A priming dose of intravenous ketamine-dexmedetomidine suppresses fentanyl-induced coughing: a double-blind, randomized, controlled study

Inhibitory effect of low-dose esketamine on cough induced by sufentanil during the induction of anesthesia and postoperative impact on mental health status: a prospective, single-center, randomized controlled trial

BACKGROUND

Intravenous administration of sufentanil during anesthesia induction induces cough (SIC), sometimes triggers a severe reaction. We wanted to investigate the inhibitory effect of low-dose esketamine on cough induced by sufentanil during the induction of general anesthesia, as well as its postoperative impact on mental status (MMSE score, RSS, and VAS-A).

METHODS

A total of 256 adult patients were randomly allocated to receive either esketamine (Group EK) or normal saline (Group C). One minute before the administration of sufentanil, Group EK and Group C were injected with esketamine (0.05 mg/kg, diluted with normal saline to 3 ml) and normal saline (3 ml), respectively. The primary outcomes were the incidence (the basis of the presence or absence of cough) and severity (the frequency of cough episodes) of cough within 2 min after sufentanil injection.The secondary outcomes included hemodynamic variables (MAP, HR, and SPi), mental status (MMSE score, RSS, and VAS-A) and postoperative events (time to awareness, duration of orientation recovery and degree of satisfaction with anesthesia).

RESULTS

A total of 236 adult patients were randomized into two groups (n = 236): Group EK (n = 118) and Group C (n = 118). The incidence of cough in Group EK (21.2%) was significantly lower than that in Group C (40.7%) (P < 0.05). The incidence rates for each grade were as follows: 9.3% and 16.9% for Grade 2, and 0% and 4.2% for Grade 3, respectively.The differences had statistical senses.The MAP and HR at T4 (during tracheal intubation) and T5 (1 min post-intubation) were significantly lower in Group EK (P < 0.05). There were no significant differences in MMSE score, RSS, and VAS-A, time to awareness, duration of orientation recovery or satisfaction with anesthesia.

CONCLUSION

Pretreatment with low-dose esketamine can reduce the incidence and severity of cough induced by sufentanil and maintain hemodynamic stability during anesthesia induction without increasing mental status (MMSE score, RSS, and VAS-A).

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2400084940, date of registration: 05/28/2024).

Comparison of Five Prophylactically Intravenous Drugs in Preventing Opioid-Induced Cough: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background: Due to the absence of direct comparisons of different therapeutic drugs in preventing opioid-induced cough (OIC) during the induction of general anesthesia, clinicians often faced difficulties in choosing the optimal drug for these patients. Hence, this network meta-analysis was conducted to solve this problem.

Methods: Online databases, including Pubmed, Embase, Web of Science, Cochrane, and Google Scholar, were searched comprehensively to identify eligible randomized controlled trials (RCTs), up to March 15th, 2021. Within a Bayesian framework, network meta-analysis was performed by the “gemtc” version 0.8.2 package of R-3.4.0 software, and a pooled risk ratio (RR) associated with 95% credible interval (CrI) was calculated.

Results: A total of 20 RCTs were finally enrolled, and the overall heterogeneity for this study was low to moderate. Traditional pair-wise meta-analysis results indicated that all of the five drugs, namely, lidocaine, ketamine, dezocine, butorphanol, and dexmedetomidine could prevent OIC for four clinical outcomes, compared with the placebo (all p-values < 0.05). Moreover, dezocine had the best effect, compared with that of the other drugs (all p-values < 0.05). Network meta-analysis results suggested that the top three rank probabilities for four clinical outcomes from best to worst were dezocine, butorphanol, and ketamine based on individual/cumulative rank plots and surface under the cumulative ranking curve (SUCRA) probabilities. The node-splitting method indicated the consistency of the direct and indirect evidence.

Conclusions: Our results indicated that all of these five drugs could prevent OIC compared with the placebo. Moreover, the top three rank probabilities for four clinical outcomes from best to worst were dezocine, butorphanol, and ketamine. Our results were anticipated to provide references for guiding clinical research, and further high-quality RCTs were required to verify our findings.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021243358].

Comparison of Two Dosages of Ketamine in Preventing Fentanyl-Induced Coughs in Children

BACKGROUND

Fentanyl is a short-acting drug used to induce anesthesia. Here, we aimed to compare the two doses of ketamine to prevent fentanyl-induced cough in children under general anesthesia.

MATERIALS AND METHODS

This is a randomized, clinical trial which was performed in 2019 in Imam Hossein Hospital in Isfahan, Iran. The study population consisted of children between 6 months and 2 years who were candidates for general anesthesia. Patients were randomized into three groups, each containing 31 patients. Groups 1 and 2 received 0.1 mg/kg and 0.2 mg/kg intravenous ketamine, respectively, 1 min before fentanyl injections. Group 3 received the same volumes of normal saline 0.9%. Patients were observed and evaluated for the incidence and intensity of coughs 1 min and 3 min after fentanyl injections.

RESULTS

We showed that the frequency of coughs 1 min after fentanyl injection was significantly lower in Group 2 compared to other groups (P < 0.001). Three min after fentanyl injection, the frequencies of coughs were significantly lower in Groups 1 and 2 compared to Group 3 (P < 0.001). We also showed that the intensity of coughs was significantly lower in Group 2 compared to other Groups 1 and 3 min after fentanyl injection (P < 0.001).

CONCLUSION

The administration of 0.2 mg/kg ketamine is more effective than 0.1 mg/kg dosage in the prevention of fentanyl-induced cough. We also showed that this method could bring more stable hemodynamics and oxygenation saturation inpatients. The comparison of the two dosages was a novel issue in the recent literature.

Risk Factors for Fentanyl-Induced Cough Following General Anesthesia in Adults: A Retrospective Study from a Single Center in China

Background

Fentanyl-induced cough (FIC) during general anesthesia induction and postoperative nausea and vomiting are common complications, yet the risk factors for FIC remain controversial. This retrospective study was conducted at a single center in China and aimed to investigate the risk factors for fentanyl-induced cough following general anesthesia in adults.

Material/Methods

A total of 601 adult patients undergoing elective surgery were enrolled, and the incidence of FIC during general anesthesia induction and postoperative adverse events were recorded. The risk factors for FIC during general anesthesia induction and postoperative nausea and vomiting were assessed using multivariate logistic regression analysis.

Results

The incidence of FIC, nausea, and vomiting were 21.8%, 6.3%, and 4.5%, respectively. The results of multivariate logistic regression analysis indicated that pharyngitis history was associated with an increased risk of FIC during general anesthesia induction (odds ratio [OR]: 2.852; 95% confidence interval [CI]: 1.698–4.792; P<0.001), whereas use of lidocaine could protect against FIC risk (OR: 0.649; 95% CI: 0.557–0.757; P<0.001). However, the characteristics of patients were not associated with the risk of postoperative nausea and vomiting.

Conclusions

The findings from this study showed that a history of pharyngitis increased the risk of FIC, while the use of lidocaine was associated with a reduced risk of FIC. The risk of postoperative nausea and vomiting was not affected by fentanyl use or patient characteristics.

Dexmedetomidine versus midazolam for sedation during endobronchial ultrasound-guided transbronchial needle aspiration: A randomised controlled trial

BACKGROUND

Desaturation is a common complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine (DEX), a commonly used sedative in intensive care, is associated with less respiratory depression compared with other sedatives.

OBJECTIVE

We compared DEX with midazolam (MDZ) when used as a sedative during EBUS-TBNA.

DESIGN

A randomised, parallel, double-blinded trial.

SETTING

A university-affiliated teaching hospital between June 2014 and July 2015.

PATIENTS

A total of 102 patients who underwent EBUS-TBNA were randomly allocated to two groups (48 DEX group, 54 MDZ group).

INTERVENTIONS

DEX group received 0.25 to 0.75 μg kg-1 h-1 (start with 0.5 μg kg-1 h-1, modulated in three steps from 0.25 to 0.75 μg kg-1 h-1) of DEX after a loading dose of 0.25 μg kg-1 h-1 for 10 min to maintain a Ramsay Sedation Scale (RSS) of 3 to 5. If the patient was agitated, 1 mg of MDZ bolus was used as a rescue drug. Patients in the MDZ group initially received 0.05 mg kg-1 of MDZ as a bolus. For maintenance and rescue, 1 mg of MDZ bolus was used.

MAIN OUTCOME MEASURES

The primary outcome was the presence of oxygen desaturation. Secondary outcomes were level of sedation (Ramsay Sedation Scale score), cough score, sedation and procedure satisfaction score.

RESULTS

The baseline characteristics of the patients, duration of EBUS-TBNA procedures and the use of rescue MDZ were not different between the groups. There was no significant difference in desaturation events between the DEX and MDZ groups (56.3 and 68.5%, respectively; P = 0.20). The level of sedation and the sedation satisfaction scores were similar between the two groups. However, cough score was significantly lower in the DEX group (41.9 vs. 53.4; P = 0.02).

CONCLUSION

The use of DEX during EBUS-TBNA was not superior to MDZ in terms of oxygen desaturation.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02157818.

Effect of ketamine on emergence agitation following septoplasty: a randomized clinical trial

Background and objectives

The risk of emergence agitation (EA) is high in patients undergoing nasal surgery. The aim of the present study was to investigate the incidence of EA in adults undergoing septoplasty and the effect of ketamine on EA.

Methods

In this randomized study, a total of 102 ASA I–II patients who underwent septoplasty between July 2018 and April 2019 were divided into two groups: ketamine (Group-K, n = 52) and saline (Group-S, n = 50). After anesthesia induction, Group-K was intravenously administered 20 mL of saline containing 1 mg kg⁻¹ ketamine, whereas Group-S was administered 20 mL of saline. Sedation and agitation scores at emergence from anesthesia, incidence of cough, emergence time, and response to verbal stimuli time were recorded. The sedation/agitation and pain levels were recorded for 30 minutes in the recovery unit.

Results

There was no significant difference between the groups in terms of the incidence of EA (Group-K: 15.4%, Group-S: 24%). The incidence of cough during emergence was higher in Group-S than in Group-K, but the response time to verbal stimuli and emergence time were shorter in Group-S. The sedation and agitation scores were similar after surgery. Pain scores were higher in Group-S at the time of admission to the recovery unit and were similar between groups in the other time points.

Conclusion

Administration of 1 mg kg⁻¹ ketamine after anesthesia induction does not affect the incidence of EA in patients undergoing septoplasty, but it prolongs the emergence and response time to verbal stimuli and reduces the incidence of cough.

Drug-Induced Cough

Since the recognition of angiotensin-converting enzyme inhibitors (ACEIs)-induced cough, drug has been considered as a potential cause of chronic cough. This review presents recent knowledge on drug-induced coughs in patients with chronic cough. The focus is placed on ACEIs, for which there are a multitude of studies documenting their associations with cough. Additional drugs are discussed for which there are reports of cough as a side effect of treatment, and the potential mechanisms of these effects are discussed.

A small dose of dezocine suppresses remifentanil-induced cough in general anesthesia induction: a prospective, randomized, controlled study

Background

The aim of this prospective randomized controlled study was to evaluate whether pretreatment with a small dose of dezocine could prevent remifentanil-induced cough in general anesthesia induction.

Trial design

a prospective, randomized, controlled study.

Methods

A total of 210 patients receiving elective operative hysteroscopy from December 2018 to April 2019 were enrolled in the present study. They were randomly equally separated into dezocine group (n = 105) and control group (n = 105). Patients were intravenously pre-administrated with dezocine 0.03 mg/kg (diluted to 5 mL) or the same volume of normal saline 1 min prior to remifentanil infusion. One minute later, intravenous injection of propofol 1.5 mg/kg and cisatracurium 0.1 mg/kg were given to all patients for induction of general anesthesia. The counts of coughs occurred during the anesthesia induction period were recorded and the severity of cough was scaled.

Results

There were 7 cases of mild cough in dezocine group and 18 cases of mild cough, 12 cases of moderate cough and 4 cases of severe cough in control group. The incidence rate of cough was significantly lower and the severity of cough was obviously relieved in dezocine group compared to control group (6.67% vs. 32.38%, P <  0.001). The two groups were not significantly different in heart rate and mean arterial pressure before the induction, before and after the intubation, and in operating time and postoperative visual analog scale pain scores.

Conclusion

This study recommends the efficacy and safety of a pretreatment with a small dose of dezocine in reducing remifentanil-induced cough during general anesthesia.

Trial Registration

ChiCTR2000032035.

Date of registration: Retrospectively registered on 2020/04/18.

Dezocine prevents sufentanil-induced cough during general anesthesia induction: a meta-analysis of randomised controlled trials

Background

Sufentanil is one of the opioids currently used to induce general anesthesia, and cough is one of the most common complications. Many drugs have been used to prevent sufentanil-induced cough (SIC), and dezocine is one of them. Dezocine is an analgesic, acting as partial antagonist of κ-receptors and agonist of μ-receptors. The purpose of our meta-analysis is to evaluate the efficacy of dezocine on SIC.

Methods

We searched multiple databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and China National Knowledge Infrastructure databases (CNKI) to identify studies that met the inclusion criteria. This meta-analysis focused on the incidence and severity of SIC after dezocine intervention, as well as adverse effects. This meta-analysis was registered on PROSPERO with reference number ID: CRD 42020144943.

Results

Five randomised controlled trials (RCTs) were identified, including 890 patients. Each study was a comparison of dezocine with an equal volume of 0.9% saline. When the injection dose of dezocine was 0.1 mg/kg, the incidence (pooled risk ratio (RR) = 0.03, [95% CI: 0.02 to 0.07], P < 0.00001, I² = 0%) and severity (mild: RR = 0.07, [95% CI: 0.03 to 0.18], P < 0.00001, I² = 0%; moderate: RR = 0.05, [95% CI: 0.02 to 0.16], P < 0.00001, I² = 0%; severe: RR = 0.04, [95% CI: 0.01 to 0.16], P < 0.00001, I² = 0%) of SIC were significantly decreased. There were no statistically significant differences in vital signs between the two groups based on the results of the pooled analysis.

Conclusion

This meta-analysis showed that dezocine significantly reduced the incidence and severity of SIC in the induction of general anesthesia, but had no significant effect on vital signs. More high-quality RCTs are needed to complement existing conclusions.

Application via mechanical dropper alleviates sufentanil-induced cough: a prospective, randomized, single-blinded trial

Background

It was reported that prolonging the injection time or diluting administration can reduce the incidence of opioid-induced cough. However, the incidence of sufentanil-induced cough (SIC) via a standardized infusion rate is unclear. A mechanical dropper is an infusion filtering device commonly used for intravenous degassing; it can also be used to administer special drugs due to its temporary storage and dilution effect. This study assesses the effectiveness of administration via mechanical dropper on SIC.

Methods

Two hundred patients undergoing general anesthesia were enrolled. Patients received sufentanil at a strength of 0.3 μg·kg^− 1 either via T-connector (group C) or by mechanical dropper (group M) at 1 ml·s^− 1. Cough severity was graded as none (0), mild (1–2), moderate (3–5), or severe (> 5), and the incidence of SIC was evaluated for 5 min after the start of sufentanil injection. Other adverse reactions such as hypotension, hypertension, bradycardia, tachycardia, hypoxemia, vomiting, and aspiration during the induction period of general anesthesia were also observed. The primary outcome was the incidence of SIC. The secondary outcomes were the severity of SIC and other adverse reactions.

Results

The incidence of SIC in group M was significantly lower than that in group C (2% versus 21%, P = 0.000), and the prevalence of moderately severe coughing was also statistically different (none in group M versus 11% in group C, P = 0.001). However, there were no statistical differences in the incidence of other adverse reactions between two groups (P > 0.05).

Conclusion

Sufentanil application via mechanical dropper can significantly alleviate the occurrence of SIC during the induction phase of total intravenous general anesthesia. This method is simple, safe, and reliable, and has wide prospective application for clinical use.

Trial registration

Chinese Clinical Trial Register, ChiCTR-IOR-17011561. Registered on 3 June 2017.

Administration of fentanyl via a slow intravenous fluid line compared with rapid bolus alleviates fentanyl-induced cough during general anesthesia induction

OBJECTIVE

Fentanyl-induced cough (FIC) is a common complication with a reported incidence from 18.0% to 74.4% during general anesthesia induction. FIC increases the intrathoracic pressure and risks of postoperative nausea and vomiting, yet available treatments are limited. This study was designed to investigate whether administering fentanyl via a slow intravenous fluid line can effectively alleviate FIC during induction of total intravenous general anesthesia.

METHODS

A total number of 1200 patients, aged 18-64 years, were enrolled, all of whom were American Society of Anesthesiologists (ASA) grade I or II undergoing scheduled surgeries. All patients received total intravenous general anesthesia, which was induced sequentially by midazolam, fentanyl, propofol, and cisatracurium injection. Patients were randomly assigned to receive fentanyl 3.5 μg/kg via direct injection (control group) or via a slow intravenous fluid line. FIC incidence and the severity grades were analyzed with the Mann-Whitney test. Other adverse reactions, such as hypotension, hypertension, bradycardia, tachycardia, hypoxemia, vomiting, and aspiration, during induction were also observed. The online clinical registration number of this study was ChiCTR-IOR-16009025.

RESULTS

Compared with the control group, the incidence of FIC was significantly lower in the slow intravenous fluid line group during induction (9.1%, 95% confidence interval (CI): 6.7%-11.4% vs. 55.9%, 95% CI: 51.8%-60.0%, P=0.000), as were the severity grades (P=0.000). There were no statistical differences between the two groups with regard to other adverse reactions (P>0.05).

CONCLUSIONS

The administration of fentanyl via a slow intravenous fluid line can alleviate FIC and its severity during induction for total intravenous general anesthesia. This method is simple, safe, and reliable, and deserves clinical expansion.

Different interventions in preventing opioid-induced cough: a meta-analysis

BACKGROUND

Cough is one of the most common complications of opioids. Many studies have evaluated the effect of various drugs in preventing opioid-induced cough (OIC). However, there is existing controversy about those reports. The present study was performed to assess the efficacy of different interventions on OIC.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase to identify randomized controlled trials on the efficacy of different drugs in the prevention of OIC. Opioids included fentanyl, sufentanil, and remifentanil. We mainly investigated the incidence and severity of OIC after different interventions.

RESULTS

Thirty-four trials including 9906 patients were analyzed in this study. Twenty different drugs were reported, and 10 drugs were indentified in more than 2 articles. These drugs, including lidocaine, ketamine, dexmedetomidine, priming of fentanyl, propofol, dezocine, dexamethasone, dextromethorphan, and magnesium sulfate (MgSO4), showed a significant efficacy compared with controls. There were insufficient numbers of trials for salbutamol, clonidine, tramadol, pentazocine, rocuronium, midazolam, atropine, terbutaline, sodium chromoglycate, beclomethasone, and ephedrine. From these data, we found that salbutamol, tramadol, midazolam, and atropine were ineffective.

CONCLUSIONS

This meta-analysis suggested that the prophylactic administration of lidocaine, ketamine, dexmedetomidine, priming of fentanyl, propofol, and dezocine was effective in preventing OIC.