Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore 169608*Corresponding author
Accepted for publication: April 10, 2000
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Abstract |
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Br J Anaesth 2000: 84; 3647
Keywords: anaesthetics, volatile, desflurane; anaesthetics i.v., opioid, morphine; anaesthetic techniques, induction; airway
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Introduction |
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Patients |
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Methods |
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The opioids were given from a syringe containing either fentanyl, morphine or saline made up to 10 ml (in saline if necessary), prepared by an assistant who was not involved in the study. The anaesthetist administered the drugs over 1 min and was not aware of the contents of the syringe.
Saline (group C), morphine 0.1 mg kg1 (group M) or fentanyl 1 µg kg1 (group F) was given 2 min before preoxygenation with 100% oxygen at 6 litre min1 for 3 min using a circle system with soda lime absorber. The oxygen flow was then reduced to 3 litre min1 and nitrous oxide (50%) was started at 3 litre min1. Desflurane 1% was started and increased by 1% after every six breaths. Every 10 s during this period, each patient was asked to open his or her eyes. The time when the patient failed to respond to this command was taken as the time of completion of inhalational induction.
We recorded the age, sex, weight, ASA status, diagnosis and the type of surgical procedure for each patient. The reading of the pulse oximeter before induction and the lowest reading obtained during induction were noted. The time between starting desflurane and loss of consciousness was calculated and the expired desflurane concentration at loss of consciousness was noted. Any coughing, apnoea, laryngospasm or excitatory movements were noted. Coughing was considered mild if there were 13 coughs, moderate if there were 47 coughs and severe if there were 8 coughs or more. Apnoea was noted as no breathing movements for more than 30 s.
If patients developed laryngospasm, i.v. propofol 2 mg kg1 was given with the addition of i.v. suxamethonium 1 mg kg1 if necessary. The patients were then ventilated using the mask with 100% O2 until saturation improved.
If apnoea and oxygen desaturation were present (SpO2 <90%, or a decrease of more than 5% from initial value), the lungs were ventilated via a mask until spontaneous respiration returned.
Statistics
Analysis of variance (ANOVA) was used to analyse parametric data and all non-parametric data were analysed using the KruskalWallis and MannWhitney tests. A P value of <0.05 was considered significant.
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Results |
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The incidence of complications is shown in Table 3. Significant differences in coughing were found between the control and fentanyl groups (P=0.002) and between the control and morphine groups (P=0.013). No differences were found between the morphine and fentanyl groups.
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Seven patients in the control group had laryngospasm. In one of these, oxygen saturation decreased to 70%. Two patients in the fentanyl group and one patient in the morphine group had laryngospasm without oxygen desaturation. There was a significant difference between the control and morphine groups (P=0.025). No differences were found between the control and fentanyl groups or the morphine and fentanyl groups.
There were more excitatory movements in the control group than in the morphine group (P=0.025), but the control and fentanyl groups and the morphine and fentanyl groups did not differ.
The blood pressure and heart rate changes in the three groups are given in Table 4. Overall there were no group differences and the magnitudes of the changes were not of clinical significance.
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Discussion |
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This study showed a significant difference in the expired desflurane concentration at the end of induction between the control and morphine groups. This difference may have been the result of sedation cause by morphine.
No differences were found between the fentanyl and control groups. Fentanyl had a peak effect at 45 min. It may be that the effect of fentanyl was beginning to wear off (even though its duration of action is 2030 min).
Time to loss of response to command
No differences were found between the three groups in the time taken to induction, which was approximately 5 min. This could be due to the slow, small increments in inhaled concentration in the study design because of the risk of laryngospasm.
Coughing occurs in 2659% of patients during desflurane inhalation.812 This is supported by our results. The control group had an incidence of coughing of 25.0%. Among the 14 patients who coughed, cough was mild in two, moderate in seven and severe in five. Morphine or fentanyl reduced the incidence of coughing. In the fentanyl group, all three patients had mild cough, whereas of the five patients who received morphine two had mild cough, two had moderate cough and one had severe cough.
Sevoflurane is often used for inhalational induction in both adults and children, with coughing in 16%.1719 The tidal volume induction technique may be associated with a greater incidence of airway complications compared with vital capacity induction.1719 Pretreatment with morphine or fentanyl reduces the incidence of airway complications below 10% during tidal volume induction using desflurane.
This study also supports the incidence of apnoea reported in the literature (1335%),812 with 20% in the control group. Pretreatment with morphine or fentanyl reduced the incidence of this adverse effect to 5 and 13.3%, respectively. These incidences are comparable with those reported for sevoflurane (16%).1719
The incidence of excitation is reported to be 2443%,812 and was 47% in this study. Pretreatment with morphine or fentanyl reduces the incidence to 8.3% and 16.7%, respectively. When sevoflurane is used for induction 12% of patients exhibit excitatory movements.1719 Morphine pretreatment reduces the incidence of excitatory movements to a comparable figure during desflurane inhalational induction.
Seven patients (11.7%) in the control group had laryngospasm during induction, similar to the reported incidence of up to 17%.812 Three of these seven patients also had cough of moderate severity, two had apnoea and five had excitatory movements. One patient, a 31-yr-old ASA I man, had significant desaturation during induction. He also had excitatory movement but he did not cough or become apnoeic during induction. His blood pressure remained stable.
One patient in the morphine group had laryngospasm. He did not cough or have apnoea or excitatory movements during induction, or show arterial desaturation during the episode. Two patients in the fentanyl group had laryngospasm with mild cough and excitatory movement. They did not have apnoea or arterial oxygen desaturation during this episode. Laryngospasm is reported in 38% of patients induced with sevoflurane and a tidal volume induction technique.18 19 Pretreatment with morphine or fentanyl reduces the incidence of laryngospasm during desflurane induction to a figure comparable with sevoflurane induction.
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Conclusion |
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References |
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