A comparison of haemodynamic responses between clinical assessment-guided tracheal intubation and neuromuscular block monitoring-guided tracheal intubation: A prospective, randomised study

Abstract

Background and Aims:Haemodynamic responses to laryngoscopy and endotracheal intubation and their hazards are well documented. The purpose of the study was to compare the effects of laryngoscopy and intubation on cardiovascular responses when the appropriate moment for intubation was directed by either clinical judgment or train-of-four assessment.Methods:A total of 68 patients, posted for laparoscopic cholecystectomy, were randomised into two groups. In Group M patients, the trachea was intubated after train of four counts became zero in adductor pollicis muscle, whereas in Group C patients, the trachea was intubated after the clinical judgment of jaw muscle relaxation. Changes in heart rate (HR) and mean arterial pressure, intubating conditions and the time between the administration of a neuromuscular blocking agent and endotracheal intubation were recorded. Results were analysed by the Analysis of variance and chi-square tests.Results:HR and mean arterial pressure were significantly higher in Group C as compared to Group M after laryngoscopy and tracheal intubation (P < 0.05). The mean time required for intubation was significantly shorter in Group C compared to Group M (175 ± 7 s vs. 385 ± 101 s). Excellent and good intubation conditions were observed in all Group M patients, whereas 24 out of 34 patients (70%) in Group C showed excellent and good intubation conditions.Conclusion:Haemodynamic responses to laryngoscopy and tracheal intubation can be significantly attenuated if tracheal intubation is performed following complete paralysis of laryngeal muscles, detected by neuromuscular monitoring of adductor pollicis muscle.

Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta‐Analysis

“…Unexpected intraoperative vocal fold movement and coughing could occur due to the inconsistency between the degree of relaxation of laryngeal muscles and the response of peripheral muscles to TOF under neuromuscular block monitoring 9–12 . In this situation, hemodynamic instability or unintended trauma could occur 13–15 . Therefore, the secondary outcome was defined as the incidence of perioperative complications.…”

“…In addition, laryngeal muscles are recovered more quickly from muscle relaxation than peripheral muscles, and they can move even when there is no movement in the adductor pollicis muscle 7–12 . Moreover, unexpected intraoperative coughing and vocal fold movement can cause hemodynamic instability or unintended trauma during endolaryngeal surgery 13–15 . Previous reports have demonstrated that deep NMB could provide better surgical conditions than moderate NMB during laparoscopic surgery, such as cholecystectomy, hysterectomy, prostatectomy, and laparoscopic bariatric surgery 16–23 .…”

“…[7][8][9][10][11][12] Moreover, unexpected intraoperative coughing and vocal fold movement can cause hemodynamic instability or unintended trauma during endolaryngeal surgery. [13][14][15] Previous reports have demonstrated that deep NMB could provide better surgical conditions than moderate NMB during laparoscopic surgery, such as cholecystectomy, hysterectomy, prostatectomy, and laparoscopic bariatric surgery. [16][17][18][19][20][21][22][23] Therefore, deep NMB anesthesia is typically preferred from the surgeon's perspective.…”

A Synopsis of Contemporary Anesthesia Airway Management

“…Absence of complete neuromuscular blockade during intubation has also been associated with increased tachycardia and hypertension. Nandi and colleagues noted that intubation conditions were worse and there was more tachycardia and hypertension during intubation when intubation proceeded according to clinical impression of adequate relaxation rather than by verifying the presence of neuromuscular blockade with a nerve stimulator [11]. This increased heart rate and blood pressure may have resulted from the increased force required during laryngoscopy to expose the larynx when neuromuscular blockade had not been fully established yet.…”

Impact of Different Stimulation Patterns of Neuromuscular Blockade Monitoring and Clinical Assessment on Intubation Time and Intensity of Hemodynamic Response During Rocuronium Induced Endotracheal Intubation

“…Nandi et al [10] concluded that using NMB monitoring offer more satisfactory intubating conditions comparing to clinical judgement as well as attenuated hemodynamic response to laryngoscopy and intubation. Study of Witkowska et al [11] showed that more time was required for intubation when NMB monitoring is used, but with better intubation conditions and minimal cardiovascular response.…”