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Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 1-2

What is new in critical illness and injury science? Benefits of co-induction anesthesia in supraglottic airway management

Department of Anaesthesiology and Critical Care, UCMS and GTB Hospital, Dilshad Garden, Delhi-110095, India

Date of Web Publication11-Apr-2012

Correspondence Address:
Sujata Chaudhary
Department of Anaesthesiology and Critical Care, UCMS and GTB Hospital, Dilshad Garden, Delhi-110095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5151.94864

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How to cite this article:
Chaudhary S. What is new in critical illness and injury science? Benefits of co-induction anesthesia in supraglottic airway management. Int J Crit Illn Inj Sci 2012;2:1-2

How to cite this URL:
Chaudhary S. What is new in critical illness and injury science? Benefits of co-induction anesthesia in supraglottic airway management. Int J Crit Illn Inj Sci [serial online] 2012 [cited 2022 Dec 9];2:1-2. Available from: https://www.ijciis.org/text.asp?2012/2/1/1/94864

Use of supraglottic airway devices has brought a revolution in modern anesthesia. This is mainly because these devices are safe to use and their use is associated with minimal hemodynamic changes. However, insertion of these devices requires certain depth of anesthesia along with suppression of pharyngeal and laryngeal reflexes. Various agents have been tried to achieve this as inadequate depth of anesthesia or inadequate suppression of these reflexes can cause coughing, gagging and even laryngospasm. [1] Earlier, agents like thiopentone were used, and succinylcholine was added to facilitate airway insertion. [2] Recently, propofol, a non-barbiturate induction agent, has been used as a drug of choice for insertion of supraglottic airways and is considered superior to thiopentone sodium. Propofol is known to cause suppression of pharyngeal and laryngeal reflexes which requires a much higher dose, often exceeding a recommended dose of 2-2.5 mg/kg. As a result of this higher dose the adverse effects like apnoea, hypotension and bradycardia can occur. [3]

Combination therapy or co-induction therapy is a well accepted and useful technique described, where two or more drugs are used with an intention to reach the same therapeutic goal. Co-induction in anesthesia is used with an aim to reduce the dose of one induction agent by adding a small dose of another anesthetic agent or sedative. [4],[5],[6] The objectives of this technique are to improve the effect profile (by increasing ratio of desired effect as against the adverse effects) and decrease the consumption of costly drugs. Thus, the aim is to achieve the delicate balance of desired versus adverse effects. The term co-induction was introduced in 1986 to describe the unplanned induction of anesthesia by non-anesthetists who practice sedation. Various authors had combined opioids with benzodiazepines and this combination had synergistic effects, causing unplanned anesthesia in variable scenarios. Currently, planned co-induction of anesthesia is widely practised by anesthetists because of drug interactions between various drugs like benzodiazepines, fentanyl and propofol. These interactions can occur in all phases of anesthesia, including induction, maintenance or recovery. For day care surgeries and surgeries in critical patients, the combinations can be an advantage, especially when combining midazolam with propofol. These reduce the risk of awareness and also alleviate the dose of propofol. This also decreases adverse effects of propofol as it is the principal intravenous induction agent for day-case anesthesia.

Propofol is widely used as induction agent in modern anesthesia because of its unique properties. It is an expensive drug with adverse effects like hypotension, bradycardia and a brief period of apnoea. With this knowledge, a drug to be used for co-induction with propofol should have properties to counter these adverse effects. Various co-induction agents like midazolam, butarphanol and others have been used as co-induction agents with propofol without much benefit.

Fentanyl, an opioid was initially thought to be a good co-induction agent along with propofol. It can cause significant bradycardia and increased incidence of coughing, especially in dosages higher than 1μg/kg when used in combination with propofol. [7] In an earlier study, it was found that though fentanyl improves conditions during laryngeal mask insertion, it also prolongs duration of apnoea due to its central respiratory depressant action. [8]

Ketamine is one of the anesthetic drugs known to cause an increase in heart rate and blood pressure even in small sub-anesthetic dose (0.5 mg/kg), primarily due to its sympathomimetic action on sinus node. [9] It is also known to preserve rather stimulate respiration. Ketamine acts on NMDA, opioid and muscarinic receptors even in small doses. In a randomized controlled trial, it was observed that ketamine maintains higher blood pressure and heart rate as compared to fentanyl. [10] Another co-induction combination is ketamine and midazolam, as both are complementary to each other including benefits or disadvantages. The adverse effects of ketamine are usually countered by properties of midazolam and thus this combination should be effective for various surgeries.

These combinations help in alleviation of hemodynamic derangements and their synergistic effects can be utilized for insertion of supraglottic airways. Thus, in the present era of supraglottic airway management for providing anesthesia, ketamine may prove to be a promising co-induction agent with propofol for insertion of these devices.

   References Top

1.Brimcombe JR, Berry AM. The Laryngeal Mask Airway. In: The Difficult Airway I. Anesthesiol Clin North America 1995;13:411-37.  Back to cited text no. 1
2.Yoshino A, Hashimoto Y, Hirashima J. Low dose of succinylcholine facilitates airway insertion during thiopental anaesthesia. Br J Anaesth 1999;83:279-83.  Back to cited text no. 2
3.Chari P, Ghai B. Comparison of butarphanol-thiopentone versus fentanyl-thiopentone for LMA insertion. J Clin Anaesth 2006;18:8-11.   Back to cited text no. 3
4.Gupta A, Kaur S, Attri JP, Saini N. Comparative evaluation of ketamine-propofol, fentanyl-propofol and butorphanol-propofol on hemodynamics and LMA insertion condition. J Anesthesiol Clin Pharmacol 2011;27:74-8.  Back to cited text no. 4
5.Uma S, Sharma N, Kumar A, Saxena S. Small dose propofol or ketamine as an alternative to midazolam co-induction to propofol. IJA 2006;50:112-4.  Back to cited text no. 5
6.Hui TW, Short TG, Hong W, Suen T, Gin T, Plummer J. Additive interactions between propofol and ketamine when used for anesthesia induction in female patients. Anesthesiology 1995;82:641-8.  Back to cited text no. 6
7.Erden IA, Pamuk AG, Akinci SB, Koseolgu A, Aypar U. Comparison of propofol-fentanyl with propofol-fentanyl-ketamine combination in pediatric patients undergoing interventional radiology procedures. Paediatr Anesth 2009;19:500-6.  Back to cited text no. 7
8.Wong CM, Critchley LA, Lee A. Fentanyl dose response curves when inserting the classic laryngeal mask airway. Anaesthesia 2007;62:654-60.  Back to cited text no. 8
9.Cheam EW, Chuii PT. Randomised double blind comparison of fentanyl- mivacurium or placebo to facilitate laryngeal mask airway insertion. Anesthesia 2000;155:323-6.  Back to cited text no. 9
10.Goh PK, Chiu CL, Wang CY, Chan YK, Loo PL. Randomised double blind comparison of ketamine-propofol, fentanyl-propofol and propofol saline on haemodynamic and laryngeal mask insertion conditions. Anaesth Intensive Care 2005;33:223-8.  Back to cited text no. 10


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