Preoperative glycopyrrolate: oral, intramuscular, or intravenous administration

Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial

Background and aim

An optimal topical pharyngeal anesthesia (TPA) is required for better patient tolerance and procedural outcomes of an unsedated upper gastrointestinal endoscopy (UGIE). Several additional strategies have been tried to improve patient tolerance with limited success. We hypothesized that premedication with glycopyrrolate would enhance TPA and improve patient tolerance and procedural outcomes of an unsedated UGIE.

Materials and methods

We conducted a randomized, double-blind, placebo-controlled trial between July 2020 and May 2022. Consecutive patients undergoing unsedated UGIE were randomly assigned to receive either intravenous glycopyrrolate or a placebo 30 minutes before TPA. Patient tolerance, comfort level for the endoscopist, cardiorespiratory fluctuations, percentage of failed esophageal intubation, and incomplete examination were studied.

Results

380 patients were randomized to 190 in each arm. The median (IQR) VAS scores for the overall patient satisfaction in the glycopyrrolate and placebo groups were 8 (1) and 7 (2), respectively (p = 0.04). The median (IQR) VAS scores for endoscopist assessment of patient cooperation in the glycopyrrolate and placebo groups were 8 (1.3) and 8 (1), respectively (p = 0.04). There was no difference in the percentage of failed esophageal intubation and incomplete examination, fluctuations in heart rate, and oxygen saturation of the participants. However, the mean arterial pressure (MAP) on-table before the start of the procedure at 1 minute and 3 minutes was significantly higher in the glycopyrrolate group (p = 0.01, 0.01, and 0.04, respectively).

Conclusion

In unsedated UGIE, glycopyrrolate premedication significantly improves the patient tolerance and endoscopist's comfort, with minimal cardiorespiratory effects. Hence, it could be incorporated into day-care unsedated endoscopy practice.Trial registration - CTRI/2020/07/026786.

How to cite this article

Ramalingam R, Senthamizhselvan K, Harichandrakumar KT, et al. Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial. Euroasian J Hepato-Gastroenterol 2023;13(2):55-60.

Effect of Intramuscular Atropine Sulphate and Glycopyrrolate on Heart Rate and Salivary Secretion in Patients Undergoing Minor Oral Surgical Procedure

Introduction

In most of the oral surgical procedures performed under local anesthesia, we often face a great difficulty while performing surgeries because of reduced accessibility and visibility which is hampered by blood and saliva at the surgical site. Anticholinergic drugs like atropine sulphate and glycopyrrolate are commonly used as antisialogogue for patients undergoing a surgical procedure under general anesthesia with little or no side effects. 

Aims and objectives

To evaluate and compare the antisialogogue effect of atropine sulphate and glycopyrrolate in patients undergoing minor oral surgical procedures. To compare the efficacy of these drugs when administered intramuscularly and to evaluate their effects on heart rate in patients undergoing minor oral surgical procedures.

Materials and methods

Thirty patients undergoing minor oral surgical procedure were selected for the study. The patients were randomly assigned to receive either 0.6 mg/ml of Atropine Sulphate or 0.2 mg/ml of Glycopyrrolate intramuscularly. Salivary secretion, heart rate and arterial pressure were noted pre-injection and 30 minutes after the administration of the drug.

Results

Atropine sulphate and glycopyrrolate were equally potent as an antisialogogue. There was a significant increase in heart rate 30 min after the administration of atropine sulphate, but there was no significant change in heart rate in glycopyrrolate group.

Conclusion

Intramuscular gycopyrrolate is safer than intramuscular atropine sulphate as an antisialogogue in minor oral surgical procedures under local anesthesia.

COPD and asthma therapeutics for supportive treatment in organophosphate poisoning

Context: Nerve agents like sarin or VX have repeatedly been used in military conflicts or homicidal attacks, as seen in Syria or Malaysia 2017. Together with pesticides, nerve agents assort as organophosphorus compounds (OP), which inhibit the enzyme acetylcholinesterase. To counteract subsequent fatal symptoms due to acetylcholine (ACh) accumulation, oximes plus atropine are administered, a regimen that lacks efficacy in several cases of OP poisoning. New therapeutics are in development, but still need evaluation before clinical employment. Supportive treatment with already approved drugs presents an alternative, whereby compounds from COPD and asthma therapy are likely options. A recent pilot study by Chowdhury et al. included β2-agonist salbutamol in the treatment of OP-pesticide poisoned patients, yielding ambiguous results concerning the addition. Here, we provide experimental data for further investigations regarding the value of these drugs in OP poisoning. Methods: By video-microscopy, changes in airway area were analyzed in VX-poisoned rat precision cut lung slices (PCLS) after ACh-induced airway contraction and subsequent application of selected anticholinergics/β2-agonists. Results: Glycopyrrolate and ipratropium efficiently antagonized an ACh-induced airway contraction in VX-poisoned PCLS (EC₅₀ glycopyrrolate 15.8 nmol/L, EC₅₀ ipratropium 2.3 nmol/L). β2-agonists formoterol and salbutamol had only negligible effects when solely applied in the same setting. However, combination of formoterol or salbutamol with low dosed glycopyrrolate or atropine led to an additive effect compared to the sole application [50.6 ± 8.8% airway area increase after 10 nmol/L formoterol +1 nmol/L atropine versus 11.7 ± 9.2% (10 nmol/L formoterol) or 8.6 ± 5.9% (1 nmol/L atropine)]. Discussion: We showed antagonizing effects of anticholinergics and β2-agonists on ACh-induced airway contractions in VX-poisoned PCLS, thus providing experimental data to support a prospective comprehensive clinical study. Conclusions: Our results indicate that COPD and asthma therapeutics could be a valuable addition to the treatment of OP poisoning.

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures

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Perioperative hypoxemia is common with horizontal positioning during general anesthesia and is associated with major adverse outcomes: a retrospective study of consecutive patients

Background

Reported perioperative pulmonary aspiration (POPA) rates have substantial variation. Perioperative hypoxemia (POH), a manifestation of POPA, has been infrequently studied beyond the PACU, for patients undergoing a diverse array of surgical procedures.

Methods

Consecutive adult patients with ASA I-IV and pre-operative pulmonary stability who underwent a surgical procedure requiring general anesthesia were investigated. Using pulse oximetry, POH was documented in the operating room and during the 48 hours following PACU discharge. POPA was the presence of an acute pulmonary infiltrate with POH.

Results

The 500 consecutive, eligible patients had operative body-positions of prone 13%, decubitus 8%, sitting 1%, and supine/lithotomy 78%, with standard practice of horizontal recumbency. POH was found in 150 (30%) patients. Post-operative stay with POH was 3.7 ± 4.7 days and without POH was 1.7 ± 2.3 days (p < 0.0001). POH rate varied from 14% to 58% among 11 of 12 operative procedure-categories. Conditions independently associated with POH (p < 0.05) were acute trauma, BMI, ASA level, glycopyrrolate administration, and duration of surgery. POPA occurred in 24 (4.8%) patients with higher mortality (8.3%), when compared to no POPA (0.2%; p = 0.0065). Post-operative stay was greater with POPA (7.7 ± 5.7 days), when compared to no POPA (2.0 ± 2.9 days; p = 0.0001). Conditions independently associated with POPA (p < 0.05) were cranial procedure, ASA level, and duration of surgery. POPA, acute trauma, duration of surgery, and inability to extubate in the OR were independently associated with post-operative stay (p < 0.05). POH, gastric dysmotility, acute trauma, cranial procedure, emergency procedure, and duration of surgery had independent correlations with post-operative length of stay (p < 0.05).

Conclusions

Adult surgical patients undergoing general anesthesia with horizontal recumbency have substantial POH and POPA rates. Hospital mortality was greater with POPA and post-operative stay was increased for POH and POPA. POH rates were noteworthy for virtually all categories of operative procedures and POH and POPA were independent predictors of post-operative length of stay. A study is needed to determine if modest reverse-Trendelenburg positioning during general anesthesia has a relationship with reduced POH and POPA rates.

Prophylactic glycopyrrolate reduces hypotensive responses in elderly patients during spinal anesthesia: a randomized controlled trial

BACKGROUND

Hypotension during spinal anesthesia is a serious complication in elderly patients. We evaluated the effect of glycopyrrolate on hypotensive responses in elderly patients undergoing spinal anesthesia.

METHODS

Sixty-six patients older than 60 yr of age scheduled for elective surgery with spinal anesthesia were included in the study. They received either glycopyrrolate 0.2 mg (group G) or normal saline (group C) intramuscularly 15 min before spinal anesthesia. The following outcomes were evaluated after the induction of spinal anesthesia: the incidence of hypotension and bradycardia, the ephedrine requirement, mean arterial pressure, heart rate, and the incidence of nausea and vomiting.

RESULTS

Twenty-three of 33 (70.0%) patients in group C experienced hypotension compared with nine of 33 (27.3%) patients in group G (difference = 42.7%; 95% confidence interval [CI]: 18.4 to 60.2; P = 0.001). The median [interquartile range] amount of ephedrine required was 5 [0-15] mg in group C compared with 0 [0-5] mg in group G (difference = 5.0 mg; 95% CI: 2.7 to 7.3; P = 0.001). Nine (27.3%) patients in group C experienced nausea and vomiting compared with 2 (6.1%) in group G (difference = 21.2%; 95% CI: 3.0 to 38.7; P = 0.044). Three (9.1%) patients in group C experienced bradycardia compared with 1 (3.0%) patient in group G (difference = 6.1%; 95% CI: -7.6 to 20.8; P = 0.613).

CONCLUSION

Prophylactic intramuscular glycopyrrolate reduced the occurrence and severity of hypotensive responses, the requirement for ephedrine, and the incidence of nausea and vomiting in elderly patients undergoing spinal anesthesia. The trial was registered at the Clinical Research Information Service, Republic of Korea (KCT0000556).

Development of a Visual Analogue Scale questionnaire for subjective assessment of salivary dysfunction

OBJECTIVE

This study's objective was to develop a Visual Analogue Scale (VAS) xerostomia questionnaire and to evaluate the validity and reliability for the clinical diagnosis of salivary gland dysfunction.

STUDY DESIGN

Thirty-six healthy adults participated in this double-blind, crossover study. Each subject received an antisialagogue (glycopyrrolate) or placebo. Unstimulated and stimulated parotid and submandibular saliva samples were collected 16 times over a period of 6 hours. An 8-item VAS xerostomia questionnaire was administered after each saliva collection.

RESULTS

The results demonstrated significant reliability for 7 of the 8 VAS items, whereas validity was significant for unstimulated submandibular saliva. Moving averages were calculated for VAS and salivary flow rate values, and significant correlations were observed between these factors, indicating that changes in VAS responses were predictive of changes in salivary flow.

CONCLUSIONS

These findings suggest that this VAS xerostomia questionnaire may be helpful in the diagnosis of salivary dysfunction and for detecting changes in salivary flow rate values over time.

Pre-emptive glycopyrrolate 0.2 mg and bradycardia during gynaecological laparoscopy with mivacurium

In a prospective, randomized, double-blind, placebo-controlled trial, the effect of pre-emptive glycopyrrolate 0.2 mg given intravenously on the incidence of bradycardia in patients undergoing elective gynaecological laparoscopy with mivacurium neuromuscular blockade was investigated. Seven out of 32 (21.6%) control patients developed bradycardia (heart rate < 50 min-1), compared with 3 of 31 (9.6%) patients receiving glycopyrrolate (P = 0.4). Glycopyrrolate 0.2 mg, given immediately before induction in gynaecological laparoscopy with mivacurium, did not significantly reduce the incidence of intraoperative bradycardia.