PREINDUCTION%20INTRAVENOUS%20LABETALOL%20FOR%20ATTENUATING%20INTUBATION%20STRESS%20RESPONSE

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PREINDUCTION INTRAVENOUS LABETALOL FOR
ATTENUATING INTUBATION STRESS RESPONSE

• DR. A. KARTHIK
• KILPAUK MEDICAL COLLEGE

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• GUIDE
• PROF. DR. P.S.SHANMUGAM, MD, DA
• HEAD OF DEPARTMENT
• DEPARTMENT OF ANAESTHESIOLOGY,
• KILPAUK MEDICAL COLLEGE.
• ETHICAL COMMITTEE APPROVAL OBTAINED

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AIM OF THE STUDY

• To study and compare the effects of
  Preinduction intravenous Labetalol at incremental
  doses of 0.25mg/kg 0.5mg/kg in attenuation of
  intubation stress response in General Anaesthesia

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STUDY DESIGN

• Randomized, Prospective study
• Pre study assessment done and consent obtained
  from all the patients

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PATIENT SELECTION

• INCLUSION CRITERIA
• 45 patients of ASA grade I II
• Age 18 60 yrs
• Both sex
• Elective surgery requiring general anaesthesia
  with endotracheal intubation

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• EXCLUSION CRITERIA
• Patient contraindicated to ?-blocker eg-
  Bronchial Asthma, Peripheral vascular disease,
  conduction defects
• Hypertensive patients, patients on Anti-HT drugs
• Systolic BP lt 90mmHg HRlt 50/mt
• Having preoperative airway or intubation problems
• Awake intubation or intubation taking more than
  20sec or requiring second attempt are excluded

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GROUPS

• GROUP A 15 patients receiving IV Normal saline
  (Placebo) prior to induction (Control)
• GROUP B 15 patients receiving Inj. Labetalol
  0.25mg/kg prior to induction
• GROUP C 15 patients receiving Inj. Labetalol
  0.5 mg/kg prior to induction

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MONITORING

• Pulse oximetry
• NIBP
• ECG

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METHODOLOGY

• 45 patients randomized into three groups of 15
  each
• Premedication Given i.m 45 min prior to surgery
• Inj. Glycopyrrolate 10ug/kg
• Inj. Pentazocine 0.5mg /kg
• Preoxygenation 100 O2 for 5 min
• Inj Labetalol/ Normal saline given iv 5 min prior
  to induction
• Induction Inj.Propofol 2mg/kg iv

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• NDMR Inj Rocuronium 0.9mg/Kg iv
• Patient ventilated with 100 O2 for 3 min
• Intubated with appropriate size ET tube
• Maintained with O2 N2O 12
• Volatile inhalational agents used only 10min
  after intubation

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• Pulse rate NIBP were recorded
• Preoperatively
• 45 min after premedication
• In the operating table before IV Labetalol/Normal
  saline
• For every min after IV Labetalol/Normal saline
  for 5 min
• After Induction
• After giving NDMR
• At laryngoscopy
• For every 1 min after Endotracheal intubation for
  10min

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Labetalol Mechanism

• Competitive, selective ?1 and non-selective
  ?-blocker
• ? gt ? blocking potency oral is 31, iv is 71
• It has intrinisic partial B2 agonistic activity
  hence causes vasodilation
• Onset 5-10 min
• Duration of action 3-6hrs
• T1/2 5-8hrs

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CVS Effects

• Decrease SVR leading to decrease in BP is by
  alpha -1 blockade
• Vasodilation also produced by partial B2 agonist
  activity
• Reflex tachycardia due to peripheral vasodilation
  is attenuated by B blockade
• Cardiac output remains unchanged
• Presynaptic alpha-2 receptors are spared- hence
  release of Norepinephrine is intact, which
  inhibits further release of catecholamine
  (Neg feedback mech)

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Adverse effects

• Orthostatic hypotension
• Bronchospasm
• Others- CCF, bradycardia, Heart block
• Increased plasma aminotransferase
• Paresthesia scalp tingling
• Urinary retention

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STATISTICAL ANALYSIS
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STATISTICAL TEST USED

• ANOVA test
• F test
• If significance is there, then subjected to Post
  Hoc Test

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ANALYSIS OF AGE AMONG THE GROUPS

• P value 0.834, which is not significant

AGE AGE AGE AGE AGE AGE AGE
95 Confidence Interval for Mean 95 Confidence Interval for Mean
Group N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 38.47 11.556 2.984 32.07 44.87
B 15 36.00 11.091 2.864 29.86 42.14
C 15 37.87 12.293 3.174 31.06 44.67
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COMPARISON OF PREOP HEART RATE AMONG THE GROUPS

PRE OP HR PRE OP HR PRE OP HR PRE OP HR PRE OP HR PRE OP HR PRE OP HR
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 85.87 12.677 3.273 78.85 92.89
B 15 86.87 8.823 2.278 81.98 91.75
C 15 85.13 11.250 2.905 78.90 91.36
P0.911 , NOT SIGNIFICANT
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COMPARISON OF PREOP SYSTOLIC BP AMONG THE GROUPS

PRE OP SBP PRE OP SBP PRE OP SBP PRE OP SBP PRE OP SBP PRE OP SBP PRE OP SBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 120.47 8.442 2.180 115.79 125.14
B 15 124.40 12.933 3.339 117.24 131.56
C 15 124.67 13.911 3.592 116.96 132.37
P0.567 , NOT SIGNIFICANT
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COMPARISON OF PREOP DIASTOLIC BP AMONG THE GROUPS

PRE OP DBP PRE OP DBP PRE OP DBP PRE OP DBP PRE OP DBP PRE OP DBP PRE OP DBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 79.33 6.287 1.623 75.85 82.81
B 15 80.13 8.684 2.242 75.32 84.94
C 15 82.87 7.717 1.993 78.59 87.14
P0.420 , NOT SIGNIFICANT
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COMPARISON OF HR AFTER 5MIN OF LABETALOL IV

5 MINUTES STUDY HR 5 MINUTES STUDY HR 5 MINUTES STUDY HR 5 MINUTES STUDY HR 5 MINUTES STUDY HR 5 MINUTES STUDY HR 5 MINUTES STUDY HR
          95 Confidence Interval for Mean 95 Confidence Interval for Mean
  N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 87.47 13.799 3.563 79.83 95.11
B 15 81.67 12.793 3.303 74.58 88.75
C 15 81.20 13.497 3.485 73.73 88.67
P0.368 , NOT SIGNIFICANT
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COMPARISON OF SYSTOLIC BP AFTER 5MIN OF LABETALOL
IV

5 MINUTES STUDY SBP 5 MINUTES STUDY SBP 5 MINUTES STUDY SBP 5 MINUTES STUDY SBP 5 MINUTES STUDY SBP 5 MINUTES STUDY SBP 5 MINUTES STUDY SBP
          95 Confidence Interval for Mean 95 Confidence Interval for Mean
  N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 121.47 8.782 2.268 116.60 126.33
B 15 122.00 12.012 3.101 115.35 128.65
C 15 122.13 12.432 3.210 115.25 129.02
P0.985 , NOT SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AFTER 5MIN OF
LABETALOL IV

5 MINUTE STUDY DBP 5 MINUTE STUDY DBP 5 MINUTE STUDY DBP 5 MINUTE STUDY DBP 5 MINUTE STUDY DBP 5 MINUTE STUDY DBP 5 MINUTE STUDY DBP
          95 Confidence Interval for Mean 95 Confidence Interval for Mean
  N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 79.27 6.076 1.569 75.90 82.63
B 15 73.40 9.635 2.488 68.06 78.74
C 15 71.80 9.445 2.180 66.12 76.48
P0.105, NOT SIGNIFICANT
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COMPARISON OF HEART RATE AT LARYNGOSCOPY

HR AT SCOPY HR AT SCOPY HR AT SCOPY HR AT SCOPY HR AT SCOPY HR AT SCOPY HR AT SCOPY
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 109.00 13.810 3.566 101.35 116.65
B 15 89.33 13.839 3.573 81.67 97.00
C 15 88.13 14.272 3.685 80.23 96.04
P0.000 , SIGNIFICANT By Post Hoc Test There
was a difference between the control Labetalol
groups, but there was no significant difference
between the two Labetalol groups (P0.815)
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COMPARISON OF HEART RATE AT 1 MIN AFTER INTUBATION

SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR SCOPY OF 1 MINUTE HR
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 104.00 11.946 3.085 97.38 110.62
B 15 87.20 13.262 3.424 79.86 94.54
C 15 86.27 15.285 3.947 77.80 94.73
P0.001, SIGNIFICANT By Post Hoc Test There
was a difference between the control Labetalol
groups, but there was no significant difference
between the two Labetalol groups (P0.851)
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COMPARISON OF HEART RATE AT 3 MIN AFTER INTUBATION

SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR SCOPY OF 3 MINUTES HR
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 96.67 11.592 2.993 90.25 103.09
B 15 83.13 13.081 3.378 75.89 90.38
C 15 83.07 13.488 3.483 75.60 90.54
P0.007, SIGNIFICANT By Post Hoc Test There
was a difference between the control Labetalol
groups, but there was no significant difference
between the two Labetalol groups (P0.989)
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COMPARISON OF HEART RATE AT 5 MIN AFTER INTUBATION

SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR SCOPY OF 5 MINUTES HR
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 92.93 11.985 3.094 86.30 99.57
B 15 81.93 12.981 3.352 74.74 89.12
C 15 80.93 12.355 3.190 74.09 87.78
P0.02, SIGNIFICANT By Post Hoc Test There was
a difference between the control Labetalol
groups, but there was no significant difference
between the two Labetalol groups (P0.827)
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COMPARISON OF HEART RATE AT 10 MIN AFTER
INTUBATION

SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR SCOPY OF 10 MINUTES HR
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 90.40 12.385 3.198 83.54 97.26
B 15 80.27 11.139 2.876 74.10 86.43
C 15 79.20 11.639 3.005 72.75 85.65
P0.022, SIGNIFICANT By Post Hoc Test There
was a difference between the control Labetalol
groups, but there was no significant difference
between the two Labetalol groups (P0.805)
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COMPARISON OF SYSTOLIC BP AT LARYNGOSCOPY

SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY SBP AT LARYNGOSCOPY
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 143.47 10.148 2.620 137.85 149.09
B 15 139.07 14.709 3.798 130.92 147.21
C 15 134.00 16.248 4.195 125.00 143.00
P0.189 , NOT SIGNIFICANT
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COMPARISON OF SYSTOLIC BP AT 1 MIN AFTER
INTUBATION

SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP SCOPY 1 MINUTES SBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 137.07 6.006 1.551 133.74 140.39
B 15 134.07 14.782 3.817 125.88 142.25
C 15 128.60 16.137 4.167 119.66 137.54
P0.212, NOT SIGNIFICANT
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COMPARISON OF SYSTOLIC BP AT 3 MIN AFTER
INTUBATION

SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP SCOPY 3 MINUTES SBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 130.07 4.448 1.148 127.60 132.53
B 15 125.20 15.232 3.933 116.76 133.64
C 15 122.07 13.614 3.515 114.53 129.61
P0.200, NOT SIGNIFICANT
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COMPARISON OF SYSTOLIC BP AT 5 MIN AFTER
INTUBATION

SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP SCOPY 5 MINUTES SBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 128.47 4.470 1.154 125.99 130.94
B 15 122.07 12.881 3.326 114.93 129.20
C 15 117.53 11.667 3.012 111.07 123.99
P0.021, SIGNIFICANT
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COMPARISON OF SYSTOLIC BP AT 10 MIN AFTER
INTUBATION

SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP SCOPY 10 MINUTES SBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 126.60 5.356 1.383 123.63 129.57
B 15 121.07 13.123 3.388 113.80 128.33
C 15 117.20 11.162 2.882 111.02 123.38
P0.051, NOT SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AT LARYNGOSCOPY

DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY DBP AT LARYNGOSCOPY
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 92.40 7.908 2.042 88.02 96.78
B 15 85.27 12.959 3.346 78.09 88.44
C 15 83.87 9.970 2.574 76.35 87.39
P0.039 , SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AT 1 MIN AFTER
INTUBATION

SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP SCOPY 1 MINUTES DBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 88.67 6.377 1.647 85.14 92.20
B 15 80.33 11.437 2.953 74.00 86.67
C 15 80.65 9.453 2.441 76.70 85.17
P0.023, SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AT 3 MIN AFTER
INTUBATION

SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP SCOPY 3 MINUTES DBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 84.80 6.472 1.671 81.22 88.38
B 15 77.27 11.455 2.958 70.92 83.61
C 15 78.93 9.869 2.032 73.58 83.29
P0.063, NOT SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AT 5 MIN AFTER
INTUBATION

SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP SCOPY 5 MINUTES DBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 82.40 5.816 1.502 79.18 85.62
B 15 74.40 10.782 2.784 68.43 80.37
C 15 71.87 8.624 1.968 67.64 76.09
P0.028, SIGNIFICANT
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COMPARISON OF DIASTOLIC BP AT 10 MIN AFTER
INTUBATION

SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP SCOPY 10 MINUTES DBP
95 Confidence Interval for Mean 95 Confidence Interval for Mean
N Mean Std. Deviation Std. Error Lower Bound Upper Bound
A 15 80.87 6.739 1.740 77.13 84.60
B 15 72.47 10.501 2.711 66.65 78.28
C 15 71.60 9.152 2.105 65.29 76.31
P0.021, SIGNIFICANT
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CONCLUSION

• Heart Rate
• Preinduction iv labetalol decreased the heart
  rate prior to induction in the Labetalol groups
  (decrease in Group CgtGroup BgtGroup A) at 5 min
  after labetalol injection. But it is not
  statistically significant
• Attenuation of heart rate at Laryngoscopy, at
  1min, 3min, 5min, 7min 10min after intubation
  (decrease in Group CgtGroup BgtGroup A) is
  statistically significant.
• Preop HR was achieved at 1 min after intubation

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HEART RATE
ANOVA ANOVA ANOVA ANOVA
F Sig.
SCOPY (0 MINUTE) HR Between Groups 10.543 .000
SCOPY OF 1 MINUTE HR Between Groups 8.116 .001
SCOPY OF 3 MINUTES HR Between Groups 5.664 .007
SCOPY OF 5 MINUTES HR Between Groups 4.292 .020
SCOPY OF 7 MINUTES HR Between Groups 4.195 .022
SCOPY OF 10 MINUTES HR Between Groups 4.164 .022
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CONCLUSION

• Systolic BP
• Preinduction iv labetalol had no change in the
  systolic BP prior to induction in the Labetalol
  groups at 5 min after labetalol injection.
• Attenuation of Systolic BP at Laryngoscopy, at
  1min, 3min, 7min 10min after intubation is not
  statistically significant (decrease in Group
  CgtGroup BgtGroup A)
• Preop systolic BP value was reached 3-5min after
  intubation

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SYSTOLIC BP
ANOVA ANOVA ANOVA ANOVA
F Sig.
SCOPY 0 MINUTES SBP Between Groups 1.731 .189
SCOPY 1 MINUTES SBP Between Groups 1.610 .212
SCOPY 3 MINUTES SBP Between Groups 1.673 .200
SCOPY 5 MINUTES SBP Between Groups 4.217 .021
SCOPY 7 MINUTES SBP Between Groups 3.086 .056
SCOPY 10 MINUTES SBP Between Groups 3.226 .051
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CONCLUSION

• Diastolic BP
• Preinduction iv labetalol decreased the diastolic
  BP prior to induction in the Labetalol groups
  (decrease in Group CgtGroup BgtGroup A) at 5 min
  after labetalol injection. But it is not
  statistically significant
• Attenuation of Diastolic BP at Laryngoscopy, at
  1min, 5min, 7min 10min after intubation is
  statistically significant (decrease in Group
  CgtGroup BgtGroup A)
• Preop diastolic BP was reached 2-3min after
  intubation

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DIASTOLIC BP
ANOVA ANOVA ANOVA ANOVA
F Sig.
SCOPY 0 MINUTE DBP Between Groups 2.154 .039
SCOPY 1 MINUTES DBP Between Groups 4.126 .023
SCOPY 5 MINUTES DBP Between Groups 3.896 .028
SCOPY 7 MINUTES DBP Between Groups 3.252 .049
SCOPY 10 MINUTES DBP Between Groups 4.236 .021
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CONCLUSION

• Both Group B C showed attenuation of intubation
  stress response(HR, Diastolic BP to a certain
  extent Systolic BP) compared to control group
  (Group A), but the difference between the two
  Labetalol groups is very less not statistically
  significant. Hence Labetalol 0.25mg/kg is quiet
  effective economical in attenuating stress
  response.

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THANK YOU