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Randomized Double Blind Control Study Comparing the Efficacy of Intracuff Alkalinized Lidocaine to Low Dose Remifentanil Infusion in Attenuating the Endotracheal Tube Induced Emergence Phenomena

Rashmi Vandse, Karina Castellon-Larios, Jeffrey Fujii, Somayah Melibary, Lai Wei, Sherry Nashed and Sergio Bergese

Emergence from general anesthesia is often complicated by the endotracheal tube (ETT) induced airway and circulatory reflexes which can lead to potentially dangerous complications. Considerable research has been focused on prevention of these emergence phenomena (EP). Nevertheless, the problem is still far from its final solution.

Objective: To compare the efficacy of intracuff alkalinized lidocaine (ICL) vs low dose remifentanil infusion in attenuating the ETT-induced EP. Methods: 120 ASA I-III patients, aged 18-65 years, were randomly assigned to receive intracuff alkalinized lidocaine (2% lidocaine mixed 1:1 with 1.4% NaHCO3) or an intravenous (IV) remifentanil infusion (0.05-0.5 mcg/ kg/min) combined with intracuff saline during desflurane-based general anesthesia. At the end of surgery, after desflurane was turned off in the assigned group, low dose remifentanil, or its equivalent placebo was decreased to one-tenth of the mean dose but not less than 0.01 mcg/kg/min and it was continued until extubation. A blinded researcher observed each patient from the time desflurane was discontinued until at least five minutes after extubation. Coughing was evaluated as either present or not, and graded on a point scale based on severity. The patients were also observed for development of any adverse events along with the vital signs during this emergence phase.

Results: The incidence (44% vs 67%, p=0.02) and severity of coughing, overall, was significantly less in the lidocaine group compared to remifentanil group). The lidocaine group also had a lower incidence of significant coughing (2-3 on point scale) (25% vs 49%, p=0.009). The mean arterial pressure (MAP) in the lidocaine group was lower than the remifentanil group at extubation and 5 minutes after extubation.

Conclusions: Intracuff alkalinized lidocaine (ICL) is more effective in reducing the incidence and severity of coughing compared to a low dose remifentanil infusion during emergence from desflurane based anesthesia