COMPARATIVE EVALUATION OF BUTORPHANOL AND FENTANYL AS CO-INDUCTION AGENT TO ASSESS THEIR EFFECT ON APNOEA TIME, RECOVERY TIME AND SEDATION SCORE USING LARYNGEAL MASK AIRWAY Dr Manisha bhatt dwivedi Mmimsr, Maharishi markandeshwar university, Mullana Ambala india

INTRODUCTION Airway management - an indispensable - integral element Conventional method -Face mask - Endotracheal tube (ETT) Another invention - laryngeal mask airway (LMA) LMA - A drastic reform in the fundamental aspects of general anesthesia

LMA INSERTION- TO ACHIEVE OPTIMAL CONDITION various induction agents available Propofol provides - rapid induction -easy insertion ►Undesirable effects - dose exceeds 2.5 mg kg-1 -hypotension -bradycardia -respiratory depression Propofol alone is unsatisfactory as a sole anesthetic agent

DECREASING PROPOFOL REQUIREMENT Benzodiazepines Ketamine Etomidate Inhalation agents Muscle relaxants Opioids

Spontaneous v/s positive pressure ventilation What if muscle relaxant is used to aid LMA insertion What if opioids are used to aid LMA insertion Opioids –butorphanol and fentanyl

Propofol and Butorphanol V/s Propofol and Fentanyl PRESENT STUDY Propofol and Butorphanol V/s Propofol and Fentanyl

METHODOLOGY Number of patients-hundred elective surgical procedures Randomly selected and divided into two groups of 50 each - Group F-Propofol and Fentanyl -Group B-Propofol and Butorphanol Inclusion criteria -ASA I and ASA II -Age-18 to 60 Yrs -Mallampati - I and II

Methods continued.. Written informed consent Detailed clinical examination was performed Kept nil by mouth overnight Standard monitoring Group B - IV Butorphanol 30 µg/kg Group F -IV Fentanyl 1.5 µg/kg

INDUCTION With IV Propofol Dose -2.5 mg/kg Duration-over a period of 60 minutes LMA specification-number 3 and 4 Maintenance of anesthesia Reversal

CRITERIA NOTED Apnea time Recovery time analyzed statistically Sedation score

STATISTICAL APPLICATION Student t test - age -weight -apnea time -recovery time Mann-Whitney U test- Ordinal data -sedation score Probability value of < 0.05 was considered significant Observation tables made and conclusions were drawn

OBSERVATION

DEMOGRAPHY Variables Group F (n=50) Group B (n=50) Z-value p-value Age (years) 33.48±11.15 31.84±11.49 0.72 0.42 NS,p>0.05 Weight (kg) 47.66±7.51 50.42±7.65 1.81 0.07 NS,p>0.05 Gender (M/F) 6/44 12/38 ﭏ2-value=2.43 0.11 NS,p>0.05

DEMOGRAPHY

APNOEA TIIME variables Group F Group B Z value P value Apnoea time (sec) 78.12 ± 9.91 57.74 ±13.08 8.78 0.000 P<0.05

APNOEA TIIME

RECOVERY TIME variables Group F Group B Z value P value Recovery Time (Min) 3.74±0.95 6.52±0.90 14.97 0.000 S,p<0.05

RECOVERY TIME

Time Grade Group F Group B ﭏ2-value p-value ½ hour 1 hour 2 hour 88.73 P<0.0001 S 2 46 3 4 5 1 hour 5.09 0.16 NS,p>0.05 49 2 hour 1.01 0.31 50 Sedation Scores

DISCUSSION LMA is a supra-glottic device which requires lesser depth of anesthesia Evokes less hemodynamic response Causes less stimulation of airway

DISCUSSING “WHY” Why we opted not to use muscle relaxant and maintain patient on spontaneous ventilation Why we want to reduce apnea time Why in our study we never encountered hypoxia due to apnea Why opioid pretreatment was decided

BUTORPHANOL VS FENTANYL AN EXPERIENCE

SUPPORT STUDIES P. Chari et al 2006; Asha Gupta et al Goh PK, Chiu CL, Wang CY, et al. 2005; Dryden GE; 1986 M .Tanaka and T.Nishikawa P.Harish and G.Subrahmanyam Critical review of butorphanol –World Health Organisation

CONCLUSION Both propofol-butorphanol and propofol-fentanyl can be used for insertion of LMA Butorphanol ,when used as a co-induction agent with propofol decreases apnea time Recovery time and sedation were prolonged with butorphanol Clinically this was within acceptable limit Butorphanol as co-induction agent can be preferred due to its - safer respiratory profile -easy availability Non-narcotic opioid BUTORPHANOL is an adoptive option as co-induction agent

References 1. Ghafoor H, Afshan G, Kamal R. General Anesthesia with Laryngeal Mask Airway: Etomidate vs Propofol for Hemodynamic Stability. Open J Anesthesiology 2012;2:161-5 2. Yousef GT,Elsayed KM .A clinical comparison of ketofol (ketamine and propofol admixture) versus propofol as an induction agent on quality of laryngeal mask airway insertion and hemodynamic stability in children. Anesth Essays Res 2013 ;7(2):194-9 3. Ramaswamy AH, Shaikh S. Comparison of dexmedetomidine-propofol versus fentanyl-propofol for insertion of laryngeal mask airway.Journal of Clinical Pharmacology 2015 ; 31(2);217-20 4.Pournajafian A,Alimian M ,Rokhtabnak F,Ghodraty M,Mojri M.Success rate of airway devices insertion:Laryngeal mask airway versus supraglottic gel device.Anaesth Pain Med march2015;5:e22068 5. Sirian R,Wills J.Physiology of apnoea and the benefits of preoxygenation. Contin Educ Anaesth Crit Care Pain 2009; 9 : 105-108.  

References-continued 6.Ziyaeifard M,Azarfarin R,Ferasatkish R,Dashti M.Management of difficult airway with laryngeal mask airway in a child with mucopolysaccharidosis and mitral regurgitation:A case report.Resp Cardiovasc Med 2014;3:e17456 7.Goh PK, Chiu CL, Wang CY, et al. Randomized double-blind comparisonof ketamine-propofol, fentanyl-propofol and propofol saline on haemodynamics and laryngeal mask airway insertion conditions. Anaesth Intensive Care. 2005; 33:223-228. 8. Leong WM, Ong EL. Laryngeal mask airway can be inserted with inhaled desflurane induction. J Anesth. 2005;19(2):112-7. 9. . Rao MH, Satyanarayana V, Srinivas B, Muralidhar A, Samantaray A, Reddy ASK, Hemanth N.Comparison of butorphanol and fentanyl for balanced anaesthesia in patients undergoing laparoscopic surgeries under general anaesthesia:a prospective, randomized, double-blind study. J Clin Sci Res 2013;2:8-15 10. J Henderson. Airway management in adult. In:Miller RD, editor. Miller textbook of anaesthesia,6th edition. Philadelphia: Elsevier; 2009.p.1573-1603

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