Comparison between transtracheal and intravenous 2% lignocaine in attenuating hemodynamic stress response following direct laryngoscopy and endotracheal intubation: a randomized controlled trial

Comparison between transtracheal and intravenous 2% lignocaine in attenuating hemodynamic stress response following direct laryngoscopy and endotracheal intubation: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison between transtracheal and intravenous 2% lignocaine in attenuating hemodynamic stress response following direct laryngoscopy and endotracheal intubation: a randomized controlled trial Monotosh Pramanik, Uddalak Chattopadhyay, Syed Sadaqat Hussain, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4628260/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 May, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 4 You are reading this latest preprint version Abstract Background and Aims Lignocaine is used through various routes to mitigate the hemodynamic surge associated with laryngoscopy and endotracheal intubation during general anesthesia. This study hypothesized that post-induction administration of transtracheal 2% lignocaine at 1.5 mg/kg would have a similar effect to intravenous 2% lignocaine at the same dosage, providing an alternative for attenuating the hemodynamic stress response. Methods A total of 138 consenting patients were randomized into two groups. Following induction, Group IV patients received 2% lignocaine at 1.5 mg/kg intravenously, while Group TT patients received 2% lignocaine at 1.5 mg/kg transtracheally. The primary outcome was the comparison of hemodynamic responses at different time points around intubation. The secondary outcome was the incidence of sore throat. Data analyses were done using the Statistical Software Jupyter Notebook, running in a Python 3.11 environment. Results The trend of vitals over time indicated that post-induction hypotension was less pronounced in the TT group. After intubation, patients in the TT group experienced a smaller surge in blood pressure and heart rate compared to the IV group. Notably, mean blood pressure (MBP) at 3 minutes post-intubation has significantly low values in patients who received transtracheal lignocaine [MBP (median with IQR) IV group 79(71-87) mm of Hg vs. TT group 73(65-81) mm of Hg, P = 0.009]. Conclusion Transtracheal lignocaine is more likely to maintain stable hemodynamics at various stages of intubation during general anesthesia compared to intravenous lignocaine. CTRI Registration CTRI/2023/06/054125 [Registered on: 19/06/2023]. This trial is registered with the Clinical Trial Registry of India https://ctri.nic.in/Clinicaltrials/login.php Transtracheal Injection Tracheal Intubation Hemodynamics Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Intubation is a preferred method for patients undergoing general anesthesia to secure a patent airway and facilitate mechanical ventilation. Direct laryngoscopy and endotracheal intubation typically trigger increased sympathetic and adrenomedullary catecholamine activity, leading to surges in heart rate and blood pressure [ 1 ] . For vulnerable patients, even a brief rise in these parameters can precipitate adverse events such as arrhythmias, myocardial infarction, cardiac failure, intracerebral hemorrhage, and elevated intracranial pressure [ 2 ] . Various methods have been employed to attenuate the hemodynamic stress response associated with laryngoscopy and intubation. Lignocaine has proven effective in mitigating these responses when administered via different routes: as an oral topical viscous solution [ 3 , 4 ] , aerosolized/nebulized solution [ 5 ] , laryngotracheal spray [ 6 ] , and intravenous (IV) injection [ 7 , 8 ] . While transtracheal lignocaine is commonly used during awake fiberoptic intubation, its use for preventing hemodynamic surges during intubation following general anesthesia has not been well-documented. This study aims to evaluate the efficacy of transtracheal 2% lignocaine in preventing post-intubation hemodynamic surge at a dosage of 1.5 mg/kg, administered after induction of general anesthesia. We hypothesized that this method would produce a hemodynamic response comparable to intravenous 2% lignocaine at the same dosage, thereby offering an alternative approach to attenuate the hemodynamic stress response associated with laryngoscopy and endotracheal intubation. Methods This prospective, interventional, single-blinded, randomized controlled trial was conducted after obtaining approval from the institutional ethics committee and was registered with the Clinical Trial Registry of India. The study involved 138 patients classified as American Society of Anesthesiologists (ASA) physical status I-II, aged 18–60 years, with a Mallampati score of I or II. Patients scheduled for elective surgical procedures under general anesthesia, requiring single-attempt oral intubation via direct laryngoscopy, were included. Exclusion criteria encompassed patient refusal, inability to provide valid consent, pregnancy, known hypersensitivity to lignocaine, anticipated difficult airway, video laryngoscope-assisted intubation, and restricted neck mobility. Written informed consent was obtained from all participants. The patients were recruited between the periods from 21st June 2023 to 20th April 2024. The study adhered to the principles of the Helsinki Declaration 2013 and followed good clinical practices. Patients were randomized into two groups using a computer-generated randomization chart: the intravenous group (Group IV) and the transtracheal group (Group TT). Baseline vitals were recorded in the preoperative holding area. A standardized anesthesia protocol was followed for all patients. In the operating room, intravenous access was secured, and standard ASA monitors were attached. Ringer lactate was initiated intravenously at a rate of 2 ml/kg/hr. Patients were pre-oxygenated with 100% oxygen at 10 L/min for 3 minutes. General anesthesia was induced using fentanyl 2 µg/kg, propofol 2-2.5 mg/kg, and atracurium 0.5 mg/kg. Hypotensive episodes were treated with a 3 mg intravenous bolus of mephentermine. Mechanical ventilation was used to maintain normocapnia, with a tidal volume of 6–8 ml/kg ideal body weight and positive end-expiratory pressure (PEEP) of 5 cm H2O. In Group IV, patients received preservative-free 2% lignocaine (Loxicard® 2%, Neon Laboratories Ltd, India) at 1.5 mg/kg intravenously immediately after induction. Three minutes post-administration, tracheal intubation was performed orally with an appropriate-sized endotracheal tube using a Macintosh laryngoscope in a single attempt. In Group TT, patients received preservative-free 2% lignocaine (Loxicard® 2%, Neon Laboratories Ltd, India) at 1.5 mg/kg transtracheally immediately after induction. With the patient in a head-extended position, the cricothyroid membrane was identified and punctured perpendicularly using a 22 G needle attached to a 5 ml syringe loaded with the drug. Aspiration of air confirmed needle placement and the drug was instilled into the trachea. After 3 minutes of transtracheal injection of lignocaine, the trachea was intubated orally with an appropriate-sized endotracheal tube using a Macintosh laryngoscope in a single attempt. Heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) were measured prior to intubation, immediately post-intubation, and at 1, 3, and 5 minutes post-intubation. The duration of laryngoscopy and intubation was recorded for both groups. General anesthesia was maintained with 50% nitrous oxide in oxygen each at 3 L/min and sevoflurane at a 2% dial concentration. After five minutes, routine anesthesia protocols were resumed, and surgical preparation commenced. The incidence of sore throat was noted in both groups once the patients were shifted to the recovery room. The sample size was calculated using the UCSF-CTSI (University of California San Francisco Clinical and Translational Science Institute) online calculator [ 9 ] , assuming a 5 mm Hg difference in mean of blood pressures between the two groups, with a standard deviation of 10 mm Hg, a 95% confidence interval, and 80% power. This resulted in a requirement of 63 patients per group. With an anticipated 10% attrition rate, the total sample size was adjusted to 138 patients. Statistical analyses were performed using Jupyter Notebook [ 10 ] running in a Python 3.11 environment. The Shapiro–Wilk test was used to assess the normal distribution of continuous data. Non-normally distributed continuous and ordinal data were analyzed using the Wilcoxon rank-sum test, while normally distributed continuous data were analyzed using the two-tailed Student's t-test. The Chi-square test was used for categorical data. A p-value of < 0.05 was considered statistically significant. A post hoc power and sample size analysis was conducted to validate the findings. Results A total of 144 patients were assessed for eligibility, with six patients not meeting the inclusion criteria. Consequently, 138 patients were recruited for the study, and data from 127 patients were included in the final analysis [Figure 1 ]. Demographic parameters were comparable between the two groups [Figure 2 ]. The duration of laryngoscopy and intubation was similar in both groups [mean ± SD: 22.15 ± 9.24 seconds in Group IV versus 20.74 ± 8.41 seconds in Group TT, P = 0.371]. The analysis of trends in vitals over time during intubation revealed distinct patterns between Group IV and Group TT. Post-induction, there was a noticeable fall in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) in both groups, with the decrease being less pronounced in the TT group. After intubation, patients in the TT group exhibited a lower surge in blood pressure and heart rate (HR) compared to the IV group. Overall, the TT group demonstrated a more stable hemodynamic profile throughout the observed time points [Figure 3 ]. Significant differences were observed in several key measurements [Table 1 ]. Post-induction, the fall in SBP and MBP was significantly less in the TT group (SBP: p = 0.009, MBP: p = 0.019). At 3 minutes post-intubation, surge in SBP, DBP, MBP, and HR were all significantly lower in the TT group compared to the IV group (SBP: p = 0.008, DBP: p = 0.002, MBP: p = 0.009, HR: p = 0.015). Additionally, at 5 minutes post-intubation, SBP remained significantly lower in the TT group (p = 0.030). Table 1 Vitals at different time point of intubation Variables Group IV (n = 61) Group TT (n = 66) P value SBPb 129.49 ± 14.41 125.73 ± 12.45 0.116 DBPb 80(73–85) 82(74.5–87) 0.412 MBPb 95.43 ± 9.66 95 ± 8.93 0.796 HRb 83.03 ± 12.71 83.06 ± 12.93 0.990 SBPpi 90(82–102) 96.5(86.25-106.75) 0.009 DBPpi 58.64 ± 14.11 63.11 ± 12.32 0.059 MBPpi 68(60–78) 71(66-82.25) 0.018 HRpi 81(73–86) 76.5(68-88.75) 0.227 SBPai 121.13 ± 22.95 122.42 ± 20.06 0.735 DBPai 79.44 ± 15.68 78.85 ± 14.22 0.823 MBPai 91.54 ± 17.83 92.15 ± 15.57 0.837 HRai 95.80 ± 18.47 89.45 ± 19.20 0.060 SBP1 113(103–133) 112(97.25-126.25) 0.320 DBP1 75.90 ± 16.17 72.06 ± 12.63 0.137 MBP1 87(78–101) 84(73.25–95.25) 0.349 HR1 89.21 ± 19.47 83.65 ± 17.67 0.094 SBP3 104(93–118) 97(88-107.75) 0.008 DBP3 68.92 ± 12.22 62.33 ± 10.75 0.002 MBP3 79(71–87) 73(65–81) 0.009 HR3 80(70–94) 71.5(64-82.75) 0.015 SBP5 96(91–107) 93(87–99) 0.030 DBP5 63.72 ± 10.75 60.30 ± 11.18 0.082 MBP5 74.31 ± 11.62 71 ± 10.09 0.088 HR5 73(65–85) 69(63.25–77.75) 0.136 Values are in mean ± SD, and median with IQR. SBP - Systolic blood pressure mm of Hg, DBP - Diastolic blood pressure mm of Hg, MBP - Mean blood pressure mm of Hg, HR - Heart rate/minute, b – Baseline, pi - prior to intubation, ai - immediately after intubation, 1–1 minutes post-intubation, 3–3 minutes post-intubation, 5–5 minutes post-intubation The analysis of the trend in Pressure-Rate Product (PRP) over time during intubation indicated that the TT group consistently exhibited lower PRP values compared to the IV group after intubation [Figure 4 ]. The Pressure-Rate Product, calculated by multiplying the heart rate (HR) by the systolic blood pressure (SBP), serves as a physiological measure to assess the workload of the heart. At 3 minutes post-intubation, the PRP was significantly lower in the TT group (p = 0.003) [Table 1 ]. Incidences of sore throat were similar in both groups (IV 6.5% vs. TT 9%, p-value: 0.842). A post hoc power analysis revealed a power of 0.804 for mean blood pressure at 3 minutes post-intubation (MBP3), with a suggested sample size of 60, indicating that the study was adequately powered to detect differences in MBP3 between the groups. Discussion Lignocaine has been employed through various routes to attenuate hemodynamic stress response associated with laryngoscopy and intubation. Intravenous administration of 2% lignocaine at a dose of 1.5 mg/kg, given 3 minutes before endotracheal intubation, is a common practice aimed at mitigating the hemodynamic response induced by laryngoscopy and intubation [ 2 ] . Transtracheal application of lignocaine is routinely utilized to facilitate intubation during awake fiberoptic intubation by anesthetizing the infraglottic larynx and upper trachea [ 11 ] , thereby aiding in the prevention of hemodynamic surge during awake intubation. We used transtracheal lignocaine after induction of general anesthesia to prevent hemodynamic surge during endotracheal intubation. It was performed after induction of general anesthesia hence patients didn’t feel any discomfort. The study revealed that transtracheal lignocaine was more likely to achieve a stable hemodynamic at different points of intubation compared to intravenous lignocaine following general anesthesia. The findings highlight the potential benefits of the transtracheal approach in managing hemodynamic responses during intubation, particularly in mitigating post-induction hypotension and controlling blood pressure and heart rate surges. Post-induction hypotension was less in the TT group. Despite the general anesthesia, a mild cough reflex was observed in most patients following transtracheal lignocaine administration. The mild cough along with sympathetic stimulation during transtracheal lignocaine administration may cause less post-induction hypotension in the TT group. Post-induction transtracheal lignocaine might not be as effective in anesthetizing the upper tracheal mucosa as during awake intubation where the cough reflex aids in drug dispersion. The stress response to intubation is primarily elicited by laryngoscopy and endotracheal tube placement, with the maximum response occurring during tracheal placement of the endotracheal tube [ 12 , 13 ] . In the TT group, the stress response during laryngoscopy was blunted by general anesthesia aided with some degree of drug spread to upper tracheal mucosa related to mild cough. The attenuating effect of intravenous lignocaine has been attributed to the arteriolar vasodilatation [ 14 ] , blunting of the autonomic response [ 15 ] , cough suppression [ 16 , 17 ] , and enhancement of the depth of general anesthesia [ 18 ] . The systemic arteriolar vasodilatory effect of IV lignocaine might have enhanced the hypotensive effects of propofol causing greater post-induction hypotension in IV group. The post-intubation hemodynamic surge was less in the TT group with significance achieved at 3 minutes. Vitals almost reached the pre-induction level at 3 minutes in the TT group indicating a subdued hemodynamic stress response post-intubation compared to those who received IV medication. The topical effect of 2% lignocaine comes in 1–3 minutes with a peak effect in 5–10 minutes [ 19 ] . Patients in the transtracheal group were intubated three minutes after lignocaine administration, with clinically significant stable vitals recorded three minutes post-intubation. The significant effect observed at 6 minutes post-transtracheal lignocaine administration aligns with the peak effect timing of topical lignocaine. The lower pressure rate product in the TT group highlights the effectiveness of the transtracheal lignocaine in minimizing cardiac workload during the post-intubation period. The trend favored the TT group, indicating a potential benefit in managing hemodynamic stability and reducing cardiac stress during intubation. To determine whether our study is adequately powered, a post hoc power analysis was done. A power of 0.804 was achieved for mean blood pressure at 3 minutes post-intubation (MBP3) with a suggested sample size of 60. Our study included 138 patients, indicating an adequate sample size to determine the superiority of transtracheal lignocaine over intravenous lignocaine in maintaining hemodynamic stability at 3 minutes post-intubation. Although statistically significant differences in hemodynamics were also noted between the intravenous and transtracheal groups prior to intubation and at 5 minutes post-intubation, the sample size of the study was not sufficient to achieve the power of 80%. Hence the study is not powered enough to compare the differences at those time points. This is the limitation of our study. Conclusion The study findings indicate that transtracheal lignocaine was more effective in maintaining stable hemodynamics at various stages of intubation during general anesthesia compared to intravenous lignocaine. In the transtracheal group, mean blood pressure at 3 minutes post-intubation was significantly low compared to the intravenous group. Declarations Consent for publication: We consent our research work to be published in the journal after completion of peer review process. Availability of data and materials: Data may be provided on request. Competing interests: None Funding: Nil Authors' contributions Contributors 1 2 3 4 5 6 7 8 Concepts ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Design ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Definition of intellectual content ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Literature search ✓ ✓ Clinical studies Experimental studies ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Data acquisition ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Data analysis ✓ ✓ ✓ Statistical analysis ✓ ✓ ✓ Manuscript preparation ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Manuscript editing ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Manuscript review ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Guarantor ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Acknowledgements: Nil References Derbyshire DR, Chmielewski A, Fell D, Vater M, Achola K, Smith G. Plasma catecholamine responses to tracheal intubation. BJA: British Journal of Anaesthesia. 1983 Sep 1;55(9):855-60. Kovac AL. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. Journal of clinical anesthesia. 1996 Feb 1;8(1):63-79. Stoelting RK. Circulatory response to laryngoscopy and tracheal intubation with or without prior oropharyngeal viscous lidocaine. Anesthesia and Analgesia. 1977 Sep 1;56(5):618-21. Stoelting RK. Blood pressure and heart rate changes during short-duration laryngoscopy for tracheal intubation: influence of viscous or intravenous lidocaine. Anesthesia & Analgesia. 1978 Mar 1;57(2):197-9. Denlinger JK, JK D, AJ O. Effects of intratracheal lidocaine on circulatory responses to tracheal intubation. Takita K, Morimoto Y, Kemmotsu O. Tracheal lidocaine attenuates the cardiovascular response to endotracheal intubation. Canadian journal of anesthesia. 2001 Sep;48(8):732-6. StoeTTing RK. Circulatory changes during direct laryngoscopy and tracheal intubation: influence of duration of laryngoscopy and tracheal intubation with or without prior lidocaine. Anesthesiology. 1977;47:381-4. Tam S, Chung F, Campbell M. Intravenous lidocaine: optimal time of injection before tracheal intubation. Anesth Analg. 1987 Oct 1;66(10):1036-8. Kohn MA, Senyak J. Sample Size Calculators [website]. UCSF CTSI. 11 January 2024. Available at https://www.sample-size.net Kluyver, T., Ragan-Kelley, B., Pérez, F., Granger, B. E., Bussonnier, M., Frederic, J., ... & Willing, C. (2016). Jupyter Notebooks – a publishing format for reproducible computational workflows. In Positioning and Power in Academic Publishing: Players, Agents and Agendas (pp. 87-90). IOS Press. Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Regional Anesthesia and pain medicine. 2002 Mar 1;27(2):180-92. Ovassapian A, Yelich SJ, Dykes MH, Brunner EE. Blood pressure and heart rate changes during awake fiberoptic nasotracheal intubation. Anesthesia & Analgesia. 1983 Oct 1;62(10):951-4. Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. British journal of anaesthesia. 1987 Mar 1;59(3):295-9. Stoelting RK, Hillier SC, editors. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2006. Pharmacology and Physiology in Anesthetic Practice; p. 191. Drenger B, Pe'er J. Attenuation of ocular and systemic responses to tracheal intubation by intravenous lignocaine. British journal of ophthalmology. 1987 Jul 1;71(7):546-8. Steinhaus JE, Gaskin L. A study of intravenous lidocaine as a suppressant of cough reflex. Anesthesiology. 1963;24:285–90. Poulton TJ, James FM., 3rd Cough suppression by lidocaine. Anesthesiology. 1979;50:470–2. Hamill JF, Bedford RF, Weaver DC, Colohan AR. Lidocaine before endotracheal intubation: Intravenous or laryngotracheal? Anesthesiology. 1981;55:578–81. McCambridge AJ, Boesch RP, Mullon JJ. Sedation in bronchoscopy: a review. Clinics in chest medicine. 2018 Mar 1;39(1):65-77. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 May, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 02 Jul, 2024 Editor assigned by journal 30 Jun, 2024 Submission checks completed at journal 30 Jun, 2024 First submitted to journal 24 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4628260","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321663374,"identity":"d6b90cc5-3e59-4b94-a775-42c21600aedd","order_by":0,"name":"Monotosh Pramanik","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Monotosh","middleName":"","lastName":"Pramanik","suffix":""},{"id":321663375,"identity":"12f75fd6-92dd-406f-b21c-f4d8223f159d","order_by":1,"name":"Uddalak Chattopadhyay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYFCCBAOGBwwJcmzMjA0SDBVAAWbmBsJaEhgSjPnZmYFazoC0MBKnJXFmP3uDBGMbSISAFoPjyRs/JNSkMW44zNh4u3JebTR/O1DLj4ptuLWceVYskXAsh9ngMGOz5dltx3NnHGZsYOw5cxu3lhs5BhIJbBVsQC1tko3bjuU2ALUwM7bh1WL8I+FfBQ9Ey5xjufOJ0GImkdiWIyHZDNLSUJO7gZAWyTPPyiwS+9IM+JmBfmk4diB3I1DLQXx+4TuevPnGh2/J9W38xx/ebKipy513/vDBBz8qcGtBB4fB5AGi1QNBHSmKR8EoGAWjYIQAABFRYjKEmitbAAAAAElFTkSuQmCC","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":true,"prefix":"","firstName":"Uddalak","middleName":"","lastName":"Chattopadhyay","suffix":""},{"id":321663376,"identity":"9e59a1ae-99ee-439f-b6e3-551d3c18c45b","order_by":2,"name":"Syed Sadaqat Hussain","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Syed","middleName":"Sadaqat","lastName":"Hussain","suffix":""},{"id":321663377,"identity":"4b35cd8e-b179-4c55-9025-a7f4707dddc3","order_by":3,"name":"Nikhil Kumar Singh","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Nikhil","middleName":"Kumar","lastName":"Singh","suffix":""},{"id":321663378,"identity":"83c53555-1867-42f7-8d0d-ca386b61a372","order_by":4,"name":"Shalini Chaudhuri","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Shalini","middleName":"","lastName":"Chaudhuri","suffix":""},{"id":321663379,"identity":"4122dd8c-65cb-427e-82fd-61ca4324e7d3","order_by":5,"name":"Sandipan Banerjee","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Sandipan","middleName":"","lastName":"Banerjee","suffix":""},{"id":321663380,"identity":"87d05f1f-89ad-48ab-8ecc-4896bd777644","order_by":6,"name":"Shreyasi Ray","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Shreyasi","middleName":"","lastName":"Ray","suffix":""},{"id":321663381,"identity":"6f54fce0-af99-4883-bb36-83465b57560e","order_by":7,"name":"Jyotirmay Kirtania","email":"","orcid":"","institution":"Homi Bhabha Cancer Hospital \u0026 Mahana Pandit Madan Mohan Malaviya Cancer Centre, Tata Memorial Centre, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Jyotirmay","middleName":"","lastName":"Kirtania","suffix":""}],"badges":[],"createdAt":"2024-06-24 07:29:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4628260/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4628260/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-025-03102-1","type":"published","date":"2025-05-24T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60930197,"identity":"d8b406a7-1e26-4ed6-9a4e-41ab5b620f06","added_by":"auto","created_at":"2024-07-23 16:58:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28245,"visible":true,"origin":"","legend":"\u003cp\u003eConsolidated Standard of Reporting Trials (CONSORT) flow diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4628260/v1/065470f913363f7468c75929.png"},{"id":60930200,"identity":"63966f9d-e2b3-4d99-b18a-35ab4bc5396d","added_by":"auto","created_at":"2024-07-23 16:58:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52282,"visible":true,"origin":"","legend":"\u003cp\u003eDemographic parameters\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4628260/v1/0ac74fece11f4defd57d14a6.png"},{"id":60931031,"identity":"2a8fe7f8-8472-404b-b19a-cbbcfec0e798","added_by":"auto","created_at":"2024-07-23 17:06:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":119217,"visible":true,"origin":"","legend":"\u003cp\u003eTrend chart of the vitals over time at different points of intubation\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4628260/v1/ee67460c9c08c51efe304a55.png"},{"id":60930199,"identity":"90b3147b-6b10-4844-8548-aab50e0f7b97","added_by":"auto","created_at":"2024-07-23 16:58:32","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":31273,"visible":true,"origin":"","legend":"\u003cp\u003eTrend chart of Pressure Rate Product over time\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4628260/v1/34ca5da9b25ad30adda1427f.png"},{"id":83460204,"identity":"168a9454-6267-4b71-bff3-f654a5af2ba6","added_by":"auto","created_at":"2025-05-26 16:12:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":812010,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4628260/v1/3d7fdf63-ca89-415b-9147-02548e5a0756.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparison between transtracheal and intravenous 2% lignocaine in attenuating hemodynamic stress response following direct laryngoscopy and endotracheal intubation: a randomized controlled trial\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntubation is a preferred method for patients undergoing general anesthesia to secure a patent airway and facilitate mechanical ventilation. Direct laryngoscopy and endotracheal intubation typically trigger increased sympathetic and adrenomedullary catecholamine activity, leading to surges in heart rate and blood pressure \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. For vulnerable patients, even a brief rise in these parameters can precipitate adverse events such as arrhythmias, myocardial infarction, cardiac failure, intracerebral hemorrhage, and elevated intracranial pressure \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVarious methods have been employed to attenuate the hemodynamic stress response associated with laryngoscopy and intubation. Lignocaine has proven effective in mitigating these responses when administered via different routes: as an oral topical viscous solution \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, aerosolized/nebulized solution \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, laryngotracheal spray \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, and intravenous (IV) injection \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. While transtracheal lignocaine is commonly used during awake fiberoptic intubation, its use for preventing hemodynamic surges during intubation following general anesthesia has not been well-documented.\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the efficacy of transtracheal 2% lignocaine in preventing post-intubation hemodynamic surge at a dosage of 1.5 mg/kg, administered after induction of general anesthesia. We hypothesized that this method would produce a hemodynamic response comparable to intravenous 2% lignocaine at the same dosage, thereby offering an alternative approach to attenuate the hemodynamic stress response associated with laryngoscopy and endotracheal intubation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This prospective, interventional, single-blinded, randomized controlled trial was conducted after obtaining approval from the institutional ethics committee and was registered with the Clinical Trial Registry of India. The study involved 138 patients classified as American Society of Anesthesiologists (ASA) physical status I-II, aged 18\u0026ndash;60 years, with a Mallampati score of I or II. Patients scheduled for elective surgical procedures under general anesthesia, requiring single-attempt oral intubation via direct laryngoscopy, were included. Exclusion criteria encompassed patient refusal, inability to provide valid consent, pregnancy, known hypersensitivity to lignocaine, anticipated difficult airway, video laryngoscope-assisted intubation, and restricted neck mobility. Written informed consent was obtained from all participants. The patients were recruited between the periods from 21st June 2023 to 20th April 2024. The study adhered to the principles of the Helsinki Declaration 2013 and followed good clinical practices.\u003c/p\u003e \u003cp\u003ePatients were randomized into two groups using a computer-generated randomization chart: the intravenous group (Group IV) and the transtracheal group (Group TT). Baseline vitals were recorded in the preoperative holding area.\u003c/p\u003e \u003cp\u003eA standardized anesthesia protocol was followed for all patients. In the operating room, intravenous access was secured, and standard ASA monitors were attached. Ringer lactate was initiated intravenously at a rate of 2 ml/kg/hr. Patients were pre-oxygenated with 100% oxygen at 10 L/min for 3 minutes. General anesthesia was induced using fentanyl 2 \u0026micro;g/kg, propofol 2-2.5 mg/kg, and atracurium 0.5 mg/kg. Hypotensive episodes were treated with a 3 mg intravenous bolus of mephentermine. Mechanical ventilation was used to maintain normocapnia, with a tidal volume of 6\u0026ndash;8 ml/kg ideal body weight and positive end-expiratory pressure (PEEP) of 5 cm H2O.\u003c/p\u003e \u003cp\u003eIn Group IV, patients received preservative-free 2% lignocaine (Loxicard\u0026reg; 2%, Neon Laboratories Ltd, India) at 1.5 mg/kg intravenously immediately after induction. Three minutes post-administration, tracheal intubation was performed orally with an appropriate-sized endotracheal tube using a Macintosh laryngoscope in a single attempt.\u003c/p\u003e \u003cp\u003eIn Group TT, patients received preservative-free 2% lignocaine (Loxicard\u0026reg; 2%, Neon Laboratories Ltd, India) at 1.5 mg/kg transtracheally immediately after induction. With the patient in a head-extended position, the cricothyroid membrane was identified and punctured perpendicularly using a 22 G needle attached to a 5 ml syringe loaded with the drug. Aspiration of air confirmed needle placement and the drug was instilled into the trachea. After 3 minutes of transtracheal injection of lignocaine, the trachea was intubated orally with an appropriate-sized endotracheal tube using a Macintosh laryngoscope in a single attempt.\u003c/p\u003e \u003cp\u003eHeart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) were measured prior to intubation, immediately post-intubation, and at 1, 3, and 5 minutes post-intubation. The duration of laryngoscopy and intubation was recorded for both groups. General anesthesia was maintained with 50% nitrous oxide in oxygen each at 3 L/min and sevoflurane at a 2% dial concentration. After five minutes, routine anesthesia protocols were resumed, and surgical preparation commenced. The incidence of sore throat was noted in both groups once the patients were shifted to the recovery room.\u003c/p\u003e \u003cp\u003eThe sample size was calculated using the UCSF-CTSI (University of California San Francisco Clinical and Translational Science Institute) online calculator \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, assuming a 5 mm Hg difference in mean of blood pressures between the two groups, with a standard deviation of 10 mm Hg, a 95% confidence interval, and 80% power. This resulted in a requirement of 63 patients per group. With an anticipated 10% attrition rate, the total sample size was adjusted to 138 patients.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using Jupyter Notebook \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e running in a Python 3.11 environment. The Shapiro\u0026ndash;Wilk test was used to assess the normal distribution of continuous data. Non-normally distributed continuous and ordinal data were analyzed using the Wilcoxon rank-sum test, while normally distributed continuous data were analyzed using the two-tailed Student's t-test. The Chi-square test was used for categorical data. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. A post hoc power and sample size analysis was conducted to validate the findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 144 patients were assessed for eligibility, with six patients not meeting the inclusion criteria. Consequently, 138 patients were recruited for the study, and data from 127 patients were included in the final analysis [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Demographic parameters were comparable between the two groups [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]. The duration of laryngoscopy and intubation was similar in both groups [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 22.15\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24 seconds in Group IV versus 20.74\u0026thinsp;\u0026plusmn;\u0026thinsp;8.41 seconds in Group TT, P\u0026thinsp;=\u0026thinsp;0.371].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe analysis of trends in vitals over time during intubation revealed distinct patterns between Group IV and Group TT. Post-induction, there was a noticeable fall in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) in both groups, with the decrease being less pronounced in the TT group. After intubation, patients in the TT group exhibited a lower surge in blood pressure and heart rate (HR) compared to the IV group. Overall, the TT group demonstrated a more stable hemodynamic profile throughout the observed time points [Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSignificant differences were observed in several key measurements [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Post-induction, the fall in SBP and MBP was significantly less in the TT group (SBP: p\u0026thinsp;=\u0026thinsp;0.009, MBP: p\u0026thinsp;=\u0026thinsp;0.019). At 3 minutes post-intubation, surge in SBP, DBP, MBP, and HR were all significantly lower in the TT group compared to the IV group (SBP: p\u0026thinsp;=\u0026thinsp;0.008, DBP: p\u0026thinsp;=\u0026thinsp;0.002, MBP: p\u0026thinsp;=\u0026thinsp;0.009, HR: p\u0026thinsp;=\u0026thinsp;0.015). Additionally, at 5 minutes post-intubation, SBP remained significantly lower in the TT group (p\u0026thinsp;=\u0026thinsp;0.030).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVitals at different time point of intubation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup IV (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup TT (n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBPb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129.49\u0026thinsp;\u0026plusmn;\u0026thinsp;14.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125.73\u0026thinsp;\u0026plusmn;\u0026thinsp;12.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBPb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80(73\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82(74.5\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBPb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.43\u0026thinsp;\u0026plusmn;\u0026thinsp;9.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHRb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.03\u0026thinsp;\u0026plusmn;\u0026thinsp;12.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.06\u0026thinsp;\u0026plusmn;\u0026thinsp;12.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.990\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBPpi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90(82\u0026ndash;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.5(86.25-106.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBPpi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.64\u0026thinsp;\u0026plusmn;\u0026thinsp;14.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBPpi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68(60\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71(66-82.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHRpi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81(73\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.5(68-88.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBPai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121.13\u0026thinsp;\u0026plusmn;\u0026thinsp;22.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122.42\u0026thinsp;\u0026plusmn;\u0026thinsp;20.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBPai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.85\u0026thinsp;\u0026plusmn;\u0026thinsp;14.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBPai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.54\u0026thinsp;\u0026plusmn;\u0026thinsp;17.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.15\u0026thinsp;\u0026plusmn;\u0026thinsp;15.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.837\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHRai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.80\u0026thinsp;\u0026plusmn;\u0026thinsp;18.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.45\u0026thinsp;\u0026plusmn;\u0026thinsp;19.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113(103\u0026ndash;133)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112(97.25-126.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.90\u0026thinsp;\u0026plusmn;\u0026thinsp;16.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.06\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87(78\u0026ndash;101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84(73.25\u0026ndash;95.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.21\u0026thinsp;\u0026plusmn;\u0026thinsp;19.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.65\u0026thinsp;\u0026plusmn;\u0026thinsp;17.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104(93\u0026ndash;118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97(88-107.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.92\u0026thinsp;\u0026plusmn;\u0026thinsp;12.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.33\u0026thinsp;\u0026plusmn;\u0026thinsp;10.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79(71\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73(65\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80(70\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.5(64-82.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96(91\u0026ndash;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93(87\u0026ndash;99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.72\u0026thinsp;\u0026plusmn;\u0026thinsp;10.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.30\u0026thinsp;\u0026plusmn;\u0026thinsp;11.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.31\u0026thinsp;\u0026plusmn;\u0026thinsp;11.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u0026thinsp;\u0026plusmn;\u0026thinsp;10.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73(65\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69(63.25\u0026ndash;77.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are in mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, and median with IQR. SBP - Systolic blood pressure mm of Hg, DBP - Diastolic blood pressure mm of Hg, MBP - Mean blood pressure mm of Hg, HR - Heart rate/minute, b \u0026ndash; Baseline, pi - prior to intubation, ai - immediately after intubation, 1\u0026ndash;1 minutes post-intubation, 3\u0026ndash;3 minutes post-intubation, 5\u0026ndash;5 minutes post-intubation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis of the trend in Pressure-Rate Product (PRP) over time during intubation indicated that the TT group consistently exhibited lower PRP values compared to the IV group after intubation [Figure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. The Pressure-Rate Product, calculated by multiplying the heart rate (HR) by the systolic blood pressure (SBP), serves as a physiological measure to assess the workload of the heart. At 3 minutes post-intubation, the PRP was significantly lower in the TT group (p\u0026thinsp;=\u0026thinsp;0.003) [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIncidences of sore throat were similar in both groups (IV 6.5% vs. TT 9%, p-value: 0.842).\u003c/p\u003e \u003cp\u003eA post hoc power analysis revealed a power of 0.804 for mean blood pressure at 3 minutes post-intubation (MBP3), with a suggested sample size of 60, indicating that the study was adequately powered to detect differences in MBP3 between the groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLignocaine has been employed through various routes to attenuate hemodynamic stress response associated with laryngoscopy and intubation. Intravenous administration of 2% lignocaine at a dose of 1.5 mg/kg, given 3 minutes before endotracheal intubation, is a common practice aimed at mitigating the hemodynamic response induced by laryngoscopy and intubation \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Transtracheal application of lignocaine is routinely utilized to facilitate intubation during awake fiberoptic intubation by anesthetizing the infraglottic larynx and upper trachea \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, thereby aiding in the prevention of hemodynamic surge during awake intubation. We used transtracheal lignocaine after induction of general anesthesia to prevent hemodynamic surge during endotracheal intubation. It was performed after induction of general anesthesia hence patients didn\u0026rsquo;t feel any discomfort.\u003c/p\u003e \u003cp\u003eThe study revealed that transtracheal lignocaine was more likely to achieve a stable hemodynamic at different points of intubation compared to intravenous lignocaine following general anesthesia. The findings highlight the potential benefits of the transtracheal approach in managing hemodynamic responses during intubation, particularly in mitigating post-induction hypotension and controlling blood pressure and heart rate surges.\u003c/p\u003e \u003cp\u003ePost-induction hypotension was less in the TT group. Despite the general anesthesia, a mild cough reflex was observed in most patients following transtracheal lignocaine administration. The mild cough along with sympathetic stimulation during transtracheal lignocaine administration may cause less post-induction hypotension in the TT group.\u003c/p\u003e \u003cp\u003ePost-induction transtracheal lignocaine might not be as effective in anesthetizing the upper tracheal mucosa as during awake intubation where the cough reflex aids in drug dispersion. The stress response to intubation is primarily elicited by laryngoscopy and endotracheal tube placement, with the maximum response occurring during tracheal placement of the endotracheal tube \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In the TT group, the stress response during laryngoscopy was blunted by general anesthesia aided with some degree of drug spread to upper tracheal mucosa related to mild cough.\u003c/p\u003e \u003cp\u003eThe attenuating effect of intravenous lignocaine has been attributed to the arteriolar vasodilatation \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, blunting of the autonomic response \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, cough suppression \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, and enhancement of the depth of general anesthesia \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The systemic arteriolar vasodilatory effect of IV lignocaine might have enhanced the hypotensive effects of propofol causing greater post-induction hypotension in IV group.\u003c/p\u003e \u003cp\u003eThe post-intubation hemodynamic surge was less in the TT group with significance achieved at 3 minutes. Vitals almost reached the pre-induction level at 3 minutes in the TT group indicating a subdued hemodynamic stress response post-intubation compared to those who received IV medication. The topical effect of 2% lignocaine comes in 1\u0026ndash;3 minutes with a peak effect in 5\u0026ndash;10 minutes \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Patients in the transtracheal group were intubated three minutes after lignocaine administration, with clinically significant stable vitals recorded three minutes post-intubation. The significant effect observed at 6 minutes post-transtracheal lignocaine administration aligns with the peak effect timing of topical lignocaine.\u003c/p\u003e \u003cp\u003eThe lower pressure rate product in the TT group highlights the effectiveness of the transtracheal lignocaine in minimizing cardiac workload during the post-intubation period. The trend favored the TT group, indicating a potential benefit in managing hemodynamic stability and reducing cardiac stress during intubation.\u003c/p\u003e \u003cp\u003eTo determine whether our study is adequately powered, a post hoc power analysis was done. A power of 0.804 was achieved for mean blood pressure at 3 minutes post-intubation (MBP3) with a suggested sample size of 60. Our study included 138 patients, indicating an adequate sample size to determine the superiority of transtracheal lignocaine over intravenous lignocaine in maintaining hemodynamic stability at 3 minutes post-intubation.\u003c/p\u003e \u003cp\u003eAlthough statistically significant differences in hemodynamics were also noted between the intravenous and transtracheal groups prior to intubation and at 5 minutes post-intubation, the sample size of the study was not sufficient to achieve the power of 80%. Hence the study is not powered enough to compare the differences at those time points. This is the limitation of our study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study findings indicate that transtracheal lignocaine was more effective in maintaining stable hemodynamics at various stages of intubation during general anesthesia compared to intravenous lignocaine. In the transtracheal group, mean blood pressure at 3 minutes post-intubation was significantly low compared to the intravenous group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWe consent our research work to be published in the journal after completion of peer review process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData may be provided on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"104%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003eConcepts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003eDesign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eDefinition of intellectual content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eLiterature search\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eClinical studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eExperimental studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eData acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eData analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eStatistical analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eManuscript preparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eManuscript editing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eManuscript review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003eGuarantor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDerbyshire DR, Chmielewski A, Fell D, Vater M, Achola K, Smith G. Plasma catecholamine responses to tracheal intubation. BJA: British Journal of Anaesthesia. 1983 Sep 1;55(9):855-60.\u003c/li\u003e\n\u003cli\u003eKovac AL. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. Journal of clinical anesthesia. 1996 Feb 1;8(1):63-79.\u003c/li\u003e\n\u003cli\u003eStoelting RK. Circulatory response to laryngoscopy and tracheal intubation with or without prior oropharyngeal viscous lidocaine. Anesthesia and Analgesia. 1977 Sep 1;56(5):618-21.\u003c/li\u003e\n\u003cli\u003eStoelting RK. Blood pressure and heart rate changes during short-duration laryngoscopy for tracheal intubation: influence of viscous or intravenous lidocaine. Anesthesia \u0026amp; Analgesia. 1978 Mar 1;57(2):197-9.\u003c/li\u003e\n\u003cli\u003eDenlinger JK, JK D, AJ O. Effects of intratracheal lidocaine on circulatory responses to tracheal intubation.\u003c/li\u003e\n\u003cli\u003eTakita K, Morimoto Y, Kemmotsu O. Tracheal lidocaine attenuates the cardiovascular response to endotracheal intubation. Canadian journal of anesthesia. 2001 Sep;48(8):732-6.\u003c/li\u003e\n\u003cli\u003eStoeTTing RK. Circulatory changes during direct laryngoscopy and tracheal intubation: influence of duration of laryngoscopy and tracheal intubation with or without prior lidocaine. Anesthesiology. 1977;47:381-4.\u003c/li\u003e\n\u003cli\u003eTam S, Chung F, Campbell M. Intravenous lidocaine: optimal time of injection before tracheal intubation. Anesth Analg. 1987 Oct 1;66(10):1036-8.\u003c/li\u003e\n\u003cli\u003eKohn MA, Senyak J. Sample Size Calculators [website]. UCSF CTSI. 11 January 2024. Available at https://www.sample-size.net\u003c/li\u003e\n\u003cli\u003eKluyver, T., Ragan-Kelley, B., P\u0026eacute;rez, F., Granger, B. E., Bussonnier, M., Frederic, J., ... \u0026amp; Willing, C. (2016). Jupyter Notebooks \u0026ndash; a publishing format for reproducible computational workflows. In Positioning and Power in Academic Publishing: Players, Agents and Agendas (pp. 87-90). IOS Press.\u003c/li\u003e\n\u003cli\u003eSimmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Regional Anesthesia and pain medicine. 2002 Mar 1;27(2):180-92.\u003c/li\u003e\n\u003cli\u003eOvassapian A, Yelich SJ, Dykes MH, Brunner EE. Blood pressure and heart rate changes during awake fiberoptic nasotracheal intubation. Anesthesia \u0026amp; Analgesia. 1983 Oct 1;62(10):951-4.\u003c/li\u003e\n\u003cli\u003eShribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. British journal of anaesthesia. 1987 Mar 1;59(3):295-9.\u003c/li\u003e\n\u003cli\u003eStoelting RK, Hillier SC, editors. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2006. Pharmacology and Physiology in Anesthetic Practice; p. 191.\u003c/li\u003e\n\u003cli\u003eDrenger B, Pe\u0026apos;er J. Attenuation of ocular and systemic responses to tracheal intubation by intravenous lignocaine. British journal of ophthalmology. 1987 Jul 1;71(7):546-8.\u003c/li\u003e\n\u003cli\u003eSteinhaus JE, Gaskin L. A study of intravenous lidocaine as a suppressant of cough reflex. Anesthesiology. 1963;24:285\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003ePoulton TJ, James FM., 3rd Cough suppression by lidocaine. Anesthesiology. 1979;50:470\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eHamill JF, Bedford RF, Weaver DC, Colohan AR. Lidocaine before endotracheal intubation: Intravenous or laryngotracheal? Anesthesiology. 1981;55:578\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eMcCambridge AJ, Boesch RP, Mullon JJ. Sedation in bronchoscopy: a review. Clinics in chest medicine. 2018 Mar 1;39(1):65-77.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Transtracheal Injection, Tracheal Intubation, Hemodynamics","lastPublishedDoi":"10.21203/rs.3.rs-4628260/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4628260/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Aims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLignocaine is used through various routes to mitigate the hemodynamic surge associated with laryngoscopy and endotracheal intubation during general anesthesia. This study hypothesized that post-induction administration of transtracheal 2% lignocaine at 1.5 mg/kg would have a similar effect to intravenous 2% lignocaine at the same dosage, providing an alternative for attenuating the hemodynamic stress response.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 138 consenting patients were randomized into two groups. Following induction, Group IV patients received 2% lignocaine at 1.5 mg/kg intravenously, while Group TT patients received 2% lignocaine at 1.5 mg/kg transtracheally. The primary outcome was the comparison of hemodynamic responses at different time points around intubation. The secondary outcome was the incidence of sore throat. Data analyses were done using the Statistical Software Jupyter Notebook, running in a Python 3.11 environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe trend of vitals over time indicated that post-induction hypotension was less pronounced in the TT group. After intubation, patients in the TT group experienced a smaller surge in blood pressure and heart rate compared to the IV group. Notably, mean blood pressure (MBP) at 3 minutes post-intubation has significantly low values in patients who received transtracheal lignocaine [MBP (median with IQR) IV group 79(71-87) mm of Hg vs. TT group 73(65-81) mm of Hg, P = 0.009].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTranstracheal lignocaine is more likely to maintain stable hemodynamics at various stages of intubation during general anesthesia compared to intravenous lignocaine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCTRI Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCTRI/2023/06/054125 [Registered on: 19/06/2023]. This trial is registered with the Clinical Trial Registry of India https://ctri.nic.in/Clinicaltrials/login.php\u003c/p\u003e","manuscriptTitle":"Comparison between transtracheal and intravenous 2% lignocaine in attenuating hemodynamic stress response following direct laryngoscopy and endotracheal intubation: a randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 16:58:27","doi":"10.21203/rs.3.rs-4628260/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-02T10:44:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-30T11:43:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-30T11:42:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2024-06-24T07:28:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"df8f45e3-0a37-41f0-b544-48e1ee995033","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:06:30+00:00","versionOfRecord":{"articleIdentity":"rs-4628260","link":"https://doi.org/10.1186/s12871-025-03102-1","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-05-24 15:57:04","publishedOnDateReadable":"May 24th, 2025"},"versionCreatedAt":"2024-07-23 16:58:27","video":"","vorDoi":"10.1186/s12871-025-03102-1","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03102-1","workflowStages":[]},"version":"v1","identity":"rs-4628260","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4628260","identity":"rs-4628260","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}