| Abstract|| |
Cannulations (peripheral vein, radial artery and jugular vein) performed for invasive monitoring before induction of anaesthesia in cardiac surgery patients may be associated with stress and anxiety. The efficacy and safety of butorphanol premedication was assessed in setting up of invasive monitoring. The study was a prospective, randomized, double blind, placebo controlled one with 70 patients undergoing elective cardiac surgery. In group-1 patients ( n = 35) (placebo) intramuscular saline was administered 1-2 hours before the surgery in equivalent volume to butorphanol. In group-2 ( n = 35) butorphanol (1, 1.5 and 2 mg for three body weight groups <40 kg, 41-60 kg and >60 kg, respectively) was administered 1-2 hours before surgery. Observer blinded for medication recorded the sedation score, pupil size and pain after each cannulation using visual analogue score (VAS). Student's ' t ' test and Chi-square test for proportions, Mann-Whitney test for non-parametric data was carried out. The median pain score of cannulation in group-2 (butorphanol) in the hand (10 mm) and neck (20 mm) were significantly ( P < 0.05) lower than group-1 (placebo) patients (hand = 30 mm and neck = 40 mm). Pain during neck cannulation was significantly ( P < 0.05) reduced (VAS < 30 mm) in patients with the pupil size of <2.5 mm. Since the pain during neck cannulation was more than pain during hand cannulations in both the groups, we conclude that the intensity of pain depends also upon the site of cannulation. Besides the analgesic effect of butorphanol, its sedative effect helped to effectively decrease the pain during neck cannulation in conscious patients.
Keywords: Butorphanol, cardiac surgery, internal jugular vein cannulation, pain, premedication, radial artery cannulation
|How to cite this article:|
Tripathi M, Nath SS, Banerjee S, Tripathi M. Butorphanol premedication to facilitate invasive monitoring in cardiac surgery patients before induction of anaesthesia. Ann Card Anaesth 2009;12:34-9
|How to cite this URL:|
Tripathi M, Nath SS, Banerjee S, Tripathi M. Butorphanol premedication to facilitate invasive monitoring in cardiac surgery patients before induction of anaesthesia. Ann Card Anaesth [serial online] 2009 [cited 2020 Jan 20];12:34-9. Available from: http://www.annals.in/text.asp?2009/12/1/34/45011
| Introduction|| |
Cannulation of radial and pulmonary artery before induction of anaesthesia is practised to get haemodynamic information at the time of induction of anaesthesia in cardiac patients. , However, since the stress of cannulation under local anaesthesia in conscious patients could potentially induce or worsen myocardial ischemia, , the cardiac patients are premedicated as a routine to minimise the stress. , Further, data suggest that the central venous catheter insertion may be faster and with fewer complications under sedation or anaesthesia.  Drugs used in premedication should be targeted to guard the patient's safety and welfare at minimal physical discomfort or pain; minimised negative psychological responses to cannulation by providing analgesia, amnesia and co-operative behaviour. While sedative premedication may be sufficient to allay the anxiety and amnesia, the analgesics may be beneficial for taking care of pain during cannulations performed before induction of anaesthesia.
Butorphanol tartarate is a potent synthetic analgesic which is an agonist-antagonist at opiate receptors  and has been used as the sole analgesic at all stages of anaesthesia-premedication, induction and maintenance in cancer surgery patients.  Since butorphanol premedication has been reported to be better than midazolam for its analgesic effect as premedicant in children,  we evaluated this drug as premedicant drug to facilitate the cannulations before anaesthesia in patients undergoing cardiac surgery.
| Materials and Methods|| |
The approval for the study protocol on humans was taken from the Institute's Ethical Committee. Informed written consent was taken from each patient. Taking into consideration the mean visual analogue score (VAS) for pain as 30 mm,  standard deviation as 1.5 and the significant improvement in pain by order of difference in VAS at 50% between the two groups, at the two-sided α-error of 0.05 and at power (1-β error - 95%), the number of patients required to be studied was 32 in each group. To avoid any short fall in number, 70 adult patients (New York Heart Association (NYHA) grades 2 and 3) undergoing elective cardiac surgery were enrolled in the study. The patients were introduced to the idea of VAS using 100 mm line to assess pain level  during preoperative visit. Patients who seemed unable to grasp the idea of VAS were excluded from the study at the time of preanaesthetic assessment.
All patients were given lorazepam (2 mg) orally the night before and the morning of surgery. Patients were randomly allocated into two study groups by computer generated random numbers kept in closed opaque envelopes. On the day of surgery, envelop was opened by the first author and the intramuscular medication was prepared and handed over to nursing staff for administration. The coding was mentioned on the file without informing the nature of premedication to the observer. At the end of study, all results were decoded to know the exact premedication received by the patients. In group 1 (control; n = 35), patients received intramuscular injection of saline 1-2 hours before surgery, equivalent in volume to the dose of butorphanol (1 mg/ml) used in group 2. In group 2 ( n = 35), patients were given intramuscular injection of butorphanol (1-2 mg) 1-2 hours before surgery depending upon the body weight (1 mg for patients weighing < 40 kg, 1.5 mg between 41-60 kg and 2 mg for >60 kg). Patients with cardiac failure or psychiatric illness or those already receiving oxygen by mask in ward were excluded.
Oxygen inhalation (8 l/min) through facemask was supplemented in all patients in preoperative ward after premedication. All patients were monitored for two leads (II and V) electrocardiography (ECG), non-invasive brachial artery blood pressure (3-minute interval), pulse oximetry and respiratory rate. In the operation theatre, three cannulations (peripheral vein with 16 G cannula, radial arterial with 22 G arterial catheter and the right internal jugular vein with 7 F sheath and pulmonary arterial catheter) were performed in each patient under local anaesthesia using lignocaine (1%) 1-2 ml at each site using insulin needle (26 G). The observer (second author) was blinded to the premedication. In the operation theatre, the observer noted down vital capacity using Wright's spirometer and the size of the pupil by matching it with pupil scale having circles drawn from 0.5 mm diameter to 5.0 mm at 0.5 mm increment and the level of sedation on six-point grades (1 = patient agitated and restless; 2 = awake, cooperative, and tranquil; 3 = drowsy, responds to commands; 4 = asleep, no response to verbal command but responds to touch; 5 = asleep, rouses sluggishly to painful stimuli; 6 = no response to painful stimuli). After securing radial artery cannula, the arterial sample was taken and blood gas analysis was performed by ABG auto-analyzer (AVL, India Ltd.).
After each cannulation, the pain of cannulation was marked by the patient on VAS on 100 mm line for the three sites. To complete all three cannulations within 15 minutes, the peripheral vein and radial artery were cannulated one-by-one by the same person and the other person completed the jugular puncture. We monitored the haemodynamic status (heart rate, arterial pressure), oxygen saturation of haemoglobin (pulse oximetry) and the incidence of side effects like, respiratory depression (respiratory rate < 8 breaths/min), hypoxaemia (oxygen saturation <90%) and hypotension (mean arterial pressure <60 mm Hg) in this period.
All data were entered in statistical program of social sciences (SPSS-12.0). Student's t test was used to compare the two study groups for patient characteristics. Chi-square test was applied to compare proportions and non-parametric Mann-Whitney test was applied to compare sedation grades and VAS for cannulation. All data of pain in neck and the pupil size were pooled together for correlation analysis between the two. Calculated value of P < 0.05 at 95% confidence was considered statistically significant.
| Results|| |
The patients were similar in terms of age, gender distribution, weight, height, body surface area, cardiac function and the predicted vital capacity in the two groups [Table 1]. The group-wise patient's distribution of the surgical procedures is given in [Table 1].
The patients in group-2 (butorphanol) were significantly ( P < 0.05) more sedated (median sedation grade-4 vs. grade-3 in group-1) in the operation theatre. The pain was significantly ( P < 0.05) higher at the neck cannulations in both groups (median VAS group-1 = 40 mm, group-2 = 20 mm) than at the hand (median VAS group-1 = 25 mm; group-2 = 10 mm) [Table 2]. Pupil size (media n = 2.0 mm) was significantly ( P < 0.01) smaller in group-2 patients than group-1 (media n = 3.5 mm) [Table 2] and [Figure 1].
The correlation analysis of the pooled data of the VAS at neck showed significant ( P < 0.001) direct correlation (Spearman rank correlation coefficient; r = 0.5210) of lesser pain with lesser pupil size [Figure 2]. The number of patients complaining more pain at neck than hand was significantly ( P < 0.05) less in group-2 (52%) than the group-1 (63%). Only 14% patients in group-2 had more pain in hand than neck, while 31% had it in group-1 [Figure 3]. Four patients in group-2 expressed zero VAS for both sites but none in group-1. While seven (20%) patients in group-1 were lightly sedated (grade-2), the deep sedation (grade-5) developed in 16 (46%) patients in group-2 [Figure 4].
The respiratory rate and forced vital capacity were similar in both groups. The mean partial pressure of oxygen (PaO 2 = 88 mm Hg), and oxygen saturation (SpO 2 = 94%) in group-2 was significantly ( P < 0.05) lower than the group-1, but the partial pressure of carbon dioxide (PaCO 2 ) was similar in both groups [Table 3]. In spite of lower mean SpO 2 in group-2, none of the patients had alarming desaturation (SpO 2 < 90%). Also, none of the patients had hypoventilation (respiratory rate below 10/min). The other side effects (nausea, vomiting, hypotension) were observed in insignificantly larger number of patients in group-2 than group-1 [Table 3].
| Discussion|| |
The study demonstrates that the butorphanol as premedicant before cardiac surgery provides better control of pain during peripheral (venous and radial arterial) or the central (jugular vein) cannulation under local anaesthesia. Patients premedicated with butorphanol had significantly reduced pupillary size correlating with decreased pain perception (< 30 mm on VAS scale) of cannulation.
Haemodynamic stability during anaesthetic induction is of utmost importance and setting up of invasive haemodynamic beat-to-beat pressure monitoring for early recognition of extreme haemodynamic changes in cardiac patients before the induction of anaesthesia has been supported, , as well as countered in different studies. ,
The premedication in cardiac surgery should provide anxiolysis, amnesia and sedation to counter stress, and adequate analgesia for the pain of needle puncture and manipulation of the catheters. Ideally, these effects should be achieved with minimal respiratory depression or hypoxia and good cooperative patient with airway control. Numerous combination regimens of drugs like benzodiazepines, antiemetic/sedative and opioids have been used to attain these goals with varied success, not to exclude the side effects. Contrary to combined premedicants resulting in over sedation, progressive hypoxaemia, hypercarbia and fresh ECG changes, , the butorphanol as premedicant was associated with good sedation, significantly lesser pain of cannulations (IJV in particular) and stress (ST segment change) than the placebo group patients.
Opioid premedication has been in use for cardiac surgery to ensure adequate sedation, analgesia and reduced anaesthetic requirement.  Butorphanol tartrate is a synthetic agonist-antagonist opioid and is approximately five times as potent as morphine. , Its suitability as premedication drug in patients for general surgery has been reported without antagonism to fentanyl.  We observed significant miosis in patients after butorphanol premedication, which correlated with the lesser pain perception, that is, smaller the pupil size lesser the pain perception for cannulation. Miosis is the characteristic of its opioid agonistic effects on central nervous system, same as with morphine.  We have found that pupil size monitoring can be of paramount importance to ascertain the effectiveness of the butorphanol and the pupil size of ≤ 2.5 mm corresponded with VAS ≤ 30 mm at the neck cannulation, which became similar to that of peripheral cannulation pain reported in another study (VAS = 30 mm). 
Methods such as, local anaesthetic (LA) application,  infiltration, ,, warming  and the superficial cervical plexus block  have been described to reduce the pain of cannulation. The pain of cannulation performed under LA infiltration did not correlate either with the size of cannula, operator's experience, patient's age and gender or the associated painful condition in emergency patients.  However, it was interesting to note that the pain during IJV puncture and cannulation in neck was higher than that of hand in our patients in both the study groups. However, a sizable number of patients (16/70 = 23%) complained of more pain in hand than in the neck and further analysis confirmed that this pain was complained by patients in whom there were multiple attempts for radial artery cannulation. The pain perception which was more at the neck in control group-1 patients was equal for both the sites in a significantly higher number of patients after butorphanol premedication including zero pain at both sites in four patients, who had no memory of the cannulation. It emphasizes that the pain of cannulation is also affected by the site of puncture in un-anaesthetized patients, that is, more pain at neck than hand. Thus, the butorphanol premedication modulated pain perception at the neck, which was more than the pain of peripheral cannulations.
Cardiac surgery patients are prone to develop hypoxaemia in the preoperative period after sedative or opioid premedication which may not respond to oxygen supplementation.  Our observation of lower PaO 2 and SpO 2 were similar with the findings of hypoxemia reported in previous studies using premedication with sedatives,  morphine or lorazepam,  in cardiac surgery patients, however, the desaturation did not reach the usually accepted clinically significant level (<90%) in any patient. It could be that all of our patients received supplementary oxygen by face mask and the lorazepam medication as part of institute's protocol. It emphasized the need to use supplemental oxygen in cardiac patients. Further, our findings of insignificant differences in the respiratory rate, PaCO 2 and forced vital capacity in the two groups indicated that butarphanol can be used safely in these patients. The incidence of side effects like nausea, vomiting and hypotension was similar to other studies using opioid premedication or butorphanol in non-cardiac surgery patients. ,
In conclusion, we wish to recommend butorphanol as premedication drug for cardiac surgeries as its combined analgesic and sedative effects adequately modified the pain perception (≤ 30 mm on VAS) by patients for the jugular cannulation as compared to placebo group. It would be interesting to compare it with other opioid premedicants.
| References|| |
|1.||Waller J, Zaidan J, Kaplan J, Bauman D. Hemodynamic responses to preoperative vascular cannulation in patients with coronary artery disease. Anesthesiology 1982;56:219-21. |
|2.||Streisand JB, Clark NJ, Pace NL. Pulmonary arterial catheterization before anesthesia in patients undergoing cardiac surgery placement of the pulmonary arterial catheter before anaesthesia for cardiac surgery-safe, intelligent, and appropriate use of invasive hemodynamic monitoring. J Clin Monit 1985;1:193-7. [PUBMED] |
|3.||Lunn JK, Stanley TH, Webster LR, Bidwai AV. Arterial blood-pressure and pulse-rate response to pulmonary and radial arterial catheterization prior to cardiac and major vascular operation. Anesthesiology 1979;51:265-9. [PUBMED] |
|4.||Dzelzkalns R, Stanley TH. Placement of the pulmonary arterial catheter before anesthesia for cardiac surgery: a stressful, painful, unnecessary crutch. J Clin Monit 1985;1:197-200. [PUBMED] |
|5.||Marjot R, Valentine SJ. Arterial oxygen saturation following premedication for cardiac surgery. Br J Anaesth 1990;64:737-40. [PUBMED] [FULLTEXT]|
|6.||Jones RD, Kapoor SC, Warren SG, Moffatt C, Merridew CG, Mackillop A, et al . Effect of premedication on arterial blood gases prior to cardiac surgery. Anaesth Intensive Care 1990;18:15-21. |
|7.||Wall MH, MacGregor DA, Kennedy DJ, James RL, Butterworth J, Mallak KF, et al . Pulmonary artery catheter placement for elective coronary bypass grafting: before or after anesthetic induction? Anesth Analg 2002;94:1409-15. [PUBMED] [FULLTEXT]|
|8.||Pircio AW, Gylys JA, Cavanagh RL, Buyniski JP, Bierwagen ME. The pharmacology of butorphanol, a 3, 14-dihydroxymorphinan narcotic antagonist analgesic. Arch Int Pharmacodyn Ther 1976;220:231-57. [PUBMED] |
|9.||Osipova NA, Petrova VV, Novikov GA, Ziai GR, Mel'nikova ZL. Synthetic analgesic moradol at various stages of surgical treatment of patients with cancer. Anesteziol Reanimatol 1990;2:56-8. [PUBMED] |
|10.||Singh V, Pathak M, Singh GP. Oral midazolam and oral butorphanol premedication. Indian J Pediatr 2005;72:741-4. [PUBMED] |
|11.||Harris T, Cameron PA, Ugoni A. The use of pre-cannulation local anesthetic and factors affecting pain perception in the emergency department setting. Emerg Med J 2001;18:175-7. [PUBMED] [FULLTEXT]|
|12.||Ho K, Spence J, Murphy MF. Review of pain measurement tools. Ann Emerg Med 1996;27:427-32. [PUBMED] [FULLTEXT]|
|13.||Kopmam EA, Ramirez-Inawat RC. Arterial hypoxemia following premedication in patients with coronary artery disease. Can Anaesth Soc J 1980;27:132-4. |
|14.||Laffey DA, Key NH. Premedication with butorphanol. A comparison with morphine. Br J Anaesth 1984;56:363-7. |
|15.||Greenwald MK, Stitzer ML. Butorphanol agonist effects and acute physical dependence in opioid abusers: comparison with morphine. Drug Alcohol Depend 1998;53:17-30. [PUBMED] [FULLTEXT]|
|16.||Selby IR, Bowles BJ. Analgesia for venous cannulation: a comparison of EMLA, lignocaine, ethyl chloride and nothing. J R Soc Med 1995;88:264-7. [PUBMED] [FULLTEXT]|
|17.||Langham BT, Harrison DA. Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula? Anaesthesia 1992;47:890-91. [PUBMED] |
|18.||Giner J, Casan P, Belda J, Gonzαlez M, Miralda RM, Sanchis J. Pain during arterial puncture. Chest 1996;110:1443-5. |
|19.||Davidson JA, Boom SJ. Warming lignocaine to reduce pain associated with injection. Br Med J 1992;305:617-8. |
|20.||Chauhan S, Baronia AK, Maheshwari A, Pant KC, Kaushik S. Superficial cervical plexus block for internal jugular and subclavian venous cannulation in awake patients. Reg Anesth 1995;20:459. |
|21.||Royse CF, Tiernan RJ, Portelli SM, Davies S, Arblaster R, Bjorksten AR, et al . The effect of supplemental oxygen on the incidence of hypoxaemia after premedication in patients undergoing cardiac surgery. Anaesth Intensive Care 1997;25:347-9. [PUBMED] |
|22.||Antrobus JH, Abbott P, Carr CM, Chatrath RR. Midazolam-droperidol premedication for cardiac surgery. A comparison with papaveretum and hyoscine. Anaesthesia 1991;46:407-9. |
|23.||Saccomanno PM, Kavanagh BP, Cheng DC, Katz J, Sandler AN. Comparison of lorazepam alone vs lorazepam, morphine, and perphenazine for cardiac premedication. Can J Anaesth 1997;44: 146-53. [PUBMED] [FULLTEXT]|
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]