Alfentanil Pretreatment for Electroconvulsive Therapy-Associated Hemodynamic Lability: A Prospective Randomized Crossover Trial.

OBJECTIVES: Electroconvulsive therapy (ECT) is frequently associated with significant hemodynamic changes that increase myocardial oxygen demand including significant hypertension poststimulus. This raises concern about the cumulative effect of repetitive stress from ECT. Historically, various agents have been used to blunt this response and reduce hemodynamic fluctuations in these patients with varying degrees of efficacy. We hypothesized that bolus alfentanil administration timed with the ECT stimulus may reduce near-term hypertension and heart rate (HR) increases in patients undergoing ECT. METHODS: A randomized, double-blind, placebo-controlled AB/BA crossover trial of 87 patients 18 years or older with mood disorders was carried out. Patients received a standardized anesthetic regimen including induction with methohexital and succinylcholine and were randomized to receive either 20 µg/kg ideal bodyweight of alfentanil or placebo 60 seconds before the ECT stimulus for the first treatment and then crossed over to the other group for the second treatment. The primary outcome was the within-individual difference in preinduction systolic blood pressure and the first systolic blood pressure after the ECT stimulus. RESULTS: Eighty-seven patients completed the protocol. The primary outcome of increase in systolic blood pressure pre-ECT to post-ECT was 16.9 mm Hg less in the alfentanil group than the placebo group (95% confidence interval, -26.0 to -7.8; P < 0.001). The maximum HR was 6.5 beats per minute lower (95% confidence interval, -12.1 to -0.9; P = 0.024) when patients received alfentanil compared with placebo. CONCLUSIONS: Premedication with alfentanil reduces poststimulus hypertension and increased HR in patients receiving ECT and therefore, may reduce morbidity related to this in susceptible patients.

A Prospective Observational Comparison of Two Approaches to Anesthetizing the Trachea for Awake Intubation.

BACKGROUND: Multiple techniques have been described for anesthetizing the lower glottis and trachea prior to awake fiberoptic intubation. The primary aim of this study is to evaluate whether direct application of local anesthetic to the lower airway via an epidural catheter under direct vision is equally efficacious when compared to use of a transtracheal block in adult patients with an anticipated difficult airway. METHODS: Patients age >18 years requiring awake fiberoptic intubation who underwent upper and lower airway topicalization were observed prospectively. Following topicalization of the upper airway, patients underwent either a transtracheal block or had their trachea and lower glottis anesthetized under direct vision via dispersion of local anesthetic through a multi-orifice epidural catheter. Choice of technique was at the discretion of the attending anesthesiologist. The primary outcome was defined as the degree of coughing observed at the time of intubation based on a 4-point ordinal scale. RESULTS: Awake intubations in 88 patients were observed with 44 patients undergoing transtracheal block and 44 patients undergoing the epidural catheter technique. Degree of coughing with intubation was similar for each approach with a coughing score of (0, IQR (0,1)) versus (0, IQR (0,1)) in the epidural catheter and transtracheal groups respectively (p = 0.385). Duration of procedure was less in the transtracheal group (1.35 ± 1.54 min) vs. epidural catheter approach (2.86 ± 2.20 min) (p< 0.001). CONCLUSION: The epidural catheter and transtracheal approach appear to be equally effective at preventing coughing with intubation during awake fiberoptic intubation.