STUDY OF THE EFFECT OF PROPOFOL & ETOMIDATE AS AN INDUCTION AGENT ON HAEMODYNAMIC CHANGES DURING INDUCTION & ENDOTRACHEAL INTUBATION”

Introduction a a sympathoadrenal Careful selection of anestheshetic is thus required, as cardiovascular reserve is decreased in certain patients, so as to avoid undue depressions of cardiac and circulatory function Aims And Objectives : This randomized double blind prospective study had been designed for comparative evaluation of inj propofol 2.5 mg/kg, inj Etomidate 0.3 mg/kg an induction agent on haemodynamic changes such as HR, SBP, DBP, MAP and oxygen saturation during induction and tracheal intubation and also to study the adverse effects the two drugs under study Material And Methods : After approval from medical ethics committee, Dr D Y Patil College and Hospital, Pune, the study was carried out on sixty (60) patients undergoing elective surgeries under standard general anesthesia. ? All patients were premedicated with Ondansetron 0.1mg/kg i.v., inj midazolam 0.02mg/kg study comparison etomidate-lipuro,propofol and admixture at induction. assigned into three groups;higher


Randomization:
Institutional ethics committee approval was taken prior to the commencement of the study. 60 patients undergoing elective surgeries under general anesthesia were selected randomly using computer generated random number table after applying already mentioned stringent inclusion and exclusion criteria. The patients were divided into two groups of 30 each.Randomized, double blinded method was used for grouping the patients.The patients and investigator were not aware of the drugs given. Drugs were prepared and administered by the theatre anaesthesiologist who was not part of data collection or analysis. 1. Group P:(n-30)received 2.5mg/kg Propofol iv given slowly for induction 2. Group E:(n-30) received 0.3mg/kg Etomidate iv given slowly for induction

Evaluation Of Parameters:
All patients were thoroughly evaluated pre-operatively. All the necessary and relevant laboratory and other investigations were carried out.

General Anesthesia Technique
The patients were kept nil per orally for 8 hrs. prior to surgery. On arrival in operation theatre standard anesthesia monitors including pulse oximeter,NIBP, ECG, etc.connected to the patient. Baseline vital parameters such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), and SPO2recorded. (T0) After securing good intravenous line using 20G cannula an infusion ofringer lactatestarted slowly.

Preoxygenation
Patient was pre-oxygenated with 100% oxygen for 3 minutes. All vital parameters were recorded again(T1).

Induction Of General Anesthesia
For induction group Preceived Inj. Propofol 2.5mg/kg i.v and group Ereceived Inj. Etomidate 0.3mg/kg i.v. given over 30 sec.After induction of anesthesia hemodynamic parameters wererecorded(T2). Time of induction was taken as period between time of start of study drug till loss of eyelash reflex. The choice of muscle relaxant will be Inj.succinylcholine(2mg/kg) given after administering induction agent.Laryngoscopy and tracheal intubation attempted with appropriate size of endotracheal tube. All vital parameters will be recorded again during Laryngoscopy. (T3) Proper placement of endotracheal tube was confirmed by capnography and bilateral auscultation of chest. Periodic monitoring of vital parameters carried out at 1, 2, 3, 5 and 10 minute intervals post intubation. Induction Time in seconds  HR, SBP,DBP,MAP and Spo2 at following time interval  T0-Baseline  T1-Before Induction  T2-Post Induction  T3 -During Laryngoscopy  After Intubation -At 1min,2min,3min,5min and 10

Maintenance Of General Anesthesia
Anesthesia maintained with Oxygen, Nitrous oxide (33:66) andIsoflurane, along with intermittent boluses of muscle relaxant inj. vecuroniumi.v. 0.1mg/kg as and when required throughout the surgery.
During surgery continuous monitoring was done as follows: 1. Continuous Heart rate monitoring SBP, DBP, Mean BP andSPO2. 2. At the end of surgery, patient will be reversed with inj. Glycopyrrolate 0.008 mg/kg i.v. along with Inj.
Neostigmine methyl sulphate 0.05mg/kg intravenously. Patient was finally be extubated after gaining consciousness and adequate power.pt was shifted to recovery room. Observations And Results:-             Episodes of apnea were not observed in both the groups. There was no significant difference in oxygen saturation data between two groups. Samples are matched with P > 0.05.  ). There was significant difference in incidence of pain on injection between the two groups. Sample showed P value < 0.05.
In Group P -2 patients out of 30 had myoclonus activity (6.7%), whereas in Group E-23 patients out of 30 had myoclonus activity (76.7%.). There was statistically significant difference in incidence of myoclonus activity between the two groups. Sample showed P value < 0.05.
In group P-2 patients out of 30 hadPONV (6.7%)whereas in Group E-3 patients out of 30 had PONV (10%). There was no statistically significant difference in incidence of PONV between the two groups. Sample showed P value > 0.05.

Discussion:-
The maintenance of hemodynamic stability during induction of anesthesia is dependent on basal tone of the autonomic nervous system and baroreceptor reflex regulation of autonomic outflow influencing cardiac function and peripheral vascular resistance.
Propofol is an intravenous induction agent which combines the desirable characteristics of smooth induction and rapid recovery from anesthesia. 52 Propofol also reduces preload, afterload and contractility which directly effects on vascular smooth muscle and has venous dilating properties. It causes reduction in tonic levels of sympathetic activity.
The salient properties of etomidate like hemodynamic stability, minimal respiratory depression, and favourable pharmacokinetics enable rapid recovery after a single dose. Etomidate causes reduction in myocardial function and basal sympathetic tone. It maintains hemodynamic stability by preserving or augmenting baroreflex mechanisms. 41

Demographic profile
In the present study, there was no significant difference in demographic data between the two groups in relation to Age,weight, gender, and ASA grades. For premedication, InjOndansetron 0.1mg/kg iv, Inj Midazolam0.02mg/kg iv and Inj fentanyl 2mcg/kg iv was used in all the cases.
Selected patients were induced with either Injpropofol 2.5 mg/kg iv or inj.Etomidate 0.3 mg iv according to the allocated groups.
Induction Time:According to our study the mean induction time in group P was 35.03 ±2.498 sec whereas in Group E was 35.33±2.218sec, which was statistically insignificant.
Dr.Supriya Agarwalet al 49 in 2020 conducted acomparative study between etomidate and propofol as an induction agent duringinduction, laryngoscopy and intubation showed that mean duration of time to loss of consciousness between two groups was statistically insignificant

Our observations showed statistically significant difference in HR values at post induction (T2), after intubation at 1min and 2 min
There was decrease in heart rate in group P as compared to group E at Post induction (T2) group P(68.10+6.48) vs group E (71.73±2.016), at 1 min after intubation group P (71.90±1.32) vs group E (73.67±3.315), at 2 min After intubation group P (70.27±1.23).vs group E (72.17±1.683) and it was statistically significant with P<0.05.
The fall in heart rate at post induction(T2), at 1 min, 2 min after intubation in Group P as compared to Group E was statistically significant with P value (<0.05).

Djordjević B, Stojiljković M P. et al 43 in 1999
Jan-Feb,conducted a study to compare the cardio vascular effects of induction doses of propofol, etomidate and thiopentone on total 165 female patients randomly divided into three groups each one received a different anestheshetic agent propofol 2.5 mg/kg (n=58), etomidate 0.3mg/kg (n=54) or thiopentone 5mg/kg (n=53) showed that slowing down of radial pulse was more marked in propofol, than in etomidate or thiopentone group at 2 min, 5 min,10 min after induction of anesthesia.
In our study, it was found that in group P at post induction( The fall in SBP at post induction(T2), at 1 min, 2 min, 3 min and 5 min after intubation in Group P as compared to Group E was statistically significant with P value (<0.05).
The following study shows similar results like our study Thomas J Elbert 41 et al 1992 compared injpropofol 2.5mg/kg and etomidate 0.3mg/kg to study the sympathetic response, and found that cardiac and baroslopoes were well maintained with etomidate but decreased with propofol.
Haemodynamic stability was seen more with etomidate due to preservation of sympathetic outflow and autonomic reflexes.
Djordjević B, Stojiljković MPet al 43 in 1999 Jan-Feb. Conducted a study to compare the cardio vascular effects of induction doses of propofol, etomidate and thiopentone on total 165 female scheduled for abortion patients randomly divided into three groups each one received a different anestheshetic agent propofol 2.5 mg/kg (n=58), etomidate 0.3mg/kg (n=54) or thiopentone 5mg/kg (n=53) showed significant greater decrease in blood pressure was in propofol group than etomidate or propofol after induction at 2,5 and 10 min after induction.
Our observations showed statistically significant difference in DBP in group P compared to group E at post induction (T2), after intubation at 1min and 2 min,3min and 5 min.
In group P at post induction (T2) mean DBP was 65.00±2.393 whereas in group E it was 70.93±3.051, after intubation at 1 min in group P mean DBP was 70.20±2.592 whereas in group E it was 78.20±2.483, at 2min after intubation in group P mean DBP was 65.20± 2.821 whereas in group E it was 73.80±2.295, at 3min after intubation in group P mean DBP was 64.40±2.660 where as in group E it was 74.37±2.076 and at 5 min after intubation in group P mean DBP was 66.47+2.837 whereas in group E it was 71.77±3.126 [ Table 6] The fall in DBP at post induction(T2), at 1 min, 2 min, 3 min and 5 min after intubation in Group P as compared to Group E was statistically significant with P value (<0.05).
Following study shows similar results like our study Shah, Jigna, et al 47 . in 2018 conducted a "Comparative study of propofol vs etomidate as an induction agent to evaluate hemodynamic changes during induction of anesthesia in controlled hypertensive patients". Sixty patients undergoing surgery under general anesthesia. 30 patients GroupP were given inj fentanyl 2 mcg/kg, followed by injpropofol 1-2 mg/kg; and patients of Group-E were given inj fentanyl 2 mcg/kg, followed by injetomidate 0.2-0.4 mg/kg. The fall mean in DBP in group P from baseline compered to group E was statistically significant at 1min ,3 min ,5 min and 10 min after induction.
Our observations showed statistically significant difference in MAP values at post induction (T2), after intubation at 1min and 2 min,3min and 5 min. The fall in Mean Arterial Pressure, post induction(T2), at 1 min, 2 min, 3 min and 5 min after intubation in Group P as compared to Group E was statistically significant with P value (<0.05).
Following studies show similar results like our study Shah, Jigna, et al 47 . in 2018 conducted a "Comparative study of propofol vs etomidate as an induction agent to evaluate hemodynamic changes during induction of anesthesia in controlled hypertensive patients".Sixtypatients undergoing surgery under general anesthesia were randomly divided into two equal groups. Patients of GroupP were given inj fentanyl 2 mcg/kg, followed by injpropofol 1-2 mg/kg; and patients of Group-E were given inj fentanyl 2 mcg/kg, followed by injetomidate 0.2 to 0.4 mg/kg.The fall in mean MAP in group P compered to group E was statistically significant at 1min ,3 min ,5 min and 10 min after induction. Etomidate is considered to be an ideal induction agent specially for cardiac patients and small short-term surgeries. 38 The myocardial oxygen supply demand ratio is well maintained with Etomidate. It provides a better safety during induction in patients at risk of cardiac disease with less cardiovascular depression than propofol. 39

Oxygen Saturation
As per our study, there was no significant difference in oxygen saturation data between the two groups. Samples are matched with p > 0.05. [ Table 8]. The episodes of apnea were not significant following induction and not associated with any fall in oxygen saturation.

Summary And Conclusion:-Result:-
The demographic profile was comparable.
There was no statistically considerable difference between the two study groups with respect to baseline parameters of HR, SBP, DBP, MAP and SpO 2.
There was decrease in mean heart rate seen in group P compared to group E at post induction (T2), after intubation 1 min, 2min, the values werestatistically significant with P value <0.05,.and decrease in mean SBP, mean DBP AND MAP in group P compared to group E at post induction (T2), afterintubation 1,2 3, 5 min values werestatistically significant withp value <0.05 Pain on injection was more in group P 26 out of 30(86.7%) than group E,which was statistically significantwith p value <0.05 Incidence of myoclonus was more in group E 23 patients out of 30(76.7%) compared to group P which was statistically significant with p value <0.05.
In group P 2 out of 30 patients (6.7%) had vomiting and in group E 3 out of 30 patients (10%) had vomiting, difference was statistically insignificant with p value >0.05