Propofol-Hydromorphone In Patients With Intubation After Maxillofacial Plastic Surgery

Due to the anatomical speciality, the respiratory track is prone to be obstructed after maxillofacial surgery because of swelling and bleeding in the surgical area or larynx, or unsuitable postoperative managements. On the other hand, preventive tracheotomy is not used to be accepted by patients and relatives while early removal of the tracheal tube may result in lethal outcome. Following the rapid development of intensive care unit (ICU) and the advancement of sedation techniques, more and more patients are administrated with postoperative tracheostomy to keep spontaneous respiration, which can fasten the recovery and shorten the hospitalization time. However, the placement of tracheal tube raises higher requirement for anesthetist to overcome the controversy between the reservation of spontaneous respiration and the placement of tracheal tube in order to maintain suitable depth of sedation.Current ideas consider that the strategy of analgesia-based sedation can effectively enhance the comfort of patients, maintain in optional sedation depth and therefore put patients through the sedation procedure in ICU under maximal physiology condition and natural sleep. As a kind of agonist of μ-opioid receptor, hydromorphone can effectively control the cardiovascular reaction to stress and maintain stable blood dynamics with slight respiration depression. Propofol is a kind of short-acting agonist of y-aminobutyric acid (GABA) and can provide good sedation effect. The study investigated if co-application of hydromorphone and propofol can improve the tolerance of postoperative intubation in patients with maxillofacial plastic surgery.Part oneTo evaluate the sedation and analgesic effects of propofol-hydromorphone in patients with postoperative intubation after maxillofacial plastic surgeryObjective To compare the sedation and analgesic effects between propofol- hydromorphone and propofol-dexmedetomidine in patients with postoperative intubation after maxillofacial plastic surgery.Methods Forty-two patients(age of 18-36 years, weight of 50-80Kg and ASA grade I) for maxillofacial plastic surgery with intubation were randomly assigned into 2 groups:propofol plus hydromorphone (P-H) group and propofol plus dexmedetomidnie (P-D) group. After admission of ICU, patients in P-H group were administrated with continuously perfusion of propofol (0.5-lmg/kg/h) and hydromorphone (4-8μg/kg/h) while patients in P-D group were administrated with continuously perfusion of propofol (0.5-lmg/kg/h) and dexmedetomidine (0.2-0.6μg/kg/h). The heart rate (HR), mean artery pressure (MAP), peripheral capillary oxygen saturation (SPO2), respiration rate (RR), visual analogue scale (VAS), cerebral state index (CSI) and ramsay sedation score physiology indices were recorded before admission (TO),30 minutes (T1),1 hour (T2),2 hours (T3),6 hours (T4) and 12 hours after admission (T5) to intensive care unit, and 10 minutes after extubation (T6).Results There was no significant difference in oxygen saturation, mean arterial pressure, VAS and respiratory rate between two groups at all time points (P>0.05). The changes of heart rate (at T4, T5 and T6), CSI (T1, T2, T3, T4 and T5), and Ramsay score (at T3) in P-H group were significantly different from that in P-D group (P<0.05).Conclusions The P-H approach takes advantages over P-D approach in enhancing the tolerance of postoperative intubation after maxillofacial plastic surgery.Part twoTo record the adverse reactions of propofol-hydromorphone in patients with postoperative intubation after maxillofacial plastic surgeryObjective To investigate the serious complications of propofol-hydromorphone in patients with postoperative intubation after maxillofacial plastic surgery.Methods Forty-two patients for maxillofacial plastic surgery with intubation were randomly assigned into propofol plus hydromorphone (P-H) group or propofol plus dexmedetomidnie (P-D) group, receiving intravenous infusion of propofol plus hydromorphone or propofol plus dexmedetomidnie, respectively. The monitored indices included:1) respiration rate (RR); 2)gas analysis of blood samples taken before removal of tracheal tube including pH, partial pressure of CO2 (PaCO2) and O2 (PaO2); 3) related complications during sedation and after termination of medications such as respiratory depression, pruritus, hypotension, tachycardia, bradycardia, nausea, vomit, and drug dependence.Results There was no significant difference in respiratory rate between two groups at all time points (P>0.05). The arterial blood gas analysis indicated that the pH, PaO2 and PaCO2 between 2 groups were similar and there was no significant difference before removal of the tracheal tube (P>0.05). There were no severe complications in 2 groups. Only 2 patients in P-D group demonstrated sinus bradycardia with HR<50bpm. In P-H group, only 1 patient incurred nausea and vomiting.Conclusions Continuously perfuse of propofol (0.5-lmg/kg/h) and hydromorphone (4-8μg/kg/h) in patients for maxillofacial plastic surgery with intubation did not result in severe complications.Part threeEffects of inflammatory response on propofol-hydromorphone in patients with postoperative intubation after maxillofacial plastic surgeryObjective To investigate the effects of inflammatory response on propofol-hydromorphone in patients with postoperative intubation after maxillofacial plastic surgery.Methods Forty-two patients for maxillofacial plastic surgery with intubation were randomly assigned into propofol plus hydromorphone (P-H) group or propofol plus dexmedetomidnie (P-D) group, receiving intravenous infusion of propofol plus hydromorphone or propofol plus dexmedetomidnie, respectively. Blood interleukin-6 (IL-6) and tumor necrosis factor (TNF-α) before surgery, end of surgery,6h and 24 h after admission was measured with enzyme-linked immunosorbent assay (ELISA).Results There were no significant difference in blood level of IL-6 and TNF-α before surgery, end of surgery between two groups (P>0.05). The level of IL-6 in P-H group was significantly lower than that in P-D group at 6h after admission (P <0.05). The level of TNF-α in P-H group was significantly lower than that in P-D group at 6h and 24 h after admission (P<0.05).Conclusions The propofol plus hydromorphone approach fully display the inflammatory response in patients with postoperative tracheal intubation after maxillofacial plastic surgery.