Comparing the Efficacy of Dexmedetomidine versus Fentanyl and Midazolam During Awake Fiberoptic Intubation
AbstractBackground: Awake oral flexible fiberoptic intubation (AFOI) is used in patients with expected difficult airways. Different drugs have been used for sedation and yet we need to define ideal drug with proper sedation and safety, less changes in hemodynamic stability and less airway compromise. We aimed to compare the efficacy of dexmedetomidine with fentanyl and midazolam during AFOI.Methods: In this randomized clinical trial, 52 patients undergoing elective surgery and candidate for AFOI were randomly allocated to two groups. First group received 1mcg/kg of dexmedetomidine in 10 minutes and then infusion of 0.5 mcg/kg/h and second group received 2 mcg/kg fentanyl and then 1 mg midazolam. Hemodynamic variables, O2 saturation (SpO2) were evaluated before and after sedation and after intubation. Ramsey sedation scale (RSS) and patient’s tolerance were evaluated during bronchoscopy and intubation.Results: Lower heart rate after intubation (p=0.008) and higher SpO2 before sedation (p<0.001) and after intubation (p=0.02) were observed in dexmedetomidine group compared to fentanyl group. The need for propofol for further sedation was comparable between groups (11.5% vs. 7.7%, respectively; p=0.63). Both groups had comparable RSS and tolerance during intubation.Conclusion: Dexmedetomidine compared to fentanyl and midazolam had comparable sedation with better hemodynamic stability and O2 saturation during AFOI.
Johnston KD, Rai MR. Conscious sedation for awake fiberoptic intubation: A review of the literature. Can J Anaesth. 2013; 60(6):584-99.
Mondal S, Ghosh S, Bhattacharya S, Choudhury B, Mallick S, Prasad A. Comparison between dexmedetomidine and fentanyl on intubation conditions during awake fiberoptic bronchoscopy: A randomized double-blind prospective study. J Anaesthesiol Clin Pharmacol. 2015; 31(2):212-6.
Chu KS, Wang FY, Hsu HT, Lu IC, Wang HM, Tsai CJ. The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation. Eur J Anaesthesiol. 2010;27(1):36‑40.
Liu HH, Zhou T, Wei JQ, Ma WH. Comparison between remifentanil and dexmedetomidine for sedation during modified awake fiberoptic intubation. Exp Ther Med. 2015; 9:1259‑64.
Tsai CJ, Chu KS, Chen TI, Lu DV, Wang HM, Lu IC. A comparison of the effectiveness of dexmedetomidine versus propofol target-controlled infusion for sedation during fibreoptic nasotracheal intubation. Anaesthesia. 2010; 65(3):254-9.
Sinha SK, Joshiraj B, Chaudhary L, Hayaran N, Kaur M, Jain A. A comparison of dexmedetomidine plus ketamine combination with dexmedetomidine alone for awake fiberoptic nasotracheal intubation: A randomized controlled study. J Anaesthesiol Clin Pharmacol. 2014;30(4):514-9.
Bergese SD, Patrick Bender S, McSweeney TD, Fernandez S, Dzwonczyk R, Sage K. A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation. J Clin Anesth. 2010;22(1):35-40.
Kar Kurt Ö, Talay F, Karğı A, Yaşar Z, Tuğ T. Sedation for fiberoptic bronchoscopy: review of the literature. Tuberk Toraks. 2015;63(1):42-7.
Chopra P, Dixit MB, Dang A, Gupta V. Dexmedetomidine provides optimum conditions during awake fi beroptic intubation in simulated cervical spine injury patients. J Anaesthesiol Clin Pharmacol. 2016;32(1):54-8.
Mirkheshti A, Memary E, Honar BN, Jalaeefar A, Sezari P. The efficacy of local dexmedetomidine during fiberoptic nasotracheal intubation: A randomized clinical trial. J Anaesthesiol Clin Pharmacol. 2017;33(2):209-14.
Hassan ME, Mahran E. Evaluation of different doses of dexmedetomidine alone versus the combination of dexmedetomidine and fentanyl in sedation during awake fiberoptic intubation in oral cancer surgery patients: A prospective, randomized, double-blind clinical trial. Saudi J Anaesth. 2017;11(2):196-202.
Hu R, Liu JX, Jiang H. Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial. J Anesth. 2013;27(2):211–7.
He XY, Cao JP, He Q, Shi XY. Dexmedetomidine for the management of awake fibreoptic intubation. Cochrane Database Syst Rev. 2014;(1):CD009798.
Puchner W, Egger P, Pühringer F, Löckinger A, Obwegeser J, Gombotz H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand. 2002;46(4):350-4.
Yousuf A, Ahad B, Mir AH, Mir AW, Wani JG, Hussain SQ. Evaluation of effectiveness of dexmedetomidine and fentanyl-midazolam combination on sedation and safety during awake fiberoptic intubation: A randomized comparative study. Anesth Essays Res. 2017;11(4):998-1003.
Sayeed T, Shenoy A, Umesh G. Comparison of the safety and effectiveness of dexmedetomidine with a combination of midazolam and fentanyl for sedation during awake fiberoptic nasotracheal intubation. Indian J Respir Care. 2013;38(2):320-7.
Yavacaoglu B, Kaya FN, Baykara M, Bozkurt M, Korkmaz S. A comparison of esmolol and dexmedetomidine for attenuation of intraocular pressure and hemodynamic responses to laryngoscopy and tracheal intubation. Eur J Anaesthesiol. 2008;25(6):517-9.
Ryu JH, Lee SW, Lee JH, Lee EH, Do SH, Kim CS. Randomized double-blind study of remifentanil and dexmedetomidine for flexible bronchoscopy. Br J Anaesth. 2012;108(3):503-11.
Jorden VS, Pousman RM, Sanford MM, Thorborg PA, Hutchens MP. Dexmedetomidine overdose in the perioperative setting. Ann Pharmacother. 2004;38(5):803-7.
Yazbek-Karam VG, Aouad MM. Perioperative uses of dexmedetomidine. Middle East J Anesthesiol. 2006;18(6):1043-58.
Agrawal A, Jadon A, Parida SS, Chakraborty S, Sinha N, Chandra O. Comparative evaluation of dexmedetomidine and fentanyl – Midazolam combination as sedative adjunct to fibreoptic intubation under topical anaesthesia. Am J Adv Med Sci. 2014; 2:29-37.