1. 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

2. 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

3. 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

4. DECREASING PROPOFOL REQUIREMENT
Benzodiazepines
Ketamine
Etomidate
Inhalation agents
Muscle relaxants
Opioids

5. 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

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

7. 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

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

9. 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

10. CRITERIA NOTED Apnea time Recovery time analyzed statistically
Sedation score

11. 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

12. OBSERVATION

13. 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

14. DEMOGRAPHY

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

16. APNOEA TIIME

17. 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

18. RECOVERY TIME

19. 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

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

22. 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

23. BUTORPHANOL VS FENTANYL
AN EXPERIENCE

24. 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

25. 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

26. 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 ;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 : 

27. 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:e 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: Leong WM, Ong EL. Laryngeal mask airway can be inserted with inhaled desflurane induction. J Anesth. 2005;19(2): 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: J Henderson. Airway management in adult. In:Miller RD, editor. Miller textbook of anaesthesia,6th edition. Philadelphia: Elsevier; 2009.p

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