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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 359-366

Effects of nitroglycerine spray and lignocaine spray on the hemodynamic responses to laryngoscopy and endotracheal intubation: A comparative study


Department of Anaesthesiology, Dr. D Y Patil Medical College, Pimpri, Pune, Maharashtra, India

Date of Submission22-Feb-2020
Date of Decision06-Jun-2020
Date of Acceptance13-Jun-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Dr. Mary Samuel
Department of Anaesthesiology, Dr. D Y Pati Medical College, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_19_20

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  Abstract 


BACKGROUND: Laryngoscopy and tracheal intubation cause hypertension and tachycardia in anesthetized patients, which is undesirable, especially in patients with cardiovascular or neurosurgical diseases undergoing anesthesia. Various drug regimens and techniques have been used from time to time for attenuating the pressor response to laryngoscopy and tracheal intubation. The aim is to study, evaluate, and compare the efficacy of nitroglycerine (NTG) spray and 10% lignocaine spray in the attenuation of hemodynamic responses to laryngoscopy and endotracheal intubation and to observe and evaluate any side effects if any associated with the use of these drugs and their management.
MATERIALS AND METHODS: This study was conducted on ninety patients under the American Society of Anesthesiologists (ASA) I and ASA II scheduled for elective surgeries. The patients were divided randomly into equal groups of 30 patients and received the following drugs before induction of general anesthesia: Group N-30 patients will be given NTG sublingual spray (2 puffs) 800 mcg 60s before laryngoscopy and group L-30 patients will be given lignocaine spray (2 puffs) 20 mg 60s before laryngoscopy. Hemodynamic variables were continuously recorded from baseline until 15 min after intubation and statistically analyzed.
RESULTS: The demographic profile was comparable. The heart rate (HR) increased in both groups, although the increase in HR in the lignocaine group is higher than the increase in HR in NTG group. There was a significant difference in HR values immediately after intubation, 1, 3 min, and 5 min after intubation when the values were lower in group N, and the difference was statistically significant (P < 0.05). At 10 min and 15 min after intubation, there was no statistically significant difference between the HR values of both the groups (P > 0.05). There was a significant difference in systolic blood pressure (SBP) values immediately after intubation, 1, 3, and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05). At 10 min and 15 min after intubation, there was no statistically significant difference between the SBP values of both the groups (P > 0.05). At 1, 3, and 5 min after intubation, the SBP values were significantly higher than baseline in the lignocaine group. However, there was a downward trend in SBP observed in the NTG group until 5 min after intubation, and it was statistically significant. There was a significant difference in diastolic blood pressure (DBP) values immediately after intubation, 1, 3 and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05). At 10 min and 15 min after intubation, there was no statistically significant difference between the DBP values of both the groups (P > 0.05). The increase in mean DBP observed in the lignocaine spray group was statistically highly significant when compared to the increase in mean DBP in the NTG spray group. There was a significant difference in mean arterial pressure (MAP) values immediately after intubation, 1, 3 and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05). At 10 min and 15 min after intubation, there was no statistically significant difference between the MAP values of both the groups (P > 0.05). NTG spray decreases the MAP more effectively as compared to lignocaine following laryngoscopy and endotracheal intubation.
CONCLUSION: Based on our study, we conclude that: In lignocaine spray group patients who received a dose of 20 mg (2 puffs), there was a significant rise in HR, SBP, DBP, mean arterial blood pressure. In the NTG spray group patients who received a dose of 800 mcg (2 puffs), there is effective attenuation of the pressor response to laryngoscopy and intubation in normotensive ASA I–II patients. However, NTG is not able to attenuate the rise in HR due to reflex tachycardia due to vasodilation. Thus, it can be a better alternative in attenuating the hemodynamic responses to laryngoscopy and intubation.

Keywords: Endotracheal intubation, hemodynamic response, laryngoscopy, lignocaine spray, nitroglycerine spray


How to cite this article:
Datla S, Samuel M, Teja V, Fathima, Kumari A. Effects of nitroglycerine spray and lignocaine spray on the hemodynamic responses to laryngoscopy and endotracheal intubation: A comparative study. Int J Health Allied Sci 2020;9:359-66

How to cite this URL:
Datla S, Samuel M, Teja V, Fathima, Kumari A. Effects of nitroglycerine spray and lignocaine spray on the hemodynamic responses to laryngoscopy and endotracheal intubation: A comparative study. Int J Health Allied Sci [serial online] 2020 [cited 2020 Nov 26];9:359-66. Available from: https://www.ijhas.in/text.asp?2020/9/4/359/298117




  Introduction Top


Endotracheal intubation has been an integral part of anesthetic management and critical care of the patient and has been practised following its description by Rowbotham and Magill in 1921.[1]

In 1940, Ried and Brace first described the hemodynamic response to laryngoscopy and tracheal intubation.[2] Subsequently, Hassan et al. in 1991 in their study reported the high incidence of untoward hemodynamic responses following laryngoscopy and intubation.[3]

Laryngoscopy and tracheal intubation are noxious stimuli that evoke a transient but marked response in the cardiovascular, respiratory, and other physiological systems, which are manifested as significant tachycardia, hypertension, and dysrhythmias.[4],[5],[6]

Usually, these transient changes have no deleterious consequences in healthy individuals, but in some patients with untreated hypertension, coronary heart disease, intracranial aneurysm, intracranial hypertension or thyrotoxicosis they can provoke cardiac arrhythmias, left ventricular dysfunction, myocardial ischemia, and cerebral hemorrhage,[5],[7] so prevention of these responses remains an important clinical goal particularly for the patients with cardiac or cerebral disease.[5]

The cardiovascular response is a reflex phenomenon mediated by vagus (X) and glossopharyngeal (IX) cranial to cause a sympathetic adrenal response to release adrenaline and noradrenaline.[4],[8],[9] These hemodynamic responses should be suppressed to balance the myocardial oxygen supply and demand which is the key to the safe conduct of anesthesia[10] otherwise, the pulse rate (PR) can increase from 26% to 66% and systolic blood pressure (SBP) from 36% to 45%. Furthermore, it is previously reported that 10%–18% of the patients develop ischemic changes during the procedure.[11],[12]

Over the years, many researchers have adopted various methods for attenuating the pressor response using various inhalational and other pharmacological agents.[13]

Many of them included deepening the level of anesthesia. These inhalational agents sufficiently blunted the laryngoscopic reactions. However, as the depth of anesthesia increased, the myocardial depression caused by these agents also increased, leading to an increased risk of bradycardia, hypotension, and dysrhythmias.[4]

Intravenous (IV) anesthetic induction agents alone do not adequately suppress the pressor responses evoked by endotracheal intubation. Therefore, before initiating laryngoscopy and endotracheal intubation additional pharmacological measures should be taken to obtund these responses including agents like lignocaine, beta-blockers, direct-acting vasodilators such as sodium nitroprusside and nitroglycerine (NTG), opioids like fentanyl, calcium channel blockers like nifedipine and verapamil have been used to prevent the pressor response to laryngoscopy and tracheal intubation.[12],[14],[15],[16],[17],[18],[19]

NTG is an organic nitrate that acts principally on venous capacitance vessels to produce peripheral pooling of blood and decreased cardiac ventricular wall tension. It acts by generating nitric oxide (NO), which stimulates the production of cyclic guanosine monophosphate to cause peripheral vasodilatation.[20] NTG is available as tablets, ointment, solution for IV use, transdermal patches, or sprays administered sublingually. The NTG spray contains 0.4 mg/dose.

Lignocaine is an amide and by its local anesthetic property has been shown to ameliorate the pressor response to laryngoscopy and endotracheal intubation.[21] Lignocaine is available as an aerosol spray, IV solution, topical ointment, transdermal patch, and eye drops. Lignocaine spray is a 10% aerosol preparation which delivers 10 mg with each puff.

Aims and objectives

This comparative study has been planned to compare the efficacy of NTG spray with lignocaine spray for the attenuation of pressor responses to laryngoscopy and endotracheal intubation and to evaluate the side effects if any. This is done by comparing the effects of NTG spray and lignocaine spray on the changes in heart rate (HR), SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP), oxygen saturation (SpO2) during laryngoscopy and endotracheal intubation.


  Subjects and Methods Top


Type of study: Prospective, randomized controlled study. Period of study: August 2017 to September 2019

  • Period required for data collection: 1.5 years
  • Period required for data analysis and reporting: 6 months
  • Sample size: 60 cases. 30 cases for each group.


By keeping the significance level of 5%, power of the study at 80% and based on the study by Madhuri Gopal, the sample size was calculated using Winpepi statistical package. The minimum sample size required was 30 in each group. Thus we conducted the study on 60 patients, after dividing 30 patients in each group for better validity of results.

Place of study: Tertiary center.

After approval from the medical ethics committee, the study was carried out on Sixty (60) patients undergoing elective surgeries under standard general anesthesia who were selected randomly after applying the already mentioned stringent inclusion and exclusion criteria.

All the patients were divided randomly into two groups, namely Group N and Group L. An informed and written consent was taken from every case selected for the study. Patients will be randomly allocated using a computer generated number table to one of the two groups according to the drug to be used:

  • Group N-30 patients will be given NTG sublingual spray (2 puffs) 800 mcg 60s before laryngoscopy
  • Group L-30 patients will be given lignocaine spray (2 puffs) 20 mg 60s before laryngoscopy.


All patients were thoroughly examined at least 48 h before surgery. All relevant laboratory and other investigations were done. Only the American Society of Anesthesiologists (ASA) grade I/II patients were accepted. All patients were kept nil per orally for at least 6 h before surgery.

All monitors, such as noninvasive blood pressure, pulse oximeter, and electrocardiogram (ECG) were connected to the patient. The vein was secured using 20G IV cannula and slow IV infusion of ringer lactate was started. Baseline vital parameters, namely PR, SBP, DBP, MAP and SpO2 were recorded. All patients received the following drugs as premedication intravenously before induction of general anesthesia:

Injection glycopyrrolate 0.004 mg/kg body weight, injection midazolam 0.02 mg/kg bodyweight, injection ondansetron 0.1 mg/kg bodyweight, injection fentanyl 1 μg/kg body weight.

After sufficient preoxygenation with 100% oxygen for 3 min, induction of general anesthesia is done with injection propofol (2 mg/kg) given intravenously slowly till the patient is induced and the vital parameters were recorded again. Oxygen and Nitrous oxide (50% each) given through a face mask along with isoflurane (0.8%–1%). The vital parameters recorded again. Laryngoscopy and tracheal intubation is attempted by the same trained and qualified anesthesiologist, followed by recording of the vital parameters. Once the tracheal intubation has been achieved, the surgery was allowed to proceed after fixing the endotracheal tube and confirming the bilateral air entry and giving positive pressure ventilation. The periodic monitoring of the vital parameters was carried out at the interval of 1, 3, 5, 10, and 15 min after laryngoscopy and tracheal intubation.

Anesthesia was maintained with 65% nitrous oxide and 35% oxygen mixture along with isoflurane 0.8-1% with controlled ventilation and intermittent doses of Vecuronium as and when required. During surgery, continuous PR, blood pressure, ECG monitoring, urine output, and blood loss were noted. Replacement of fluid was done with crystalloids or colloids, and if blood loss is extensive (>10% of blood volume), fluid will be replaced with the appropriate quantity of cross-matched blood. At the end of the surgery, the patient was reversed with injection neostigmine (0.05 mg/kg body weight) along with injection glycopyrrolate (0.008 mg/kg body weight) IV, the patient was extubated and the patient's PR, blood pressure, MAP, SpO2 and ECG were recorded. The patient was then shifted to the recovery room.

Statistical analysis

All cases were completed in stipulated time. Data were collected, compiled, and tabulated. The statistical analysis was performed using the parametric test and the final interpretation was based on Z-test (standard normal variate) with 95% level of significance. The confidence interval is taken as 95%, so P < 0.005 is considered statistically significant.

  • Results were statistically analyzed
  • Quantitative data were analyzed by the Student t-test
  • Qualitative data were analyzed by Chi-square test.



  Results Top


In the current study, we have assessed the effect of NTG spray and Lignocaine spray-on hemodynamic responses to laryngoscopy and endotracheal intubation.

The hemodynamic response and postoperative complications, if any after administering the drugs, were assessed as a prospective randomized controlled study.

Following were the observations in our study:

  • The study includes a total of 60 patients. Thirty patients in each group N (NTG) and group L (lignocaine)
  • Comparison of age: Mean age in group N was 34.63 (standard deviation [SD] ± 10.555), in group L was 36.43 (SD ± 10.464). Mean age among different groups was analyzed quantitatively and was statistically not significant (P > 0.05)
  • Comparison of gender: There was no statistically significant difference between the two groups with respect to gender distribution (P > 0.05)
  • Comparison of weight: Mean weight in group N was 57.60 (SD ± 7.295), in group L was 54.27 (SD ± 5.4777). Mean weight among the two groups was analyzed quantitatively and was statistically not significant (P > 0.05)
  • ASA distribution: There was no statistically significant difference between ASA grade distribution in both groups (P > 0.05).


[Table 1] shows the comparison of HR between group N and group L at baseline, after administering drug, immediately after intubation, 1 min after intubation and 5 min after intubation, 10 min after intubation and 15 min after intubation. Mean and SD of HR was calculated at each interval.
Table 1: Comparison of heart rate in study groups

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We recorded the values of HR at fixed intervals in both the groups, as shown in the observation table. These values were compared using two independent sample t-tests. We found that there was no statistically significant difference between group N and group L with respect to HR at baseline and while administering the drug (P > 0.05).

There was a significant difference in HR values immediately after intubation, 1, 3, and 5 min after intubation when the values were lower in group N, and the difference was statistically significant (P < 0.05).

At 10 min and 15 min after intubation, there was no statistically significant difference between the HR values of both the groups (P > 0.05).

[Table 2] shows the comparison of SBP among groups N and L at baseline, after administering the drug, immediately after intubation, 1 min after intubation, 5, 10, and 15 min after intubation. Mean and SD of SBP was calculated at each interval.
Table 2: Comparison of systolic blood pressure in study groups

Click here to view


We recorded the values of SBP at fixed intervals in both the groups, as shown in the observation table. These values were compared using two independent sample t-tests. We found that there was no statistically significant difference between group N and group L with respect to SBP at baseline and while administering the drug (P > 0.05).

There was a significant difference in SBP values immediately after intubation, 1, 3, and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05).

At 10 min and 15 min after intubation, there was no statistically significant difference between the SBP values of both the groups (P > 0.05).

[Table 3] shows a comparison of DBP among groups N and L at baseline, after administering the drug, immediately after intubation, 1 min after intubation, 5, 10, and 15 min after intubation. Mean and SD of DBP was calculated at each interval.
Table 3: Comparison of diastolic blood pressure in study groups

Click here to view


We recorded the values of DBP at fixed intervals in both the groups, as shown in the observation table. These values were compared using two independent sample t-tests. We found that there was no statistically significant difference between group N and group L with respect to DBP at baseline and after administering the drug (P > 0.05). There was a significant difference in DBP values immediately after intubation, 1, 3, and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05). At 10 and 15 min after intubation, there was no statistically significant difference between the DBP values of both the groups (P > 0.05).

[Table 4] shows a comparison of MAP among groups N and L at baseline, after administering the drug, immediately after intubation, 1 min after intubation, 5, 10 and 15 min after intubation. Mean and SD of MAP was calculated at each interval.
Table 4: Comparison of mean arterial pressure in study groups

Click here to view


We recorded the values of MAP at fixed intervals in both the groups, as shown in the observation table. These values were compared using two independent sample t-tests. We found that there was no statistically significant difference between group N and group L with respect to MAP at baseline and after administering the drug (P > 0.05). There was a significant difference in MAP values immediately after intubation, 1, 3, and 5 min after intubation when the values were lower in group N and the difference was statistically significant (P < 0.05). At 10 and 15 min after intubation, there was no statistically significant difference between the MAP values of both the groups (P > 0.05).

Comparison of saturation

We recorded the values of SpO2 at fixed intervals in both the groups, as shown in the observation table. These values were compared using two independent sample t-tests. We found that there was no statistically significant difference between group N and group L with respect to SpO2 values (P > 0.05).

Electrocardiogram

ECG was monitored continuously in all cases for both the groups. ECG was within normal limits throughout the procedures in all the patients.

In group N, out of the 30 patients, three patients had an incidence of hypotension, and no patients in group L showed any episodes of hypotension [Table 5].
Table 5: Comparison of side effects in study groups

Click here to view



  Discussion Top


Laryngoscopy and tracheal intubation are potent stimuli that increase HR and blood pressure, as has been recognized since 1951 by King and Harris.[4] These are produced due to sympathetic reflex provoked by stimulation of epipharynx and laryngopharynx. Reid and Brace[2] in 1940 first described the effect of endotracheal intubation on electrocardiograph which were in the form of the premature ventricular beat, nodal rhythm, and sinus bradycardia. The sensitive receptor area of epiglottis when mechanically stimulated by instrumentation evokes reflex response. Measurements of the plasma catecholamines have demonstrated an increase in noradrenaline following laryngoscopy and thus confirmed sympathetic mediation to this response. The increase in blood pressure is usually transitory, variable, and unpredictable. Complications of the pressor response following laryngoscopy and tracheal intubation include left ventricular failure, myocardial ischemia, increase in intracranial pressure, intracranial hemorrhage, and convulsions. These above-mentioned effects may have serious repercussions on the high-risk patients like those with cardiovascular disease, increased intracranial pressure, or anomalies of the cerebral vessels. Attenuation of such responses is of great importance in the prevention of perioperative morbidity and mortality.[9]

An ideal drug should have a rapid onset of action, be safe, and easily administrable with a relatively short duration of action. Hence, a drug which can blunt sympathetic response to laryngoscopy and intubation without any adverse effects is required for the purpose.

Selection of drugs and dosages

Lignocaine spray and NTG spray have been employed in their various routes to attenuate the pressor response to laryngoscopy and endotracheal intubation. NTG spray has been found by various authors to blunt the hemodynamic response to laryngoscopy and intubation. NTG originally used as antianginal agent, was found to reduce the blood pressure by preferentially dilating the venous capacitance vessels in low doses. Nitrates profoundly affect cardiac performances, myocardial oxygen demand and coronary blood flow; thus, reduction in myocardial ischemia, improves myocardial contractility. NTG is available for various routes of administration, such as IV, sublingual tablet, ointment, and pen spray. Lignocaine has been used in a number of studies and in its various modes of administration to attenuate the hemodynamic responses to laryngoscopy and intubation. Lignocaine, as an IV agent and as a topical agent, has been used widely for this purpose.

In the current study, we have used and compared the effectiveness of NTG spray 800 mcg and 10% lignocaine spray 20 mg in the attenuation of pressor response to laryngoscopy and endotracheal intubation.

Demographic profile

In each group, 30 patients were selected after considering inclusion and exclusion criteria.

The patients in both groups did not show any statistically significant differences in their age, gender, and weight distribution and in terms of ASA grading (P > 0.05).

Hemodynamic parameters

Baseline parameters

In our study, baseline values (before administering any drug) of HR, SBP, DBP, and MAP were comparable in both the groups N and L, i.e., P value was not significant (P > 0.05).

All the groups were similarly premedicated.

Heart rate

In this study, HR was analyzed quantitatively within groups for each stage from baseline to 15 min after intubation.

[Table 1] shows the variation in HR.

There was a clinically and statistically significant difference in HR values 1, 3, and 5 min after intubation (P < 0.05). After intubation, until 10 min, the HR in both the groups is raised. The HR was lower in group N compared to group L at both these times. There was an increase in the HR in NTG group in the immediate postintubation period and the following few minutes due to its direct action of reflex tachycardia caused by peripheral vasodilatation. The increase in the HR of the lignocaine group was higher when compared to the NTG group. Both the drugs do not completely abolish the increase in HR after intubation but the increase is higher in the lignocaine group when compared to NTG group, although the increase in HR in the NTG group can be attributed to reflex tachycardia that occurs as a consequence of vasodilation.

Systolic blood pressure

[Table 2] shows “Variation in Systolic blood pressure.”There was no statistically significant difference in SBP values between the two groups, at baseline and while administration of study drugs (P = 0.27).

At intubation, 1, 3 and 5 min after intubation, the SBP was lower than baseline in the NTG group; however, the values were higher in the lignocaine group as compared to NTG group and this was statistically significant (i.e., P < 0.05). The maximum rise in SBP values in the lignocaine group was seen at 3 min after intubation in our study (140.47± 5.93). In comparison, there was a fall in SBP in the NTG group, with the maximum fall seen 3 min after intubation.

NTG spray totally abolished the rise in SBP due to laryngoscopy and intubation, but lignocaine spray is ineffective in attenuating the rise in SBP as a consequence of laryngoscopy and intubation.

Diastolic blood pressure

[Table 3] shows “Variation in Diastolic blood pressure.”There was no statistically significant difference in DBP values between the two groups, at baseline and while administration of study drugs (P = 0.16 and P = 0.21, respectively). In the Lignocaine spray group, the increase in mean DBP was observed at 1, 3, 5 min after intubation when compared with baseline DBP and was statistically significant. In the NTG spray group, the increase in mean DBP observed is only marginal when compared with basal DBP and was statistically not significant. Statistical evaluation between the groups showed that the increase in mean DBP observed in the lignocaine spray group was statistically highly significant when compared to increase in mean DBP in the NTG spray group. The DBP values were significantly higher than baseline in the lignocaine group with the peak at 5 min after intubation. However, there was no significant increase in DBP observed in the NTG group. NTG spray totally abolished the rise in DBP due to laryngoscopy and intubation, but lignocaine spray is ineffective in attenuating the rise in DBP as a consequence of laryngoscopy and intubation.

Mean arterial pressure

[Table 4] shows “Variation in Mean arterial pressure.”There was no statistically significant difference in MAP values between the two groups at baseline and during the administration of the drug (P = 0.08, P = 0.09, respectively).

After 1, 3, and 5 min after intubation, the MAP was lower than baseline in NTG group; however, the values were higher than baseline in lignocaine, and this was statistically significant (i.e., P < 0.05). In the present study, after laryngoscopy and endotracheal intubation, the lignocaine group had an increase in MAP and the NGT group had a decrease in MAP. Hence, as per study, NTG spray decreases the MAP more effectively as compared to lignocaine following laryngoscopy and endotracheal intubation. Among the two drugs studied in the present study, NTG spray proved to be the better choice for attenuation of hemodynamic responses to laryngoscopy and endotracheal intubation.

In 1999, Mostafa et al.[22] attempted to attenuate the pressor response to laryngoscopy and intubation by using lignocaine spray and found out that there was a significant increase in HR by 28%, increase in SBP by 18%, increase in DBP by 28% when the spray was used before intubation.

Manjunath and Ravi,[23] in 2015 used 10% lignocaine spray for the attenuation of pressor response to laryngoscopy and intubation and found that there was a significant increase in HR by 13%, increase in SBP by 2.23%, increase in DBP BY 3% when the spray was used before intubation.

In 2016, Kumari et al.[24] studied the efficacy of nitro-glycerine lingual spray in attenuating the pressor response following intubation. They observed that NTG spray does not attenuate the increase in HR, and they observed a trend toward fall in blood pressure, but it was clinically insignificant.

In 2017, Madhuri Gopal[25] conducted a comparative study comparing the efficacy of 0.8 mg oral spray of NTG and 100 mg oropharyngeal spray of lignocaine in attenuating the pressor response to laryngoscopy and intubation. In the lignocaine group, the HR increased by 24 bpm from baseline levels, and the NTG group had an increase of 21 bpm in the HR. The increase in mean SBP and DBP observed in the lignocaine spray group was statistically highly significant when compared to an increase in mean SBP and DBP in the NTG spray group.

In 2019, Alukkal et al.[26] compared the effects of NTG spray and lignocaine spray in the attenuation of pressor response to laryngoscopy and intubation and the rise in HR in both the groups after intubation and the rise in HR is significant in the NTG group in the first 3 min after intubation compared to lignocaine group that is because of its direct action of reflex tachycardia caused by peripheral vasodilation. They observed that the rise in SBP was significantly higher in the lignocaine group from the time of laryngoscopy till 5 min after that and there is significant attenuation of DBP caused by NTG spray in the immediate postintubation period.

Oxygen saturation

Mean SpO2 of group N and group L was compared at baseline, 5 min after administration of study drug, after induction, at intubation, 1, 3, 5, 10, and 15 min after intubation. The SpO2 was maintained between 99% and 100% in both groups. No fall in saturation was observed in any patient (P > 0.05).

The principal advantage of using NTG is that, while desirable and transient hypotension is achieved, cardiac output is not likely to decrease. Preload reduction and the accompanying decrease in ventricular end-diastolic pressure reduces myocardial oxygen demand and increases endocardial perfusion by dilating the coronary vessels, NTG may increase the coronary blood flow and oxygen delivery to the myocardium. Because of its predominantly vasodilatory action, it seems to be the best choice in patients with low cardiac output and moderately elevated resistance.

Myocardial oxygen consumption or demand (as measured by the pressure-rate product, tension-time index, and stroke-work index) is decreased by both the arterial and venous effects of NTG, resulting in a more favorable supply-demand ratio.

Limitations

There were some limitations to the study. First, the study was carried out in patients who were normotensive, not having associated cyclic vomiting syndrome or central nervous system disease. Our findings cannot be extrapolated in patients with hypertension, ischemic heart disease or difficult airway. Second, no invasive methods of recording blood pressure or pulmonary artery pressure were used, so beat to beat fluctuation of BP cannot be measured. Our study was conducted on ASA grades I and II patients. Hence, further studies on elderly patients and those with compromised cardiac function, are required to recommend its use in such high-risk patients. Furthermore, we did not measure plasma catecholamine levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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