1. A SMOOTH EMERGENCE Lidocaine vs. Alfentanil: its uses perioperatively Jerod Schell, SRNA Oakland University-Beaumont Hospital Graduate Program of Nurse Anesthesia

2.  Why so concerned? What is the incidence of coughing on emergence from general anesthesia (GA) with an endotracheal tube?? Adverse side effects: HTN, tachycardia, tachyarrhythmia, ICP, IOP to name a few… Current methods for a smooth emergence = deep extubation, lidocaine jelly, LITA, short acting opioids.

3.  Sadegi, M., Firozian, A., Ghafari, M.H. and Esfehani, F. (2008).  Comparison in Effect of Intravenous Alfentanil and Lidocaine on Airway-Circulatory Reflexes during Extubation.  International Journal of Pharmacology. 4(3). 223- 226.  Dr. Ali Shariati Hospital, Medical Sciences/University of Tehran, Iran. Research Study Info:

4.  RCT, double-blind study  Female patients undergoing Cesarean Section with ETT GA.  Ages 18-35  ASA I or II -----------------------------------------------------------------  Respiratory Disease, recent URI, previous laryngeal pathology or surgery, CAD, HTN (taking cardiac meds), smokers, opioid addiction, local anesthetic allergy – All Excluded. Materials with Inclusion/Exclusion:

5. Methods: 1) Standard Induction using Thiopental and Succinylcholine 1.5 mg/kg. 2) Used cuffed 7.0 mm OET, inflated with 2 ml greater than minimal leak pressure 3) GA with Isoflurane at 1 MAC before delivery and 0.5 MAC after, with Oxygen and Nitrous Oxide (50%). Muscle relaxant sustained with Atracurium then IV morphine given after birth. 4) After delivery, anesthetic gases turned off, oropharynx suctioned then 100% oxygen delivered for remainder of case. 5) Then……

6. Now the actual experiment…  “Randomly generated computer assignment” 1) 15 mcg/kg Alfentanil -or- 2) 1.5 mg/kg 2% Lidocaine IV Anesthetists would administer the given dose after return of spontaneous respiration, then after 2 minutes the patient was extubated.

7. What was measured?  Systolic and Diastolic BP  Heart Rate  Cough: yes or no. -Hemodynamics measured 2 minutes after the end of surgery and served as baseline values Then re-assessments 2 minutes after study drug given and 1 minute after extubation with comparisons made.

8. Coughing

9. Statistics

10. Hemodynamic Statistics Statistically significant data for both categories except baseline values.

11. Statistical analysis  Distribution was checked by Kolmogorov Test  Statistical comparison by T-test, Mann-Whitney U- test, and Chi-square Test.  Significant when P <.05, two tailed.

12. How were subjects treated??  Narcotics and Lidocaine are both used in practice today, merely a comparison to current acceptable therapies.  Typically do not have scheduled Cesarean Sections with a GETA…

13. Study Notes: Discussion  No patients excluded  No laryngospasm or bronchospasm  Negative effects avoided: -Stress reactions -Intracranial, Intrabdominal pressure -Avoid bleeding or severe injury during emergence.

14. Study Notes (cont.)  Controlled timing very well.  Previous Lidocaine studies cannot statistically prove an improved emergence, only clinical experience with practitioners.  Narcotic delay?? -No clinically significant delay in emergence with narcotic use.

15. Study Limitations:  Narrow patient population  Healthy individuals  Not all institutions use Alfentanil

16. Can we use this tomorrow?  Alfentanil = opioid agonist - Precaution with Respiratory disease, can use as surgical anesthesia or analgesia.  Cost: 500 mcg/ml = $5.26 per ml.  - about $10 per 70 kg patient.

17. The Art of Anesthesia…. Emergence