Relieving Hemodynamic Adverse Effects During Tracheal Intubation

A recent meta-analysis published in Anesthesia Progress found that dexmedetomidine more effectively reduces heart rate and blood pressure increases following tracheal intubation compared to esmolol, though it carries a higher risk of bradycardia; researchers note further validation is needed due to study variability.

GLEN ALLEN, Va., March 31, 2025 /PRNewswire-PRWeb/ -- Relieving Hemodynamic Adverse Effects During Tracheal Intubation

Anesthesia Progress – Tracheal intubation (TI)—insertion of a tube into the windpipe to assist with breathing—can accompany general anesthesia (GA) during surgical procedures because it helps ensure a clear and controlled airway for breathing. However, TI can cause tachycardia and elevated blood pressure, putting individuals with cardiac conditions at increased risk for adverse effects. Traditionally, opioids, beta blockers and α2 agonists have been used to offset the hemodynamic alterations that come with TI. However, more recently, opioid-sparing techniques have been considered to help relieve some of the common opioid side effects.

To assess which medications will best reduce adverse effects during TI and GA, researchers from the University of Toronto and Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, and McGill University in Montreal, Quebec, Canada, recently published a study in the current issue of Anesthesia Progress. Lead author Abbass Saleh, DMD, MSc, and colleagues state, "The primary objective of this systematic review and meta-analysis was to compare dexmedetomidine with esmolol for hemodynamic response (eg, [heart rate] HR and [blood pressure] BP) at 1, 3, 5, and 10 minutes after TI in non-[rapid sequence induction] RSI studies with patients undergoing noncardiac surgery. The secondary objective was to identify any adverse effects related to dexmedetomidine or esmolol such as tachycardia, bradycardia, hypotension, and extrasystoles."

A total of 112 publications were reviewed and evaluated; 19 were randomized control trials reviewed for descriptive analysis, and 15 were meta-analyses that included 948 total patients. Cases were further subdivided based on dosing: high-dose (≥1 μg/kg) versus low-dose (≤1 μg/kg) dexmedetomidine compared with high-dose (≥1.5 μg/kg) versus low-dose (≤1.5 μg/kg) esmolol to examine hemodynamic stability dosing effects. Researchers also performed sensitivity analyses regarding patients who received anticholinergic medication (e.g., glycopyrrolate or atropine) within 24 before surgery.

Saleh et al. report the primary outcomes related to HR and BP were that dexmedetomidine reduced the rise in:

• HR better than esmolol at 1, 3, 5 and 10 minutes after TI
• Systolic BP (SBP) better than esmolol at 1, 3, 5 but not at 10 minutes after TI
• Diastolic BP (DBP) better than esmolol at 1, 3, 5 but not at 10 minutes after TI
• Mean arterial pressure (MAP) better than esmolol at 1, 3, 5 and 10 minutes after TI

High-dose dexmedetomidine reduced the rise in:

• HR better than high-dose esmolol at 1, 3, 5 and 10 minutes after TI
• SBP better than high-dose esmolol at 1 and 3 minutes after TI

There was no difference in DBP or MAP at any time intervals with either high-dose dexmedetomidine or esmolol. Regarding the sensitivity analyses, using glycopyrrolate before TI did not impact HR. When an anticholinergic agent was used, dexmedetomidine reduced the rise in HR better than esmolol at 1, 3, 5 and 10 minutes after TI. When propofol was used, dexmedetomidine reduced the rise in SBP better than esmolol at 1, 3, and 5 but not at 10 minutes after TI, and it reduced the rise of MAP better at all time intervals.

For the secondary outcomes, 12 studies reported adverse effects as follows: five cases where dexmedetomidine causes a higher risk of bradycardia (0 cases for esmolol), one case of hypotension after dexmedetomidine use, three cases of hypotension with esmolol, and no cases of tachyarrhythmia or hypertensive events.

The results of this retrospective study show that dexmedetomidine alleviates the hemodynamic response to TI better than esmolol. Saleh and colleagues conclude, "Patients receiving dexmedetomidine vs esmolol prior to TI had less of a hemodynamic response (ie, lower MAP and HR) up to 10 minutes postinduction according to this meta-analysis;

however, the clinical relevance of these findings should be determined on a case-by-case basis… Additional validation is necessary to confirm our conclusions due to the unexplained heterogeneity noted in this study."

Full text of the article, "Effects of Dexmedetomidine vs Esmolol on Postintubation Hemodynamics: A Meta-Analysis," Anesthesia Progress, Vol. 72, No. 1, 2025, is now available at https://doi.org/10.2344/anpr-70-01-02

About Anesthesia Progress

Anesthesia Progress is the official publication of the American Dental Society of Anesthesiology (ADSA). The quarterly journal is dedicated to providing a better understanding of the advances being made in the science of pain and anxiety control in dentistry. The journal invites submissions of review articles, reports on clinical techniques, case reports, and conference summaries. To learn more about the ADSA, visit: http://www.adsahome.org/.

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SOURCE Anesthesia Progress