Abuse of AAS was associated with significant decreases (p< 0

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

Comparative Effects of Fentanyl, Medazolam, Lignocaine and

Propranolol on Controlling the Hemodynamic Pressor Response

during Laryngoscopy and Intubation

May S. Al-Sabbagh*
,1

*Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq.

Abstract
Laryngoscopy and tracheal intubation are considered the most invasive stimuli in anesthesia.

They provoked cardiovascular responses that include hypertension, tachycardia and dysrhythmias.

Various pharmacological approaches have been used to blunt or attenuate such pressor responses. The

present study was designed to evaluate the effect of medazolom, lignocaine and propranolol as a

valuable adjuvant to fentanyl in attenuating hemodynamic responses to endotracheal intubation in

normotensive patients. Thirty two patient with physical status I or II according to the score of

American Society of Anesthesiologist (ASA), scheduled for elective surgery under standard general

anesthesia, were randomly allocated into four groups (8 patients in each group), assigned as F, M, L

and P groups. Each patient in the four groups received 1 µg/kg i.v fentanyl. Patients in groups M, L

and P are treated with 0.2 mg/kg i.v medazolam, 1.5mg/kg i.v lignocaine and 0.01mg/kg i.v

propranolol respectively. Induction of anesthesia was then accomplished with 2mg/kg thiopental

sodium followed by1.5mg/kg succinylcholine. Tracheal intubation was performed 2 minutes after

induction of anesthesia. Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial

pressure and rate pressure product were measured before induction, after induction and at 2, 4, 6 and 8

minutes after intubation. The results indicated no significant variation in the hemodynamic pressor

response in all four groups with tracheal intubation. In conclusion, a minimum effective dose of i.v

pre-medications (fentanyl, medazolom, lignocaine and propranolol) were found to be individually

successful in attenuating and providing a reliable control of all hemodynamic response changes

accompanied the process of laryngoscopy and intubation. Therefore, all are proved effective

premedication and no one being superior.

Key words: fentanyl, medazolom, lignocaine, propranolol, endotracheal intubation,

hemodynamic response.

الخالصة
ٔاألٔػٍخانمهت أفؼبلانزخذٌش , كالًْب ٌثٍش سدٔد أثُبءٌؼزجش رُظٍش انحُجشح ٔانمصجخ انٕٓائٍخ ٔكزنك انزُجٍذ يحفض غضٔي

أٔرحذ أٌيخزهفخ يٍ شبَٓب أعبنٍتانذيٌٕخ انزً رشًم اسرفبع ضغظ انذو ٔػذو اَزظبو ضشثبد انمهت ٔخهم انُظى , ٔلذ اعزخذيذ

ٍ ْزا انمجٍم . نمذ رى رصًٍى ْزِ انذساعخ نزمٍٍى رأثٍش كم يٍ انًٍذاصٔالو , انٍكُٕكٍٍ ٔانجشٔثشإَنٕل ثبػزجبسْب يٕاد رخفف سدٔد انفؼم ي

يغبػذح راد لًٍخ نهفُزبٍَم فً انذٔسح انذيٌٕخ نزخفٍف سدٔد انفؼم غٍش انًشغٕة فٍٓب خالل ػًهٍخ انزُجٍذ انشغبيً نهًشضى رٔ

أٔ األٔلانزخذٌش , حبل ألطجبءانؼشٕائً الثٍٍُ ٔثالثٍٍ حبنخ صُفذ اػزًبداً ػهى َظى انجًؼٍخ االيشٌكٍخ انضغظ انطجٍؼً . رى انزٕصٌغ

8يجبيٍغ ) أسثغ إنىػًهٍخ جشاحٍخ نٓى رحذ انزخذٌش انؼبو ثبالَزخبة انمٍبعً . رى رمغًٍٓى إجشاءانثبًَ يٍ انًشضى , يٍ انزٌٍ رمشس

يٍ ىيٍكشٔغشاو / كغ 1يجًٕػبد األسثغفبء ، يٍى ، الو ٌٔبء . رهمى كم يشٌض فً بألحشفثيشضى فً كم يجًٕػخ ( ، ٔسيض نٓى

يهغى /كغى نكُٕكٍٍ 1.1يهغى / كغى يٍذاصٔالو ٔسٌذٌب 2.0انفُزبٍَم ٔسٌذٌب . ٔرؼبنج انًشضى فً يجًٕػبد يٍى ، الو ، ٌبء ثًمذاس

يهغى /كغى يٍ انصٕدٌٕو ثبٌٕثُزٌٕ ٌزجؼّ 0نً . رى ثؼذْب اعزمشاء انزخذٌش يغ يهغى / كغى ثشٔثشإَنٕل ٔسٌذٌب ػهى انزٕا 2.21ٔسٌذٌب

دلٍمخ يٍ رحشٌض انزخذٌش ، ٔرى لٍبط يؼذل َجضبد انمهت ٔضغظ انذو 0يهغى /كغى يٍ انغكغٍُم كٕنٍٍ .َفز انزُجٍذ انشغبيً ثؼذ 1.1

دلبئك 8،6،8، 0ج لجم االعزمشاء ، ٔرنك ػُذ انحث ثى ثؼذ االَمجبضً ، ضغظ انذو االَجغبطً ، انضغظ انششٌبًَ ٔيؼذل ضغظ انًُز

أثُبء األسثؼخانذٔسح انذيٌٕخ فً جًٍغ انفئبد أٔسدٔد انمهت إثبسحانُزبئج ػذو ٔجٕد اخزالف كجٍش فً اعزجبثخ أٔضحذثؼذ انزُجٍذ ،

) انفُزبٍَم ، انًٍذاصٔالو ، انكُٕكٍٍ األسثؼخ األدٌٔخانفؼبنخ يٍ لجم األدَىجشػخ انحذ إٌرُجٍذ انمصجخ انٕٓائٍخ . فً انخزبو رجٍٍ

ٔانجشٔثشإَنٕل( َبجحخ فً رخفٍف حذح جًٍغ انزغٍشاد انزً رصبحت ػًهٍخ رُظٍش انحُجشح ٔانزُجٍذ ٔرٕفٍش يشالجخ يٕثٕق ثٓب نزا فكم

ثًٍُٓب . اَخشيٍ أفضميٍ ْزِ انًٕاد انًغبػذ رؼزجش يفضهخ ٔنٍظ ُْبنك يٍ ْٕ

Introduction
Laryngoscopy and intubation are

mandatory for most patients undergoing

surgery under general anesthesia, often

accompanied by a hemodynamic pressor

response
(1,2,3)

. The rise in pulse rate and blood

pressure is usually transient, variable and

unpredictable; these changes are usually

tolerated by healthy individuals, however, they

may be deleterious in patients with

hypertension, coronary artery diseases or

intracranial hypertension, culminating

perioperative myocardial ischemia, cardiac

arrhythmias, acute heart failure and

cerberovascular accident
(4)

1Corresponding author E- mail : may_sabbagh @ yahoo.com

Received : 13/4/2010

Accepted : 8/6/2010

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

Various drugs including calcium channel

blockers
(5)

, vasodilators
(6)

, β-adrenergic

blockers
(7,8)

, topical and intravenous

lignocaine
(9,10)

, opioids
(11,12)

and deep

inhalational anesthesia
(13,14)

have been used in

an attempt to attenuate or prevent pressor

responses that accompanied endotracheal

intubation, but non have been satisfactory.

Fentanyl, a synthetic opioid, is one of the

potent analgesics, when used before induction

helps to attenuate hemodynamic response to

intubation
(1)

. Medazolam, a short acting

benzodiazepine, most commonly used for its

anxiolytic, muscle relaxant and sedative

properties
(15,16)

, has slow onset of action with

more gradual effects on circulation and greater

degree of antegrade amnesia than thiopental;

so it may offer an advantage in situation where

hemodynamic stability is crucial
(17,18)

. Recent

studies suggested that propranolol and osmolol

can also provide consistent and reliable

protection against the increase in both heart

rate and systolic blood pressure that

accompany intubation, and may reduce the

risk of adverse cardiac events in patient

undergoing major surgical operation
(8,19)

Lignocaine hydrochloride, an amine

ethylamide local anesthetic and class I B-

antidysrrhythmic drug is also acceptable for

attenuation of cardiovascular response to

intubation, and can also diminish cough

reflexes, dysrhythmias and increase in

intracranial pressure
(4)

. The present study was

designed to evaluate the effects of medazolam,

lignocaine and propranolol, as adjuvants to

fentanyl, on the hemodynamic pressor

response during endotracheal intubation in

normotensive patients.

Patients and Methods
The present study was conducted at the

Neurosurgery Hospital in Baghdad in 2007

and involved thirty two ASA physical status I

or II patients, with age range of 18-45 years,

scheduled for elective surgery, requiring

general anesthesia with endotracheal

intubation. Patients with abnormal

electrocardiogram, significant bronchospastic,

neurologic or cardiovascular diseases,

including those receiving medication known to

affect blood pressure and heart rate were

excluded. On arrival to the operating room,

electrocardiograph monitoring, pulseoximetry

and noninvasive arterial blood pressure

monitoring were applied, and baseline values

of heart rate (HR), systolic blood pressure

(SBP), diastolic blood pressure (DBP), mean

arterial pressure (MAP), and the rate pressure

product (RPP) were obtained. Patients were

randomly allocated into four groups (each

include 8 patients) treated as follow: group F

considered as control received only 1µg/kg i.v

fentanyl, group M; patients in this group

received 1µg/kg i.v fentanyl plus 0.2mg/kg i.v

medazolam, group L; received both 1µg/kg i.v

fentanyl and 1.5mg/kg i.v lignocaine, while

group P received 1µg/kg i.v fentanyl together

with 0.01mg/kg i.v propranolol. After 2

minutes of administrating pre-medications,

induction of anesthesia was achieved with

2mg/kg thiopental and 1.5 mg/kg

succinylcholin (all steps and doses were

utilized according to the guidelines adopted in

the neurosurgery hospital, Baghdad). After

loss of eyelash reflex, the lungs were manually

ventilated with oxygen. Direct laryngoscopy

was performed at 2 minutes and trachea was

intubated with proper sized disposable cuffed

tube and fixed after confirmation of proper

position. Following intubation, anesthesia was

maintained with O2, 1% halothane and

pancuronium according to the requirements of

surgery. The follow up of targeted parameters

was started after administration of pre-

anesthetic medications up to 8 minutes later

on. HR, SBP, DBP and MAP were recorded

before and after induction, then after

intubation every 2 minutes for 8 minutes

interval. The rate pressure product (RPP) was

calculated by multiplying SBP by HR
(20)

. The

data were statistically evaluated utilizing

paired Student's t-test to compare pre- and

post-treatment values. Intergroup comparison

was performed using unpaired t-test and

ANOVA. Results were considered

significantly different at P<0.05.

Results
Demographic data of included patients

are shown in table 1. No significant

differences reported among groups with

respect to sex, age, weight, hemoglobin (Hb),

and hematocrit (HCT) values. The changes in

hemodynamic variables from pre-induction

(baseline values), at induction and after

intubation in all groups (F, M, L and P) were

shown in tables 2-6. After induction of

anesthesia, SBP, DBP, MAP, HR and RPP

showed less variation from the baseline values

in the four groups. They slightly decreased,

increased or remained unchanged, but no

significant differences were reported. Tracheal

intubation produces non-significant increase in

SBP, DBP and MAP in all groups at 2 minutes

after intubation. All parameters gradually, but

non significantly, decreased with each 2

minutes increment until 8 minutes post

intubation, with some exception like in L

group, in which there was non significant

increase in DBP and MAP at 6 minutes after

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

intubation. Compared to base line values, both

HR and RPP showed gradual but non

significant increase at 2, 4, 6 and 8 minutes

after intubation and reach optimal value at 6-8

minutes of intubation in all groups.

Table 1: Demographic data of patients included in the present study

Groups Sex Age (year) Weight (kg) Hb (%) HCT (%)

Gr F

(n=8)

6 M

2 F

25.8 ± 8.2

64.0 ± 11.6

13.0 ± 1.7

41.1 ± 5.1

Gr M

(n=8)

5 M

3 F

25.6 ± 7.4

64.6 ± 13.9

12.1 ± 1.5

37.0 ± 4.7

Gr L

(n=8)

6 M

2 F

27.6 ± 9.0

64.1 ± 18.2

13.1 ± 1.1

38.0 ± 4.2

Gr P

(n=8)

6 M

2 F

28.0 ± 9.4

61.9 ± 13.6

13.1 ± 1.5

39.4 ± 5.2

F: Fentanyl group; M: Medazolam group; L: Lignocaine group; P: Propranolol group; Data are

presented as mean ± SD; n=number of patients. NS: non significant

Table 2: Effects of Fentanyl or its combination with Medazolam, Lignocaine or Propranolol on

systolic blood pressure during intubation in surgery

Stages

Systolic Blood Pressure (mmHg)

Groups

F M L P

Pre-induction

(base line)
129.8 ± 22.4

a
135.5 ± 15.1

a,b
125.5 ± 21.5

a
137.4 ± 10.5

Induction 121.3 ± 21.2
a,b

129.6 ± 15.7
a,b

126.3 ± 20.8
a
134.6 ± 10.2

Post-

intubation

2 min 126.1 ± 20.7
a
140.9 ± 20.1

a
132.0 ± 20.0

a
139.4 ± 10.7

4 min 117.3 ± 11.1
a
127.8 ± 16.3

a,b
127.5 ± 21.2

a,b
134.3 ± 13.1

6 min 116.4 ± 8.4
a
124.4 ± 23.1

a
130.9 ± 26.0

a
132.0 ± 33.8

8 min 110.8 ± 26.3
a
113.8 ± 24.6

a
117.9 ± 21.9

a
128.6 ± 23.2

Data are presented as mean ± SD; number of patients was 8 in each group; no significant difference

existing with respect to induction value; non-identical superscripts (a,b) within the same time represent

significant difference (P<0.05)

Table 3: Effects of Fentanyl or its combination with Medazolam, Lignocaine or Propranolol on

diastolic blood pressure during intubation in surgery

Stages

Diastolic Blood Pressure (mmHg)

Groups

F M L P

Pre-induction

(base line)
72.4 ± 11.9

a
75.4 ± 11.8

a,b
74.4 ± 9.6

a
78.6 ± 3.8

Induction 69.6 ± 12.5
a
72.4 ± 10.3

a
75.1 ± 12.7

a
76.6 ± 6.1

Post-

intubation

2 min 71.6 ± 13.0
a
84.5 ± 14.6

a,b
73.4 ± 10.1

a
81.8 ± 8.5

4 min 70.8 ± 16.8
a,b

78.3 ± 14.6
a,b

67.3 ± 11.2*
a
78.8 ± 6.0

6 min 70.6 ± 9.8
a
74.4 ± 10.8

a
87.3 ± 33.5

a
75.1 ± 15.8

8 min 69.0 ± 9.9
a,b

63.6 ± 14.1
a,b

62.8 ± 17.0
b
78.9 ± 16.9

Data are presented as mean ± SD; number of patients was 8 in each group;

*P<0.05 with respect to induction value; non-identical superscripts (a,b) within the same time

represent significant difference (P<0.05)

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

Table 4: Effects of Fentanyl or its combination with Medazolam, Lignocaine or Propranolol on

mean arterial pressure during intubation in surgery

Stages

Mean Arterial Pressure (mmHg)

Groups

F M L P

Pre-induction

(base line)
93.6 ± 12.7

a
97.9 ± 12.9

a
91.8 ± 12.2

a
98.5 ± 8.5

Induction 90.0 ± 13.3
a
96.0 ± 17.2

a
93.1 ± 12.9

b
96.4 ± 18.3

Post-

intubation

2 min 94.5 ± 22.4
a
101.3 ± 30.3

a
95.4 ± 10.6

b
100.1 ± 8.6

4 min 89.6 ± 15.7
a
96.6 ± 13.7

a
91.9 ± 13.4

b
98.3 ± 8.9

6 min 88.9 ± 8.0
a
93.8 ± 14.2

a
99.4 ± 19.2

a
95.8 ± 21.9

8 min 83.8 ± 13.9
a
82.5 ± 14.3*

a
82.6 ± 16.5

a
94.4 ± 25.4

Data are presented as mean ± SD; number of patients was 8 in each group; *P<0.05 with respect to

induction value; non-identical superscripts (a,b,c) within the same time represent significant difference

(P<0.05)

Table 5: Effects of Fentanyl or its combination with Medazolam, Lignocaine or Propranolol on

heart rate during intubation in surgery

Stages

Heart Rate (Beat/min)

Groups

F M L P

Pre-induction

(base line)
92.0 ± 32.6

a
97.5 ± 23.1

a
93.4 ± 29.8

a
95.5 ± 95.9

Induction 98.9 ± 40.6
a
103.1 ± 30.8

a
98.3 ± 33.2

a
101.3 ± 22.4

Post-

intubation

2 min 101.5 ± 33.1
a
107.8 ± 24.6

a
100.1 ± 33.8

a
108.3 ± 24.3

4 min 122.0 ± 39.2*
a
118.0 ± 29.6

a
111.8 ± 25.2

a
109.3 ± 24.3*

6 min 149.0 ± 36.4*
a
128.4 ± 29.9*

a,b
122.1 ± 35.0

a,b
117.1 ± 21.4*

8 min 136.5 ± 36.8*
a
123.5 ± 30.1

a
134.5 ± 21.2*

a
124.6 ± 8.6*

Data are presented as mean ± SD; number of patients was 8 in each group; *P<0.05 with respect to

induction value; non-identical superscripts (a,b) within the same time represent significant difference

(P<0.05)

Table 6: Effects of Fentanyl or its combination with Medazolam, Lignocaine or Propranolol on

rate pressure product during intubation in surgery

Stages

Rate Pressure Product

Groups

F M L P

Pre-induction

(base line)
11953 ± 4322

a
13224 ± 3441

a
11929 ± 5196

a
13232 ± 4772

Induction 11973 ± 4850
a
13450 ± 4448

a
12580 ± 5421

a
13673 ± 3558

Post-

intubation

2 min 12814 ± 4557
a
15429 ± 5200

a
13362 ± 5801

a
15253 ± 4225

4 min 14121 ± 4253
a
15269 ± 4901

a
14192 ± 3845

a
14772 ± 3866 *

6 min 17360 ± 4501*
a
15946 ± 4440

a
16394 ± 6997

a
15549 ± 5354

8 min 15452 ± 6082
a
14231 ± 4754

a
15806 ± 3779*

a
15957 ± 2646

Data are presented as mean ± SD; number of patients was 8 in each group; *P<0.05 with respect to

induction value; non-identical superscripts (a,b) within the same time represent significant difference

(P<0.05)

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

Discussion
Laryngoscopy and tracheal intubation

produced stressful hemodynamic changes in

the form of hypertension and tachycardia,

attributed to increase in the circulating levels

of catecholamines
(21,22)

. Control of such

hemodynamic changes are very important to

prevent detrimental effects, and the need for

safe and effective therapeutic agents that may

attenuate, blunt, suppress or abolish such

changes became an important intervention

during surgical procedures under general

anesthesia. The results obtained from the

present study revealed that all studied patients

groups showed quantitatively and qualitatively

similar hemodynamic pressor response at

induction, intubation and post-intubation; the

differences, if present, failed to reach

statistically significant values. In the present

study, failure to predict superiority for each

pattern of drug intervention may be attributed

to the limited number of patients in each

group, and increase the number of patients

may lead to more predictable values.

However, pre-operative use of minimum

effective doses of pre-anesthetic medications

(1μg/kg fentanyl, 0.2mg/kg medazolam,

1.5mg/kg lignocaine and 0.01mg/kg

propranolol) in the present study was found to

be effective in restricting the non-significant

increase in SBP, DBP and MAP values during

short period of time (up to 2 minutes post-

intubation), then each parameter start to

decrease gradually (but non-significantly) until

8 minutes post- intubation; this means that all

studied medications produce consistent and

reliable protection against the abnormal

increase in hemodynamic pressor response

during laryngoscopy and intubation, similar to

observations reported by other investigators
(4,8,19,23)

. Additionally in the present study, a

non-significant increase in mean pulse rate and

rate pressure product (good indicator for

oxygen consumption) was reported in all

groups of operated patients, starting from

intubation and reach optimal values after 6-8

minutes post-intubation; this could be

explained by the fact that surgical intervention

usually starts after 6-8 minutes post-

intubation, which is by itself a stressful

procedure, predominantly suppresses the

pressor response more effectively than

tachycardia as a response
(24)

. Light anesthesia

(fewer drugs by the intravenous route or via

inhalational means) is claimed to be the major

factor responsible for pre-operative awareness

and hemodynamic instability
(17)

; to overcome

this problem, fentanyl and/or medazolam are

administered for the purpose of analgesia,

sedation and anxiolysis
(16)

. Many evidence

indicated that each of them, when used alone

or in combination, enables reduction of the

thiopental dose required to produce induction,

and consequently limit potential side effects

and help in attenuating the hemodynamic

response to laryngoscopy and intubation
(16,25,26)

. Despite the potential advantages of the

drug combination, reluctance to incorporate

medazolam during light anesthesia persists

due to concern regarding the potential for

prolonged recovery
(27,28)

. However, a small

pre-induction bolus dose of medazolam

utilized in the present study did not prolong

both recovery and discharge time from the day

care unit following general anesthesia; this can

be explained by the fact that the effects of

medazolam on CNS is dose dependent
(27)

. In

the present study, although fentanyl was

administrated in relatively small doses, it

produces sufficient analgesia for short surgical

procedures, and no one of the operated

patients experienced pain of relatively long

duration or great severity. Although there is a

possibility that administration of narcotic

analgesic like fentanyl may affect

pharmacokinetics of the anesthetic agents

during induction, which is mostly due to

changes in hemodynamic response
(29,30,31)

, the

patients in F and M groups showed non-

significant increase in HR and RPP during

laryngoscopy up to 6 minutes post-intubation;

this increase seems to be suppressed in

medazolam-treated group compared to

fentanyl-treated group. This indicates that

administration of medazolam before induction

lead to hemodynamic stability most probably

by mutual potentiation
(32)

.Many studies have

reviewed the effect of lignocaine to blunt the

hemodynamic response after endotracheal

intubation
(4)

. It has been reported that the

strength and timing of lignocaine

administration are equally important to

prevent hemodynamic changes
(33)

, however,

irrespective of the dose and time of

administration of lignocaine, there are still

significant increase in hemodynamic

parameters after intubation
(34)

. Kindler et al

and Durrani et al reported that i.v.

administration of 1.5mg/kg lignocaine did not

prevent the increase in hemodynamic response

associated with laryngoscopy and intubation
(35,36)

. Meanwhile, other investigators reported

that 1.5mg/kg lignocaine effectively blocked

the increase in SBP, DBP and HR after

intubation
(4,9)

. In the present study, i.v

administration of 1.5mg/kg lignocaine, 2

minutes before intubation provide reliable

protection against the rise in hemodynamic

response that associated with intubation

process; this result was in accordance with

Iraqi J Pharm Sci, Vol.19(2) 2010 Preanesthetic medications and hemodynamic changes

many previously reported data, but not

consistent with others
(4,9)

Such effect may be

attributed to rapid equilibration of lignocaine

between blood and brain with production of

sedative effect when administrated in

appropriate dose
(37)

. Blocking and blunting

adrenergic responses of tracheal intubation is

the key pathophysiological step connecting β-

blockers. Most of the studies concerned with

evaluating the benefit of β-blockade on

mortality and myocardial ischemia after

tracheal intubation are based on using ultra-

short acting selective β-blockers
(38,39)

, while

very limited reports were available about using

propranolol in this respect
(19)

. In the present

study, 0.01mg/kg i.v propranolol was used,

and no significant differences were reported in

HR and RPP between patients groups. Even a

slight rise in HR and RPP that occurs at 6

minutes postintubation (a time of surgical

intervention) was non significantly slowered

in the β-blockade group in compare to other

groups. These results are in accordance with

those reported by Hussain et al and Yutaka et

al
(7,39)

. The results of the present study shed a

light on the possibility of using minimum

doses of thiopental sodium for induction and

maintenance of light anesthesia, for the aim of

decreasing the time to discharge the patient

from the recovery room and the day care unit;

this situation seems to be compatible with the

condition of shortage in medications required

for anesthesia. In conclusion, minimum

effective doses of pre-anesthetic medications

(fentanyl, medazolam, lignocaine and

propranolol) can maintain hemodynamic

stability during laryngoscopy and intubation.

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