About 29 (96.6%) patients in Group N had fully relaxed jaw, whereas 28 (93.3%) patients in Group D had fully relaxed jaw with mild resistance to insertion in the remaining patients in both the groups and this difference was not statistically significant (P = 0.27). For patients who had mild resistance during insertion, additional propofol of 0.5 mg/kg intravenously was given and LMA insertion done after 30 s. In Group N, only one patient had bucking during insertion of LMA (3.33%), whereas three patients in Group D had bucking during LMA insertion (10%), but this difference was not statistically significant (P = 0.3). Incidence of breath holding was slightly greater in Group D (33.3%) as compared to Group N (26.67%), but this difference was also not significant (P = 0.39). None of the patients in both the groups had expiratory stridor which suggests adequate depth of anesthesia in both the groups.
Table  2: Laryngeal mask airway insertion conditions

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The duration of apnea was 120 s in Group N, whereas it was 140 s in Group D.

The LMA insertion conditions were labeled as acceptable if the score was <2 and accordingly 29 (96.6%) patients in Group N had acceptable conditions, whereas 28 patients (93.3%) had acceptable LMA insertion conditions, but this difference was not statistically significant (P = 0.27).

While comparing the hemodynamic parameters, it was found that the incidence of bradycardia (heart rate <60 bpm) was more in Group D, especially at 1 and 3 min after LMA insertion and the difference in heart rates during this period was statistically significant (P = 0.001). The heart rate was then almost similar in both the groups during the rest of surgery [Table 3] and [Figure 1].
Table  3: Changes in heart rate

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Figure 1: Changes in heart rate

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The MAP was almost similar in both the groups throughout surgery [Table 4] and [Figure 2], and the difference was not statistically significant (P > 0.05).
Table  4: Changes in mean arterial pressure

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Figure 2: Changes in mean arterial pressure

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The basal respiratory rate (RR) was comparable in both the groups [Table 5] and [Figure 3]. RR decreased to around 13/min in both the groups after induction and LMA insertion but the difference in the two groups was not statistically significant (P > 0.05). At 10 min of LMA insertion, the RR increased slightly to around 15/min and then remained in the same range thereafter, but the difference was comparable in both the groups [Figure 3]. The duration of apnea was longer in Group D (140 s) as compared to Group N (120 s).
Table  5: Changes in respiratory rate

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Figure 3: Changes in respiratory rate

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  Discussion Top


LMA has gained wide acceptance for routine airway management, difficult airway, and in emergency situation. Safe insertion of LMA requires deep levels of anesthesia with suppression of airway reflexes.

Propofol is a widely used induction agent for insertion of LMA due to its depressant action on upper airway reflexes and it is superior to thiopentone which was used earlier for LMA insertion. However, propofol when used alone has some limitations such as involuntary movement, pain on injection, and no analgesic action.[15] To overcome these limitations, it was combined with drugs such as ketamine, opioids, or muscle relaxants. When used with ketamine, there was a problem of adequate jaw relaxation.[7] Use of muscle relaxants provided good insertion conditions but had an increased risk of aspiration.[7],[16] Opioids such as fentanyl, though improved the insertion conditions, caused more respiratory depression and chest rigidity.[10],[11]

Newer drugs such as dexmedetomidine and nalbuphine have been tried along with propofol. Nalbuphine is a potent analgesic which binds to mu, kappa, and delta receptors, but not to sigma receptors. It is primarily a kappa agonist/partial mu antagonist analgesic. It has several advantages such as cardiovascular stability, long duration of analgesia, no respiratory depression, and less nausea and vomiting.[12],[13]

In our study, the LMA insertion conditions were excellent with the use of nalbuphine as well as with dexmedetomidine. Various studies have shown the superiority of nalbuphine as well as dexmedetomidine over fentanyl in providing good LMA insertion conditions. In our study, 96% of patients in nalbuphine group had acceptable insertion conditions, whereas 93% patients in dexmedetomidine group had acceptable conditions and this difference was not statistically significant. The dose of nalbuphine (0.2 mg/kg) and the dose of dexmedetomidine (1 µg/kg) used in our study was based on prior published observations.[17],[18] Both dexmedetomidine and nalbuphine, when used 30 s before a propofol bolus, provided optimum jaw relaxation and mouth opening 90 s after propofol injection. The predetermined periods of 30 and 90 s were derived from earlier published experience.[19],[20],[21] Only one patient in Group N and two patients in Group D required additional 0.5 mg/g dose of propofol to facilitate LMA insertion which shows that addition of these study drugs reduces the dose of propofol to 2 mg/kg. The dose of propofol required to facilitate LMA insertion when used alone without any adjuvant is was about 2.5 mg/kg and causes more respiratory depression.[22],[6] Hence, addition of these adjuvants provided better insertion conditions with minimal risk of respiratory depression as observed by Salman [17] and Uzümcügil et al.[23] The less incidence of coughing in nalbuphine group could be attributed to its antitussive action.

The incidence of breath holding though was slightly more with dexmedetomidine; the difference was no statistically significant. In both the groups, after induction, there was a proportionate fall in the RR (13/min) which increased to 15/min, 10 min after LMA insertion. This increase in RR could be due to surgical stimulus as the patient was on spontaneous ventilation. This shows that both the drugs are safe and do not cause respiratory depression as observed with opioids such as fentanyl.

In our study, we found that there was significant bradycardia in Group D, especially at 1 and 3 min of LMA insertion. It was found that dexmedetomidine decreases the heart rate by 27% after induction and returns to normal by around 15 min.[24] This bradycardia can be even be potentiated when used with propofol which also causes bradycardia. In contrast to this, the heart rate remained almost stable throughout in Group N, and there was no episode of bradycardia in any of the patients. This finding is in accordance with the observations made by Khan and Hameedullah and Chestnutt et al.[25],[26] which also showed smooth hemodynamic response with intravenous nalbuphine. The MAP was comparable in both the groups throughout which shows that nalbuphine is more hemodynamically stable as compared to dexmedetomidine which has a risk of bradycardia. Hence, nalbuphine would be a safer alternative to be used along with propofol for LMA insertion.

Our study has some limitations such as a control group using propofol alone was not included in our study, but propofol alone was inadequate for LMA insertion and increasing its dose to facilitate insertion would be unsafe for hemodynamics and respiration.[22],[6] We did not use any inhalational anesthetic agent to avoid any interference with the observations in various parameters. Pain, recovery, and sedation scale were not included in our study as it was designed only on insertion conditions.


  Conclusion Top


To conclude, nalbuphine can be a better alternative to dexmedetomidine along with propofol for LMA insertion providing stable hemodynamics.

Acknowledgments

Special thanks to the postgraduate students of Department of Anaesthesiology, S.R.T.R.G.M.C, Ambajogai, for their valuable support

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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