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Original
Article The effects of dexmedetomidine on
attenuation of stress response to
endotracheal intubation in patients
undergoing elective off‑pump
coronary artery bypass grafting
Sajith Sulaiman, Ranjith Baskar Karthekeyan, Mahesh Vakamudi1, Ayya Syama Sundar,
Harish Ravullapalli, Ravikumar Gandham
Departments of Cardiac Anaesthesiology, 1Anaesthesiology and Critical Care, Sri Ramachandra Medical College and
Research Institute, Porur, Chennai, India
ABSTRACT This study was designed to study the efficacy of intravenous dexmedetomidine for attenuation of cardiovascular
responses to laryngoscopy and endotracheal intubation in patients with coronary artery disease. Sixty adult
patients scheduled for elective off‑pump coronary artery bypass surgery were randomly allocated to receive
dexmedetomidine (0.5 mcg/kg) or normal saline 15 min before intubation. Patients were compared for
hemodynamic changes (heart rate, arterial blood pressure and pulmonary artery pressure) at baseline, 5 min
after drug infusion, before intubation and 1, 3 and 5 min after intubation. The dexmedetomidine group had a
better control of hemodynamics during laryngoscopy and endotracheal intubation. Dexmedetomidine at a dose
of 0.5 mcg/kg as 10‑min infusion was administered prior to induction of general anesthesia attenuates the
sympathetic response to laryngoscopy and intubation in patients undergoing myocardial revascularization.
The authors suggest its administration even in patients receiving beta blockers.
Received: 09‑06‑11
Accepted: 24‑09‑11 Key words: Dexmedetomidine, laryngoscopy, off‑pump coronary artery bypass grafting, stress response
Address for correspondence: Dr. Ranjith Baskar Karthekeyan, Department of Cardiac Anaesthesiology, Sri Ramachandra Medical College and Research
Institute, No 1, Ramachandra Nagar, Porur, Chennai ‑ 600116, India. E‑mail: ranjithb73@gmail.com
sedative and analgesic effects. Dexmedetomidine has saline were prepared in a double‑blind fashion
been shown to decrease induction doses of intravenous by a team member who was not involved in data
anesthetics and to decrease intraoperative opioid and recording. Peripheral, central venous and arterial
volatile anesthetic requirements for maintenance of cannulations were performed under local anesthesia.
anesthesia. In addition, it has been shown to decrease Electrocardiogram, pulse oximetry, intra‑arterial blood
perioperative catecholamine concentrations and pressure, pulmonary arterial pressures nasopharyngeal
promote perioperative hemodynamic and adrenergic temperature, urine output and capnography were
stability. The present study was designed to investigate also monitored. After 5 min of stable cardiovascular
the effect of dexmedetomidine on hemodynamic variables, baseline hemodynamic variables were
responses to orotracheal intubation. recorded.
the mean value was less than two times the standard No statistical significance was noted in systolic
deviation. A P value of less than 0.05 was considered pulmonary artery pressure between groups at baseline,
statistically significant. The package SPSS 17.0 before intubation and 3rd and 5th min after intubation.
(SPSS Inc., Chicago, IL, USA) was used for statistical There was a statistical significance noted in systolic
analysis. pulmonary artery pressure after drug administration
and 1 min after intubation. At any time period of
RESULTS measurement, the mean pulmonary artery pressure
was similar in both groups. Except at 5 min post
The groups were well-matched for their demographic intubation, diastolic pulmonary artery pressures
data, regional wall motion abnormality and number were similar between the two groups. Overall, the
of coronary vessels involved. No patient was excluded dexmedetomidine group was better controlled than
from the study. Ejection fraction was significantly the control group [Table 4]. There were no incidences
higher in the dexmedetomidine group [Table 1]. of hypotension (systolic blood pressure ≤25% of
The presence of risk factors and preoperative baseline), arrhythmias or other Electrocardiography
cardiovascular medications were comparable between (ST depression ≥1 mm below the baseline) observed
the groups [Table 2]. Except heart rate, all other during the study period in any group.
baseline hemodynamic variables were similar in both
groups [Table 3]. Heart rate values were statistically DISCUSSION
significantly lower in the dexmedetomidine group at all
time intervals when compared with the control group. Laryngoscopy and endotracheal intubation are
There was a statistical significance in the systolic considered as the most critical events during general
arterial pressure, mean arterial pressure and diastolic anesthesia. They provoke a transient, but marked,
arterial pressure between groups after drug at the 1st,
sympathetic and sympathoadrenal response. In
3rd and 5th min post intubation. The dexmedetomidine
patients undergoing coronary artery bypass (CABG)
group had a better control of heart rate and blood
surgery, tachycardia and hypertension increase
pressure than the control group [Table 3].
the risk of perioperative myocardial ischemia and
infarction. Alfa2‑adrenergic drugs, such as clonidine or
Table 1: Patient characteristics dexmedetomidine, attenuate these potentially harmful
Variable Dexmedetomidine Placebo P value cardiovascular reactions during induction of anesthesia.
Mean age in years 56.73 57.37 0.790
In our study, we compared dexmedetomidine, a
Male sex (n) 20 23 0.39
newer alfa 2 ‑agonist, with additional properties
Mean body mass 22.88 22.53 0.647
index
such as sedation, anxiolysis and sympatholysis for
Mean ejection 60.73 56.13 0.035* attenuating the hemodynamic response to laryngoscopy
fraction % and tracheal intubation.
No. of diseased 2.40 2.50 0.498
coronary vessels
Dexmedetomidine offers a unique pharmacological
Regional wall motion 16 15 0.796
abnormality (n)
profile with sedation, sympatholysis, analgesia,
*Statistically significant (P<0.05); n ‑ Number of patients
cardiovascular stability and with great advantage to avoid
respiratory depression. In particular, dexmedetomidine
Table 2: Risk factors and medication can provide a dose‑dependent cooperative sedation
Variable Group A Group B P value that allows ready interaction with the patient. All
Angina (NYHA II) 22 22 1.000
these above-said aspects of its pharmacological profile
Angina (NYHA III) 8 8 1.000
render it suitable as an anesthetic adjuvant and also as
Hypertension 17 18 0.793
Diabetes mellitus 16 14 0.606
intensive care unit sedation.
Old myocardial infarction 13 10 0.426
Beta blockers 24 23 0.754 Dexmedetomidine increases the hemodynamic stability
CCB 8 5 0.347 by altering the stress‑induced sympathoadrenal
ACEI 14 15 0.796 responses to intubation during surgery and during
Diuretics 5 3 0.448 emergence from anesthesia.[8] Jaakola et al.,[9] in their
CCB ‑ Calcium channel blockers; ACEI ‑ Angiotensin-converting
enzyme inhibitors; NYHA ‑ New York Heart Association. All values are
study concluded that dexmedetomidine attenuates
expressed in numbers the increase in heart rate and blood pressure
during intubation. The dose used for this study was better in the dexmedetomidine group and bradycardia
0.6 mcg/kg, which is almost similar to the dose used was not observed during our study.
by us.
It is a well-known fact that depression of sympathetic
Scheinin et al., studied the effect of dexmedetomidine
[8]
response against laryngoscopy and intubation is
on tracheal intubation, required dose of induction an important advantage, especially in high‑risk
agent and preoperative analgesic requirements. They patients. Nevertheless, the mean intubation induced
concluded that the required dose of thiopentone was pressor response was modest in our control group,
significantly lower in the dexmedetomidine group and which suggests that a relatively low intensity of
the drug attenuated the hemodynamic responses to stress is associated with the present anesthetic
intubation. The concentration of noradrenaline in mixed technique.
venous plasma was lesser in the dexmedetomidine
group. The hypotension and bradycardia caused by
dexmedetomidine, theoretically, could limit its usage
Lawrence et al.,[10] found that a single dose of 2 mcg/kg in previously beta‑blocked ischemia heart patients.
of dexmedetomidine before induction of anesthesia Few studies used dexmedetomidine as an anesthetic
attenuated the hemodynamic response to intubation as adjuvant in CABG patients receiving beta blockers,
well as that to extubation. Bradycardia was observed and reported that the intraoperative incidence of
at the 1st and 5th min after administration. This might bradycardia requiring treatment was not more common
have been due to bolus administration. The dose of in the dexmedetomidine group than in the control
dexmedetomidine in our study was 0.5 mcg/kg as an group.[11,12] This finding supports and correlates to our
infusion over 10 min. Hemodynamic response was study.