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Original article 99

Effect of nitrous oxide inhalation on induction dose of


propofol, induction time, oxygen saturation, and hemodynamic
responses to laryngoscopy and intubation
Rajan Sunil, Sarath Vijayakrishna Pillai, Kumar Lakshmi

Department of Anaesthesiology and Critical Context


Care, Amrita Institute of Medical Sciences,
Nitrous oxide enhances the anesthetic potential of other agents and thereby reduces their
Amrita Vishwa Vidyapeetham, Kochi,
Kerala, India requirement.
Aims
Correspondence to Sunil Rajan, DNB,
This study aimed to determine the effect of nitrous oxide inhalation on the induction dose of
Department of Anaesthesiology and Critical
Care, Amrita Institute of Medical Sciences, propofol, induction time, oxygen saturation, and hemodynamic responses to laryngoscopy
Kochi, Kerala, 682 041, India and intubation.
Tel: +91 944 746 4652; fax: 91 484 2802020; Settings and design
e-mail: sunilrajan@aims.amrita.edu This was a randomized, prospective clinical trial.
Received 03 November 2014 Participants and methods
Accepted 07 April 2015 A total of 150 surgical patients ASA status I and II were included in the study. Patients in
Ain-Shams Journal of Anesthesiology group A inhaled 66% nitrous oxide in oxygen for 3 min, whereas in group B, 100% oxygen
2016, 9:99–103 was used. In both the groups, patients were administered a propofol bolus 20 mg every minute
intravenously after 3 min of gas inhalation until induction was achieved. Loss of response to
verbal command and no response to jaw thrust were considered the endpoint of induction.
Patients were then intubated after administration of suxamethonium 2 mg/kg.
Results
The mean dose of propofol required for induction was significantly lower in group A compared
with group B (30.4 ± 26.17 vs. 101.87 ± 26.19), as was the induction time (1.52 ± 1.31 vs.
5.09 ± 1.33). Heart rate was comparable throughout the study period. At induction, group A
had a significantly higher mean arterial pressure (MAP) (94.51 ± 16.21 vs. 86.57 ± 15.47). At
5 and 10 min, MAP was significantly high in group B and significantly high oxygen saturation
was observed at induction (99.81 ± 0.46 vs. 99.96 ± 0.26). No patient developed desaturation
(SpO2<90%) during the study.
Conclusion
Inhalation of 66% nitrous oxide for 3 min significantly reduced the induction time and the dose
of propofol, prevented a precipitous decrease in MAP at induction, and effectively attenuated
stress response to laryngoscopy and intubation without desaturation.

Keywords:
induction dose, nitrous oxide, propofol

Ain-Shams J Anesthesiol 9:99–103


© 2016 Department of Anesthesiology, Intensive Care and Pain Managment,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt
1687-7934

Participants and methods


Introduction
This study was carried out at the Amrita Institute of
Nitrous oxide, the time-tested anesthetic gas, is used Medical Sciences and Research Centre, Kochi, Kerala,
commonly as an adjuvant analgesic and as a vehicle for India, during the period September 2012 to September
the administration of more potent volatile agents. It 2014. On the basis of the results obtained on the
enhances the anesthetic potential of other agents and dose of propofol and induction time from the earlier
publications [2] and with 99% confidence and 99%
thereby reduces their requirement [1].
power, the minimum sample size came to 19 in each
group. Therefore, after obtaining Institutional Ethical
The primary objective of this study was to determine Committee clearance, we recruited 150 consenting
whether the induction dose of propofol could be patients in this randomized, prospective clinical trial. The
reduced when nitrous oxide was administered before study population included patients undergoing surgery
intravenous induction. The secondary objectives under general anesthesia with endotracheal intubation,
aged 20–50 years, ASA physical status I and II.
included assessment of induction time, oxygen
saturation, and hemodynamic response to laryngoscopy Patients were divided randomly into two equal groups
and intubation. using the closed-envelope technique: group A and
1687-7934 © 2016 Department of Anesthesiology, Intensive Care and Pain Management,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt DOI: 10.4103/1687-7934.178887
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100 Ain-Shams Journal of Anesthesiology

group B. Patients in group A received incremental Statistical analysis


doses of propofol following nitrous oxide inhalation for Data were analyzed using IBM SPSS statistics 20
3 min and patients in group B received only propofol software (Bengaluru, India). To compare the averages
as an induction agent. of continuous variables following a normal distribution,
an independent-sample t-test was used and for those
Patients belonging to ASA III and above and pregnant not following a normal distribution, the Mann–
patients and those with obesity, chronic obstructive Whitney U-test was used. Paired-sample t-test was
pulmonary disease, bronchial asthma, interstitial lung used to compare the average parameters and the 2-test
diseases, and uncontrolled hypertension were excluded was used for categorical variables. Level of significance
from the study. was considered at P value less than 0.05.

Both the groups were kept nil per os, 8 h for solids
and 2 h for clear fluids. All patients received ranitidine
150 mg, metoclopramide 10 mg, and alprazolam 0.5 Results
mg orally on the night before surgery. Ranitidine 150 Distribution of age, sex, height, weight, and
mg and metoclopramide 10 mg were repeated with ASA grading of the patients in both groups were
a sip of water on the day of surgery. In the theater, a comparable.
large bore intravenous access was started under local
anesthesia and patients were premedicated with The mean dose of propofol required for induction was
intravenous glycopyrrolate 0.2 mg and intravenous significantly lower in group A compared with group
fetanyl 2 g/kg. B (30.4 ± 26.17 vs. 101.87 ± 26.19, Table 1, Fig. 1).
Similarly, the induction time was also significantly
Patients in group A were asked to inhale 4 l/min nitrous shorter in group A (1.52 ± 1.31 vs. 5.09 ± 1.33,
oxide and 2 l/min of oxygen, whereas patients in group Table 2, Fig. 2).
B were preoxygenated with 6 l/min of oxygen for
3 min with a tight-fitting face mask. Loss of response Heart rate in both groups at preinduction as well
to verbal command (taking deep breaths/opening eyes) as throughout the study period were comparable
and no response to jaw thrust were considered the
endpoint of induction. Figure 1

Starting at the end of 3 min, after assessing response


to verbal command and jaw thrust, both groups
were administered a propofol bolus 20 mg every
minute intravenously. Induction time was calculated
as the time from the start of propofol injection to
loss of response to verbal command and jaw thrust,
and induction dose as the total amount of propofol
administered till that time.

After confirming the ability to mask ventilate, patients


were administered suxamethonium 2 mg/kg and
midazolam 1 mg intravenously and ventilated with
the same gas mixture plus isoflurane 1%. After 1 min,
a quick and gentle laryngoscopy was performed and Comparison of induction dose of propofol.
patients were intubated with an appropriate-sized
endotracheal tube.
Table 1 Comparison of the induction dose of propofol (mg)
Heart rate, systolic blood pressure, diastolic blood Groups Mean SD P value
pressure, and mean arterial pressure (MAP) of Group A 30.4 26.17 <0.001
each patient were measured at preinduction, at Group B 101.87 26.19
induction, and 1, 3, 5, 10, and 15 min after induction.
Desaturation was defined as SpO2 less than 90% and
if any patient developed desaturation during nitrous Table 2 Comparison of induction time (min)
Groups Mean SD P value
oxide inhalation, the patient was ventilated with
100% oxygen and the data were not used for statistical Group A 1.52 1.31 <0.001
Group B 5.09 1.33
analysis.
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Nitrous oxide inhalation reduces induction dose of propofol Rajan et al. 101

(P < 0.05, Table 3, Fig. 3). Preinduction MAP was Preinduction oxygen saturation was comparable
comparable between groups, but at induction, group between groups. Statistically, there was a significant
A had a significantly higher MAP (94.51 ± 16.21 difference at induction, with group B showing a
vs. 86.57 ± 15.47, P = 0.002). However, MAP higher value (99.81 ± 0.46 vs. 99.96 ± 0.26, P = 0.887).
values were significantly higher in group B at 5 min Thereafter, it was comparable in both groups (Table 5,
(83.09 ± 12.935 vs. 88.42 ± 14.600, P = 0.019) and 10 Fig. 5). No patient developed desaturation (SpO2<90%)
min (82.12 ± 12.013 vs. 87.21 ± 13.225, P = 0.014), during the study.a
Table 4, Fig. 4).
Table 4 Comparison of the mean arterial pressure

Table 3 Comparison of heart rate Time Group A Group B P value


(mean ± SD) (mean ± SD)
Time Group A Group B P value
(mean ± SD) (mean ± SD) Preinduction 99.39 ± 14.927 96.31 ± 20.136 0.288
Loss of response 94.51 ± 16.208 86.57 ± 15.467 0.002
Preinduction 78.85 ± 14.865 79.96 ± 13.100 0.627
(min)
Loss of 75.79 ± 13.873 80.26 ± 15.818 0.066
1 94.88 ± 20.718 99.69 ± 19.930 0.147
response (min)
1 82.65 ± 15.641 84.78 ± 13.426 0.370 3 89.03 ± 17.578 91.50 ± 18.401 0.387
3 80.44 ± 15.740 84.82 ± 15.224 0.83 5 83.09 ± 12.935 88.42 ± 14.600 0.019
5 78.28 ± 12.905 81.47 ± 12.816 0.129 10 82.12 ± 12.013 87.21 ± 13.225 0.014
10 77.23 ± 13.590 78.55 ± 13.610 0.559 15 86.72 ± 12.903 85. 92 ± 13.485 0.710
15 75.92 ± 12.595 75.61 ± 12.545 0.880

Figure 3
Figure 2

Comparison of the mean heart rate.


Comparison of induction time.

Figure 4 Figure 5

Comparison of the mean arterial pressure. Comparison of oxygen saturation.


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102 Ain-Shams Journal of Anesthesiology

Table 5 Comparison of oxygen saturation not very effective in preventing this hypotension,
Time Group A Group B P value whereas combining propofol with ketamine [15,16] or
(mean ± SD) (mean ± SD)
etomidate [16] may prevent hypotension. Conflicting
Preinduction 99.87 ± 0.475 99.92 ± 0.270 0.887 results have been found on the effectiveness of
Loss of 99.81 ± 0.460 99.96 ± 0.257 0.004
response (min)
ephedrine in this respect [13–15,17–19]. However, this
1 99.79 ± 0.890 99.82 ± 0.421 0.135 drawback of propofol induction could be overcome to
3 99.85 ± 0.485 99.49 ± 0.455 0.146 a huge extent by 3 min of nitrous oxide inhalation, as
5 99.891 ± 0.452 99.83 ± 0.571 0.298 observed in our study, as hypotension at loss of verbal
10 99.89 ± 0.388 99.94 ± 0.296 0.482 response was comparatively less.
15 99.85 ± 0.425 99.90 ± 0.347 0.549
Whether a reduction in the induction dose of
propofol could lead to an exaggerated stress response
Discussion to laryngoscopy and intubation would be a natural
The essential components of anesthesia include concern. It was found that nitrous oxide inhalation
immobility, unconsciousness, and suppression of effectively suppressed the heart rate as well as the
autonomic responses. This can be achieved with the hypertensive responses, at the same time maintaining
judicious use of multiple drugs, which include inhaled MAP at induction.
and intravenous agents. Use of a single drug to provide
Another concern while adopting this technique could
adequate depth of anesthesia could be dangerous
be desaturation. No desaturation was observed at
as higher doses may be required with an increased
induction and saturations in both groups remained
risk of side effects. Thus, combinations of drugs
well within clinically acceptable limits (99.81 ± 0.46
that potentiate the anesthetic effects will enable the
vs. 99.96 ± 0.26). Thus, if patients are chosen carefully,
usage of fewer drugs, which will subsequently reduce
avoiding those with anticipated difficult airway and
complications. It has been documented that when used
low cardiorespiratory reserve, the technique seems to
in conjunction, nitrous oxide decreases the requirement
be quite safe in experienced hands.
of intravenous anesthetic agents such as thiopentone
and propofol [2–4].

Although in the west, there are moves to omit Conclusion


routine use of nitrous oxide [5,6], it still remains the Inhaling 66% nitrous oxide for 3 min significantly
most commonly used inhalation agent in developing reduced the induction dose of propofol. In addition,
countries. The future of nitrous oxide does not seem to this technique reduced induction time, prevented
be bleak, mainly because of its cost effectiveness [7]. a precipitous decrease in MAP at induction, and
The available alternative, xenon, seems to be more effectively attenuated stress response to laryngoscopy
potent than nitrous oxide and requires only a minimal and intubation without desaturation.
supplement of a hypnotic anesthetic to suppress
noxious stimulation [8]. However, because of the high
cost, xenon is an unlikely replacement for nitrous oxide
in the near future. Acknowledgements
Conflicts of interest
Nowadays, propofol has become the most commonly There are no conflicts of interest.
used agent for induction of anesthesia [9]. It is a
costlier drug compared with the older induction agents
and an additional financial burden occurs as unused References
1 Becker DE, Morton Rosenberg M. Nitrous oxide and the inhalation
drug is thrown away in partially full syringes because of anesthetics. Anesth Prog 2008; 55:124–131.
its recommended expiration of 6 h once opened [10]. 2 Ng JM, Hwang NC. Inhaling nitrous oxide reduces the induction dose
requirements of propofol. Anesth Analg 2000; 90:1213–1216.
Thus, the patients end up paying more than what they
3 Dominguez VC, Bellolio PC. Iinfluence of inhaled nitrous oxide on the
have actually consumed. As economy of treatment is induction doses of propofol and thiopental assessed by auditary evoked
a growing concern in the health sector nowadays, the potentials. Anestesiol Reanim 2007; 54:475–479.

observation in our study that inhalation of nitrous oxide 4 Stuart PC, Stott SM, Millar A, Kenny GN, Russell D. Cp50 of propofol with
and without nitrous oxide 67%. Br J Anaesth 2000; 84:638–639.
for 3 min leads to a 70% reduction in the induction 5 Enlund M, Edmark L, Revenäs B. Ceasing routine use of nitrous oxide – a
dose of propofol should be paid attention. follow up. Br J Anaesth 2003; 90:686–688.
6 L Dimpel, M Enlund. Use of nitrous oxide in anaesthesia. Br J Anaesth
Hypotension is invariably associated with propofol 2003; 91:605–606.
7 Lyratzopoulos G, Blain KM. Inhalation sedation with nitrous oxide as an
induction [11], more so in elderly individuals [12]. alternative to dental general anaesthesia for children. J Public Health Med
Preloading with colloid [13] or crystalloids [14] is 2003; 25:303–312.
[Downloaded free from http://www.asja.eg.net on Sunday, May 21, 2017, IP: 125.163.244.237]

Nitrous oxide inhalation reduces induction dose of propofol Rajan et al. 103

8 Barakat AR, Schreiber MN, Flaschar J, Georgieff M, Schraag S. The 15 Dutta V, Ahmad M, Gurcoo S, Ommid M, Qazi MS. Prevention of
effective concentration 50 (EC50) for propofol with 70% xenon versus hypotension during induction of anesthesia with propofol and fentanyl:
70% nitrous oxide. Anesth Analg 2008; 106:823–829. comparison of preloading with crystalloid and intravenous ephedrine.
9 Stoelting RK, Hillier SC, editors. Pharmacology and Physiology in IOSRJDMS 2012;1:26–30
Anaesthetic Practice. 4th ed. Philadelphia: Lippincott Williams and 16 Ozkoçak I, Altunkaya H, Ozer Y, Ayoğlu H, Demirel CB, Ciçek E.
Wilkins; 2006. Nonbarbiturate intravenous anaesthetic drugs; p. 155–178.
Comparison of ephedrine and ketamine in prevention of injection pain
10 Gillerman R, Browning R. Drug use inefficiency: a hidden source of wasted and hypotension due to propofol induction. Eur J Anaesthesiol 2005;
health care dollars. Anesth Anal 2000; 91:921–924. 22:44–48.
11 Miner JR, Burton JH Clinical practice advisory: emergency department
17 Hosseinzadeh H, Eidy M, Golzari SEJ, Vasebi M. Hemodynamic
procedural sedation with propofol. Ann Emerg Med 2007; 50:182–187.
stability during induction of anesthesia in elderly patients:
12 Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. propofol+ketamine versus propofol+etomidate. J Cardiovasc Thorac
Predictors of hypotension after induction of general anesthesia. Anesth
Res, 201 3; 5:51–54.
Analg 2005; 101:622–628.
18 Ayatollahi V, Behdad S, Kargar S, Yavari T. Comparison of effects
13 Dhungana Y, Bhattarai BK, Bhadani UK, Biswas BK, Tripathi M. Prevention
of ephedrine, lidocaine and ketamine with placebo on injection pain,
of hypotension during propofol induction: a comparison of preloading
with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous hypotension and bradycardia due to propofol injection: a randomized
ephedrine. Nepal Med Coll J 2008; 10:16–19. placebo controlled clinical trial. Acta Med Iran 2012; 50:609–614.
14 M Kumar, N Saxena, AK Saxena. The effect of a colloid or crystalloid 19 El-Tahan MR. Preoperative ephedrine counters hypotension with propofol
preload on hypotension caused by induction of anaesthesia with propofol anesthesia during valve surgery: a dose dependent study. Ann Card
and fentanyl. J Anaesth Clin Pharmacol 2008; 24:409–412. Anaesth 2011; 14:30–40.

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