Abstract
The study was designed to understand the effects of oxycodone hydrochloride and sufentanil used in painless fiberoptic bronchoscopy. A total of 90 patients aged 3–84 years undergoing painless fiberoptic bronchoscopy were selected, American Society of Anesthesiologists (ASA): I–III criteria—the equal number of subjects were randomly divided into sufentanil group (group A) and oxycodone hydrochloride group (group B). The vital signs, surgical examination and anesthesia, the effect of anesthesia, and adverse reactions were compared between the two groups during the operation. The change of heart rate and changes of hemodynamics in group B were found to be lower than in group A. The number of breaths was significantly lower than group B. The decrease of SpO2 in group A was higher than in group B. Cases of SpO2 <90% was higher in group A than in group B. The dosage of propofol and the recovery time in group A was significantly higher than in group B. The incidence of nausea and vomiting in group A was higher than in group B. Oxycodone hydrochloride combined with propofol used in painless fiberoptic bronchoscopy could improve the safety and efficiency of analgesia compared to sufentanil combined with propofol. The effect was found to have stable hemodynamics and fewer adverse reactions.
Introduction
Fiberoptic bronchoscopy (bronchoscopy) is a common outpatient procedure performed employing local surface anesthesia during which patient is always awake. Pain and fear during surgery can lead to physical and psychological discomfort. Application of bronchoscopy has not only been confined to the examination but also been used for therapeutic procedures. 1 Painless bronchoscopy anesthesia involves the use of sedative and analgesic drugs intravenously or by inhaling to make the patient safe and comfortable. Painless bronchoscopy allows the patient to wake up quickly after bronchoscopy avoiding physiological and psychological discomfort compared to the conventional bronchoscopy. Opioid drugs combined with propofol or diazepam are used in painless fiberoptic bronchoscopy. These drugs still pose some problem such as respiratory or circulatory inhibition or poor anesthesia effect.2–4 Oxycodone hydrochloride injection is a new type of μ and κ opioid receptor agonist, which has a rapid onset, lower rate of respiratory depression, 5 and better effect on visceral pain compared to μ opioid receptor agonists. However, there are only few studies on the use of oxycodone for painless bronchoscopy and its effect is still not clear. In this study, we compared the effect of oxycodone hydrochloride and sufentanil in painless fiberoptic bronchoscopy, trying to provide more reference for clinical applications.
Data and methods
Study subjects
Methods
We selected 90 patients aged 36–84 years who were undergoing fiberoptic bronchoscopy (from February 2014 to October 2016).
Inclusion criteria
(1) American Society of Anesthesiologists (ASA) grade I to grade III and (2) informed patients and their families agreed. The signed informed consents were obtained voluntarily.
Exclusion criteria
Patients with suspected difficult airway, coagulation abnormalities, suffering from mental illness or un-controlled mental disorders, long-term user of sedatives and analgesics, and allergic to lidocaine, propofol, oxycodone, or use-dependent patients.
Withdrawal criteria
The emergence of intractable hypoxemia during the examination, severe arrhythmias, and hemodynamic fluctuations in the examination.
Research group
All the patients were randomly divided into sufentanil group (group A) and oxycodone hydrochloride group (group B), 45 subjects in each group. Randomization was done by the study statistician with blocks of four using a computer-generated list. The descriptions of the two groups are shown in Table 1.
Basic information of two groups.
ASA: American Society of Anesthesiologists.
Anesthesia
Each patient was asked for a preoperative 8-h fasting. Using the ECG monitor, blood pressure (every 3 min), heart rate, oxygen saturation, electrocardiogram, and respiratory rate were then routinely monitored. Upon establishing vein channel, 0.5 mg of penehyclidine hydrochloride was then intravenously injected. The patient was employed with a special fiberoptic bronchoscopy mask and connected to the anesthesia machine with continuous oxygen inhalation at a flow rate of 3 L/min. We then used lidocaine aerosol (7% total 25 g per bottle, each containing lidocaine 4.5 mg) on patients as throat surface anesthesia (time interval = 2 min, each of two press; each press = 2.5 mg, total = 27 mg), while second surface anesthesia is through slow intravenous injection in advance by hand and diluted to 10 mL with liquid: group A, 0.15 µg/kg sufentanil and group B 0.1 mg/kg oxycodone. Three minutes after topical anesthesia, 2 mg/kg of propofol was intravenously infused, which was pumped continuously at 4–6 mg/kg/h. When patients did not respond to our call and no eyelash reflex was observed, bronchoscopy was started through the glottis and into the trachea. A total of 1–2 mL of 2% lidocaine hydrochloride (gas) was injected to perform as surface anesthesia to treat pain caused by bronchoscopic biopsy hole. The patient underwent spontaneous breathing during the surgical examination. If the airway was obstructed but SpO2 was <90%, we assisted ventilation, but if SpO2 was <85%, the patient was immediately withdrawn from the bronchoscope and the pressure mask was manually ventilated until SpO2 was >98%. In case the patient appeared to cough and move, we intravenously injected 20–30 mg propofol. In case of less than 50 bpm heart rate, intravenous injection of 0.2 mg atropine was administered. When the blood pressure was less than 30% of the basal blood pressure, the ephedrine hydrochloride 6 mg was injected. On the contrary, when the blood pressure was above 30% of the basal blood pressure, intravenous injection of urapidil 5–10 mg was given. At the end of the examination, we stopped pumping propofol. When the patient was fully awake, breathing well, and the life characteristics were stable (after 30 min), they were sent back to the ward.
Instruments and drugs
Equipments
Mindray PM-8000 ECG (Shenzhen MINDRAY Bio Medical Electronic Limited by Share Ltd), OLYMPUS MH-553 bronchoscopy (OLYMPUS Medical Corporation), Drager Fabius plus anesthesia machine (Shanghai Drager Medical Instrument Limited Company), bronchoscopy mask (Guangzhou City Mingjia Medical Instrument Manufacturing Co. Ltd), and micro-injection pump (Smith Medical Instrument Co., Ltd, Zhejiang).
Pharmaceuticals
Penehyclidine hydrochloride injection (1 mg; Chengdu Lisite Pharmaceutical Co Ltd, No: H20020606), lidocaine aerosol (25 g; Shanghai Xinyi Pharmaceutical Co. Ltd, No: H10920107), sufentanil citrate injection (50 µg; Yichang Renfu Pharmaceutical Co., Ltd, No: H20054172), oxycodone hydrochloride injection (10 mg; HAMOL Ltd, the drug import registration certificate number: H20130314), lidocaine hydrochloride injection (0.1 g; Chinese Medicine Group Rongsheng Pharmaceutical Co. Ltd, No: H20043676), and propofol injection(0.2 g; Sichuan Guorui pharmaceutical Ltd Liability Company, No: H20030115).
Prepared instruments and medicine
Aspirator, sputum suction tube, laryngoscope, various endotracheal tubes, oropharynx, airway, and other possible rescue equipment and drugs.
Observation index
Time and target of vital signs in patients
The patients were observed and recorded when entering the operating room (T1), the bronchoscopy was monitored when reaching the glottis (T2), after tracheal carina (T3), inspected completely (T4), 10 min after the completion of the examination (T5), and mean arterial blood pressure (MAP), heart rate (HR), SpO2, and respiratory rate (RR) were monitored.
Index of surgical examination and anesthesia
Total dose of propofol, time of bronchoscopy, and time of recovery (from discontinuation to Alertness/Sedation Scale) (OAA/S) = 3 min were recorded.
The effect of anesthesia and the index of adverse reaction
Following criteria were set for the evaluation of anesthesia. 6 Excellent anesthetic effect: smooth bronchoscopy operation, patients remaining silent during microscopic examination, occasional slight cough, no nausea and retching; good anesthetic effect: smooth bronchoscopy operation, mild cough during microscopic examination, cough less than six times, occasional nausea and retching; medium anesthetic effect: smooth bronchoscopy operation, continuous cough during microscopic examination, mild nausea and retching; and poor anesthetic effect: no smooth bronchoscopy operation, restless patient, violent cough lasting for a long time during microscopic examination, symptoms of nausea and frequent retching, hard breath or hypoxia cyanosis for long time.
We also recorded more than three body-moving incidents, the number of patients with SpO2 <90%, the number of postoperative nausea and vomiting in 6 h, and the number of vertigo occurred within 6 h after operation.
Statistical method
SPSS V23 statistical software was used for statistical analysis. The measurement data were expressed as mean ± standard deviation (x ± sd). Measurement data were compared using t test, count data were compared using χ
2
test. The value of
Result
Comparison of basic data of two groups
There were no significant difference of the basic data, including age, gender, weight, and ASA classification, between the two groups (
Comparison of vital signs in patients undergoing surgery
The MAP, HR, SpO2, and RR were not significantly different between two groups (groups A and B) at T1 (
Vital signs of patients during operation.
MAP: mean arterial blood pressure; HR: heart rate; RR: respiratory rate.
Comparison of examination and anesthesia
There was no significant difference in the time between the two groups (
Comparison of anesthetic effect and adverse reaction
There was no significant difference in the anesthetic effect (
Anesthetic effect and adverse reactions.
Discussion
This study compared the effect of propofol combined with oxycodone and propofol combined with sufentanil for fiberoptic anesthesia. There are relatively few works on the use of oxycodone for painless fiberoptic bronchoscopy. Our study found that, when the operating time is also the most intense stimulation from bronchofibroscopic after tracheal carina (T3) to complete the examination of fiberoptic bronchoscopy (T4), left the glottis in group B than group A; the blood flow mechanics changed, the change in heart rate was more stable and small during the procedure indicating the patients with a better analgesic effect in group B than group A. Oxycodone could be directly applied to μ and κ receptors in the bronchus that increases the tolerance of bronchoscopy patients and reduces the stress response during the operation. 7 These effects are conducive to the stability of circulatory system.
It is interesting to note that the number of breaths, counted from the beginning of stage T2 until T5, in group A was significantly lower than in group B. However, the decrease in SpO2 in group A was significantly higher than in group B from stage T3 to stage T5. The number of cases of SpO2 <90% during the entire procedure in group A was more than in group B suggesting the respiratory inhibition of sufentanil was stronger than oxycodone. Action of the anesthetic drugs may be explained as follows: (1) inhibitory effect of sufentanil with μ receptor typical respiration can produce synergistic effect with propofol. Oxycodone produces analgesia by μ and κ receptors inhibiting the respiration itself, may be light, and does not significantly increase the propofol respiratory inhibition; 8 (2) sufentanil group may not provide enough inhibition of stress response of the airway, causing cough and airway spasm, checking the bronchoscopic placement, which in turn may result in a decline in ventilation and reduce SpO2. In addition, oxycodone has a good analgesic effect. It may also function in the bronchial mucosa and smooth muscle in μ and κ receptors, reduce airway sensitivity, and reduce the stress response of inspection. But the oxycodone may also have a direct effect on the central and medulla cough antitussive effect and reduce the occurrence of bucking less inspection. 7
The number of patients included in our study was relative small. Further study with larger sample size is recommended to validate our data.
Conclusion
Oxycodone hydrochloride injection combined with propofol used in painless fiberoptic bronchoscopy provided safe and effective analgesia than traditional sufentanil combined with propofol anesthesia. The effect was very good providing stable hemodynamics and fewer adverse reactions.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
This work was supported by the Chengdu Health and Family Planning Commission medical research project (Project Number: 2015045).
