A SMOOTH
EMERGENCE
Jerod Schell, SRNA
Oakland University-Beaumont Hospital
Graduate Program of Nurse Anesthesia
Lidocaine vs. Alfentanil: its uses perioperatively
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Why so concerned?
What is the incidence of coughing on emergence from
general anesthesia (GA) with an endotracheal tube??
Adverse side effects: HTN, tachycardia, tachyarrhythmia,
ICP, IOP to name a few…
Current methods for a smooth emergence = deep
extubation, lidocaine jelly, LITA, short acting opioids.
Research Study Info:
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Sadegi, M., Firozian, A., Ghafari, M.H. and
Esfehani, F. (2008).
Comparison in Effect of Intravenous Alfentanil and
Lidocaine on Airway-Circulatory Reflexes during
Extubation.
International Journal of Pharmacology. 4(3). 223226.
Dr. Ali Shariati Hospital, Medical
Sciences/University of Tehran, Iran.
Materials with Inclusion/Exclusion:
RCT, double-blind study
 Female patients undergoing Cesarean Section with ETT
GA.
 Ages 18-35
 ASA I or II
---------------------------------------------------------------- Respiratory Disease, recent URI, previous laryngeal
pathology or surgery, CAD, HTN (taking cardiac meds),
smokers, opioid addiction, local anesthetic allergy – All
Excluded.
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Methods:
1)
2)
3)
4)
5)
Standard Induction using Thiopental and Succinylcholine 1.5
mg/kg.
Used cuffed 7.0 mm OET, inflated with 2 ml greater than
minimal leak pressure
GA with Isoflurane at 1 MAC before delivery and 0.5 MAC
after, with Oxygen and Nitrous Oxide (50%). Muscle
relaxant sustained with Atracurium then IV morphine given
after birth.
After delivery, anesthetic gases turned off, oropharynx
suctioned then 100% oxygen delivered for remainder of
case.
Then……
Now the actual experiment…
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1)
2)
“Randomly generated computer assignment”
15 mcg/kg Alfentanil
-or1.5 mg/kg 2% Lidocaine IV
Anesthetists would administer the given dose after
return of spontaneous respiration, then after 2
minutes the patient was extubated.
What was measured?
Systolic and Diastolic BP
 Heart Rate
 Cough: yes or no.
-Hemodynamics measured 2 minutes after the end of
surgery and served as baseline values
Then re-assessments 2 minutes after study drug given
and 1 minute after extubation with comparisons
made.

Coughing
Statistics
Hemodynamic Statistics
Statistically significant data for both
categories except baseline values.
Statistical analysis
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Distribution was checked by Kolmogorov Test
Statistical comparison by T-test, Mann-Whitney Utest, and Chi-square Test.
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Significant when P <.05, two tailed.
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How were subjects treated??
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Narcotics and Lidocaine are both used in practice
today, merely a comparison to current acceptable
therapies.
Typically do not have scheduled Cesarean Sections
with a GETA…
Study Notes: Discussion
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No patients excluded
No laryngospasm or bronchospasm
Negative effects avoided:
-Stress reactions
-Intracranial, Intrabdominal pressure
-Avoid bleeding or severe injury during emergence.
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Study Notes (cont.)
Controlled timing very well.
 Previous Lidocaine studies cannot statistically prove
an improved emergence, only clinical experience
with practitioners.
 Narcotic delay??
-No clinically significant delay in emergence with
narcotic use.
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Study Limitations:
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Narrow patient population
Healthy individuals
Not all institutions use Alfentanil
Can we use this tomorrow?

Alfentanil = opioid agonist
-Precaution with Respiratory disease, can use as surgical
anesthesia or analgesia.
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Cost: 500 mcg/ml = $5.26 per ml.
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- about $10 per 70 kg patient.
The Art of Anesthesia….
Emergence