Laryngoscopy and tracheal intubation produce pressor responses and sympatho-adrenal responses following induction of anaesthesia, which are hypothesised to be somato-visceral reflexes triggered by stimulation of the laryngopharynx.Laryngoscopy without intubation produces approximately the same pressor response as laryngoscopy with intubation. It begins in 5 seconds, peaks in 1–2 minutes, and then returns to baseline in 5 minutes.Increased circulatory catecholamines leads to increased heart rate (HR), blood pressure, myocardial oxygen demand, and dysrhythmias arise from these reactions. Heart rate and blood pressure increases are often temporary, varied, and unexpected. The average rise in heart rate was 23 beats, with an increase in blood pressure of 53/34 mmHg and a 20 percent drop in left ventricular ejection fraction. Although healthy individuals would generally tolerate such a reaction, people with substantial coronary artery or cerebrovascular disorders may have myocardial ischemia and cerebral haemorrhage as a result of these alterations.1,2 During laryngoscopy and intubation, topical anaesthesia on the upper airway has been demonstrated to reduce hemodynamic pressor response. Because the circulatory alterations are assumed to be somatovisceral reflexes caused by proprioceptor stimulation in the laryngopharynx, it was anticipated that topical anaesthesia on the airway, either alone or in conjunction with other treatments, could help to reduce these responses.3 The fundamental pharmacological action of local anaesthetic medicines is suppression of the excitation—conduction pathway in peripheral nerves. Potency, rapidity of onset, and duration of anaesthetic action are all therapeutically relevant features of many local anaesthetic drugs. The physicochemical features of the various compounds, which are in turn reliant on their chemical structure, largely dictate the clinical profile of the particular medications. Lipid solubility, protein binding, and pKa are physicochemical factors that determine anaesthetic action.4 Therefore, it is important to suppress the hemodynamic responses and airway irritability. Previously many methods were used to attenuate hemodynamic responses. Intravenous drugs such as propofol, fentanyl and its congeners, trinitro glycerine, sodium nitroprusside, clonidine, dexmedetomidine, magnesium sulphate, and local anaesthetics such as preservative free lignocaine. Surface anaesthesia of the airway by means of nebulization using local anaesthetics also suppresses the hemodynamic responses to laryngoscopy and intubation. Cough and bucking are seen in nearly 40% of the patients while emergence from general anaesthesia . Coughing is important physiological consequence because it increases intrathoracic pressure, decreases venous return to right atrium, increased intra-abdominal pressures and decreased functional residual capacity and increased blood pressures.

Severity Of Cough Using Following Scoring Guidelines 0: No cough. 1: Mild cough, cough without obvious contraction of abdomen. 2: Moderate cough, strong and sudden contraction of abdomen lasting for<5seconds 3: Severe cough, strong and sudden contraction of the abdomen sustained >5seconds. Study setting: study was conducted at Navodaya Medical College, Hospital and Research Centre, Raichur. Study Population: Patients aged between 18-50 yrs,belonging to ASA 1 and ASA 2 satisfying inclusion and exclusion criteria undergoing elective surgeries under general anaesthetia with endotracheal intubation Study design: randomized double blinded study Study sample: To keep the sample size higher,20 samples from each group has been taken. So, the total sample size is 80. Study Period: 2 years Inclusion Criteria: • Age -18 to 50 years of either sex. • Patients belonging to ASA -Grade I and II • MallamPatti Class I and II • Elective minor, major and day care surgical procedure • patients willing for the study. Exclusion Criteria: • Patients with Cardiorespiratory compromise. • Patients with Asthma and COPD (Chronic Obstructive Pulmonary Disease) • Patients with history of drug abuse or alcohol abuse • 4) Patients with known allergy to amide group of local anesthetics. • Patients on beta-blockers, antidepressants, antipsychotics, anxiolytics and anticonvulsants. • Morbid obesity • Pregnancy. Brief Procedure: After obtaining institutional ethical committee approval and written informed consent from the patient, explaining about the procedure.A total of 80 patients satisfying the inclusion and exclusion criteria were selected and was randomly allocated using a computer-generated random number table to one of the following four groups of 20 patients each. GROUP 1 - 5ml of 0.25% Ropivacaine nebulization. GROUP 2 - 5ml of 0.5% Ropivacine nebulization. GROUP 3 - 5ml of 2% Lignocaine nebulization. GROUP 4 - will be receiving 5ml of 4% Lignocaine nebulization. All patients had undergone thorough pre anesthetic evaluation which includes a detailed history taking, physical examination and necessary investigations as required. Tablet Alprazolam 0.5 mg and Tablet ranitidine 150 mg perorally was given on the night before the surgery.

Table 1: Comparison heart rate at various timeline between the groups Heart rate at various time line 2% Lignocaine Mean ± SD N=20 4% Lignocaine Mean ± SD N=20 0.25% Ropivicaine Mean ± SD N=20 0.5% Ropivicaine Mean ± SD N=20 P value (Inter group) T1 82.62 ± 1.57 82.46 ± 1.4 78.18 ± 0.96 76.22 ± 1.49 0.01 T2 77.02 ± 1.15 74.47 ± 1.43 74.65 ± 1.41 72.59 ± 2.09 0.02 T3 100.84 ± 1.48 96.06 ± 1.53 84.27 ± 1.89 84.60 ± 1.34 0.001 T4 103.41 ±1.40 98.42 ± 1.76 88.24 ± 1.43 86.63 ± 1.50 0.001 T5 96.50 ± 1.25 94.63 ± 1.52 84.61 ± 1.43 84.68 ± 1.25 0.001 T6 90.50 ± 1.54 90.78 ± 1.36 80.57 ± 1.46 78.29 ± 1.26 0.003 T7 86.06 ± 1.33 88.52 ± 1.40 76.47 ± 1.16 77.05 ± 1.37 0.01 T8 85.43 ± 1.44 86.40 ± 1.35 74.39 ± 1.26 79.01 ± 1.12 0.01 T9 84.53 ± 1.51 78.26 ± 1.31 74.54 ± 1.59 79.14 ± 1.55 0.01 In our study heart rate was compared between the groups (1,2,3,4)at various time line such as baseline (T1), during anaesthesia induction (T2), during intubation 0 minute (T3), 2 minute (T4), 4 minute (T5), 6 minute (T6), 8 minute (T7), 10 minute (T8), 15th minute of intubation(T9),In our observation the maximum heart rate was documented at T3 and T4 for all the four groups, Group 1 (0.25% Ropivacaine) and Group 2 (0.5% ropivicaine),Group 3(2% lignocaine ), Group 4 (4% lignocaine)on comparision in between the groups, Group 3 (2% lignocaine) had highest heart rate, the mean was 103.41 and followed by Group 4 (4% lignocaine ) with mean heart of 98.42. There was significant statistical difference between the groups with p value was 0.001(<0.05). In out study,the oxygen saturation at various time intervals were compared between the study groups and we observed that there was no change in saturation during and after the time of intubation . Table 2: Comparison SBP at various timeline between the groups SBP at various Time points 2% Lignocaine Mean ± SD N=20 4% Lignocaine Mean ± SD N=20 0.25% Ropivicaine Mean ± SD N=20 0.5% Ropivicaine Mean ± SD N=20 P value (Inter group) T1 129.73 ± 1.16 130.97 ±1.36 120.04 ± .96 119.73 ±1.63 0.001 T2 119.78 ± 1.12 110.45 ±1.43 110.65 ±1.43 110.78 ±1.07 0.001 T3 141.32 ±3.39 140.55 ± 1.33 130.55 ±1.45 129.76 ±1.11 0.001 T4 140.49 ± 1.45 140.22 ±1.17 130.70 ±1.45 130.00 ±1.64 0.001 T5 120.59 ± 1.39 129.78 ±1.07 130.67 ±1.48 130.14 ±1.83 0.001 T6 130.45 ± 1.29 120.65 ±1.69 119.91 ±1.20 120.29 ±1.24 0.001 T7 130.15 ± 1.33 119.97 ±1.04 110.08 ±1.24 111.09 ±1.27 0.001 T8 120.51 ± 1.52 120.44 ±1.49 105.37 ±4.04 110.71 ±1.20 0.001 T9 120.46 ± 1.36 120.06 ±1.08 111.31 ±1.10 110.21 ±1.48 0.001 Comparision of systolic blood pressure at various time line such as baseline(T1), during anaesthesia induction (T2), during intubation 0 minute (T3), 2 minute (T4), 4 minute (T5), 6 minute (T6), 8 minute (T7), 10 minute (T8), 15th minute from the time of tracheal intubation(T9) between the groups and it revealed that the maximum SBP was documented at T3 and T4 for all the four groups 1,2,3,4.,Group 1 (0.25%Ropivacaine) and Group 2(0.5% Ropivacaine) Group 3 (2%lignocaine), Group 4 (4% lignocaine).Highest Systolic blood pressure was documented in Group 3( 2% lignocaine) with mean value of 141.32 and followed by Group 4 (4% lignocaine)with mean value of 140.55.Between the groups,Group 3( 2% lignocaine) had study showed statistical difference between the groups with P value 0.001(<0.05). Table 3:Comparison DBP at various timeline between the groups DBP at various Time points 2% Lignocaine Mean ± SD N=20 4% Lignocaine Mean ± SD N=20 0.25% Ropivicaine Mean ± SD N=20 0.5% Ropivicaine Mean ± SD N=20 P value (Inter group) T1 80.43±1.37 80.64 ± 1.51 80.35 ± 1.48 80.37 ± 1.20 0.28 T2 70.21 ± 1.36 70.58 ± 1.40 70.54 ± 1.80 70.75 ± 1.51 0.45 T3 80.74 ± 1.28 80.09 ± 2.07 80.68 ± 1.87 80.62 ± 1.36 0.29 T4 80.89 ± 1.43 80.73 ± 1.33 80.50 ± 1.42 80.67 ± 1.57 0.75 T5 80.23 ± 1.40 80.47 ± 1.31 80.08 ± 1.53 80.28 ± 1.50 0.68 T6 80.38 ± 1.48 80.11 ± 1.96 80.73 ± 1.33 80.51 ± 1.34 0.34 T7 80.65 ± 1.42 80.63 ± 1.25 70.51 ± 1.21 70.58 ± 1.55 0.001 T8 80.71 ± 1.72 80.52 ± 1.43 70.21 ± 1.41 70.26 ± 1.43 0.001 T9 80.65 ± 1.92 80.58 ± 1.81 70.55 ± 1.59 70.83 ± 1.66 0.001 Diastolic blood pressure between the groups measured at various time line such as baseline(T1), during anaesthesia induction (T2), during intubation 0 minute (T3), 2 minute (T4), 4 minute (T5), 6 minute (T6), 8 minute (T7), 10 minute (T8), 15th minute from the time of tracheal intubation(T9).Among Group 1 (0.25%Ropivacaine) and Group 2 (0.5% ropivicaine) Group 3 (2%lignocaine), Group 4 (4% lignocaine),maximum DBP was documented at T3 and T4 for all the four groups which was at 0 minute and 2 minute after tracheal intubation. Among the four groups, Group 4 (4% lignocaine)had highest diastolic blood pressure which was followed by Group 3 (2% lignocaine). There was no statistically significant difference between the groups at T3,T4 levels with P value (>0.05). Table 4: Comparison MAP at various timeline between the groups MAP at various Time points 2% Lignocaine Mean ± SD N=20 4% Lignocaine Mean ± SD N=20 0.25% Ropivicaine Mean ± SD N=20 0.5% Ropivicaine Mean ± SD N=20 P value (Inter group) T1 97.17 ± 1.05 97.42 ± 1.09 93.58 ± 0.85 93.49 ± 0.93 0.001 T2 86.73 ± 0.936 83.87 ± 1.05 83.91 ± 1.39 84.09 ± 1.08 0.001 T3 100.62 ±0.99 100.50 ±1.14 97.31 ± 1.41 97.00 ± 0.99 0.001 T4 100.33 ± 0.86 100.56 ± 0.92 97.23 ± 1.17 97.12 ± 1.04 0.001 T5 93.68 ± 0.98 96.91 ± 0.85 96.94 ± 1.04 96.90 ± 1.10 0.001 T6 97.27 ± 1.08 93.62 ± 1.05 93.79 ± 0.84 65.64 ±27.15 0.001 T7 97.24 ± 0.98 93.74 ± 0.85 83.70 ± 0.88 59.32 ±23.77 0.001 T8 93.96 ± 1.40 93.83 ± 1.23 81.93 ± 1.73 83.74 ± 1.01 0.001 T9 93.92 ± 1.31 93.74 ± 1.19 84.14 ± 1.27 83.95 ± 1.34 0.001 In our study Mean arterial blood pressure was compared between the groups at various time line such as baseline (T1), during anaesthesia induction (T2), during tracheal intubation 0 minute (T3), 2 minute (T4), 4 minute (T5), 6 minute (T6), 8 minute (T7), 10 minute (T8), 15th minute of tracheal intubation (T 9). The maximum MAP was documented at T3 and T4 for all the four groups Group(1,2,3,4). Group 1(0.25%Ropivacaine) and Group 2 (0.5% ropivicaine) .Group 3(2%lignocaine), Group 4(4% lignocaine), While among the four groups,Group 3(2% lignocaine)which had highest MAP blood pressure with mean value of 100.62 followed by Group 4( 4% lignocaine) with mean value of 100.56 .Significant difference obsereved between groups with p value of 0.001(<0.05). Table 5: Comparison of duration of surgery and duration of anaesthesia between the study groups Parameter (In minutes) 2% Lignocaine Mean ± SD N=20 4% Lignocaine Mean ± SD N=20 0.25% Ropivicaine Mean ± SD N=20 0.5% Ropivicaine Mean ± SD N=20 P value (Inter group) Duration of surgery 108.71 ±25.97 116.45 ±23.01 100.28 ± 20.78 100.18 ±21.67 .004 Duration of anaesthesia 125.66 ±24.04 123.31 ±21.27 125.67 ± 21.48 121.16 ±23.89 0.780 From the above table and graph it is evident that the highest duration of surgery was documented among Group 4 (4% lignocaine )with the mean of time duration of 116.45 minutes after that it was Group 3(2% lignocaine )with the mean of time duration of 108.71 minutes. This difference in duration between the groups was statistically significant as ANOVA test p value showed as 0.004. And for duration of anaesthesia , highest time taken for Group 1 (0.25% ropivacaine)with the mean of time duration 125.67 minutes followed by Group 3 (2% lignocaine )which was 125.66 minutes. Table 6: Comparison of cough response during post operative period Cough response 2% Lignocaine Mean ± SD N (%) 4% Lignocaine Mean ± SD N (%) 0.25% Ropivicaine Mean ± SD N(%) 0.5% Ropivicaine Mean ± SD N(%) P value (Inter group) Nil 6 (30) 4 (20) 16 (80) 18 (90) 0.002 mild 12 (60) 15 (75) 3 (15) 2 (10) moderate 2 (10) 1 (5) 1 (5) 0 Severe nil nil nil nil In the above table and figure, cough response was documented during post operative period. Among 2% lignocaine group (Group3) ,60% had mild cough and in 4% lignocaine group(Group 4) 75% had mild cough. Whereas for 0.25% Ropivcaine group(Group 1)and 0.5% Ropivacaine group (Group 2) it was only 15% and 10% respectively. And 10% of 2% lignocaine group had moderate cough, whereas for 4% lignocaine and 0.25% ropivicaine group had only 5%.Nil in 5% Ropivacaine group.None of the four groups showed severe cough.Among the 0.5% Ropivacaine group, 90% of subjects had no cough, 80% in the 0.25% Ropivacaine group, 20% in the 4% Lignocaine group and 30% in the 2% Lignocacaine group.This difference in trend between the groups was statistically significant as chi-square test p value was 0.002.

Laryngoscopy without intubation produces the same pressor and sympathoadrenal reactions as laryngoscopy with intubation. This suggests that the stimulation of the supraglottic region by tissue tension induced by laryngoscopy is the primary cause of the sympathoadrenal response to tracheal intubation, and that placing a tube through the cords and inflating a cuff in the infraglottic region provides very little additional stimulation.5 Although many individuals take it well, it might lead to serious complications such as myocardial infarction, arrhythmias, and cerebrovascular haemorrhage in others. To attenuate the airway and circulatory reactions to laryngoscopy and intubation, a variety of procedures and medicines are utilised, including alpha-2 agonists, short-acting opioids, topical anaesthetics, and beta-blockers. The sympathetic responses to laryngoscopy and tracheal intubation, which include hypertension, tachycardia, and tachyarrhythmias, are associated with an acute increase in plasma concentrations of epinephrine and norepinephrine.6 A vast number of studies have been conducted with local anaesthetics for attenuation of pressor response using 2% solution of lidocaine. In this dose, given prophylactically just before extubation was able to inhibit and prevent coughing in the recovery period after general anaesthesia. Although several research have shown that lignocaine is helpful in lowering these pressor responses, a review of the literature revealed that only few studies have employed ropivacaine topically for the same reason. 7 Hence this interventional study was conducted to study the effect of 2% and 4% lignocaine, and 0.25% and 5% ropivicaine in supression of pressor response during laryngoscopy and intubation and We have included totally 80 patients in our study and through randomization these patients were distributed uniformly into the four groups ,Group 1(0.25% ropivicaine) and Group 2 (0.5% roipivicaine),Group 3 (2% lignocaine),Group 4 (4% lignocaine). The distribution of age and gender did not show any significant difference between the groups but there was significant difference in BMI among the four groups. In our study, the heart rate values during laryngoscopy and intubation (T3) were higher in both 2% lignocaine and 4% lignocaine groups when compared to 0.25% and 0.5% Ropivacaine group , this difference between the groups was found to be statistical significant with P value 0.001. But after tracheal intubation the heart rate was raised to peak in all four groups at T3 and T4, similarly the difference between the groups were statistically significant.During and After intubation the mean arterial blood pressure were higher in both 2% lignocaine and 4% lignocaine groups when compared to 0.25% and 0.5% Ropivacaine group , this difference between the groups was found to be statistical significant with the p value of 0.001.The difference between the groups were statistical significant in MAP (P = 0.001).8 Our study results were in consensus with study conducted Meng et al who studied the effects of topical ropivicaine anaesthesia on hemodynamic response. They proved that the ropivicaine and lignocaine can inhibit the hemodynamic responses which will develop after intubation and moreover they stressed that ropivicaine inhibited the hemodynamic response more effectively when compared to lignocaine. Similarly a study conducted by Gao et al showed that there was decrease in hemodynamic parameters during intubation and extubation. On contrary a study done by Thangavelu et al., who showed that there was no significant difference between lignocaine and ropivacaine after induction and tracheal intubation. They have explained in their study that lignocaine and ropivacaine were effective in stopping neural conduction and inhibiting the airway reflexes caused by contact with an endotracheal tube.9 And they stressed that the difference between ropivicaine and lignocaine lies only in duration of topical anaesthesia. The study conducted by Jee D, Park SY et al shows lignocaine administered topically for airway anesthesia in the form of endotracheal instillation, intracuff lignocaine, and lignocaine sprays have been found to reduce pressor response associated with extubation. The hemodynamic parameters (HR, MAP, and SPO2) were compared between the three groups at various time points. There was an overall statistically significant difference among the three groups regarding heart rate and mean arterial pressure at lignocaine administered topically for airway anesthesia in the form of endotracheal instillation sprays have been found to reduce pressor response associated with extubation which is in par with our study findings. 10 Study conducted by Jain S and Khan RM et al on the effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia which shows that patients who received preservative free 2% lignocaine 1.5 mg/kg IV bolus showed less rise in pulse rate (PR) and mean arterial pressure (MAP) during intubation as well as during extubation and significanty increased the mean pain free period post operatively compared to the Group A who recieved 6 ml of normal saline.11 Studies conducted by Lignocaine administered topically for airway anesthesia in the form of endotracheal instillation, intra-cuff lignocaine, and lignocaine sprays have been found to reduce pressor response associated with extubation. The results were similar to a study done by Thangavelu et al., who showed significant difference between lignocaine and ropivacaine in attenuating pressor response during intubation and extubation by airway nebulisation. The action of ropivacaine, a newer amide and a longer-acting local anaesthetic, is mostly attributable to its blockage of sympathetic nerves located throughout the airway. As the patients are emerged from anaesthetic effect, The stimulating action of positive pressure breathing and endotracheal tube on mechanosensitive receptors in the trachea and bigger bronchi may cause coughing when patients awaken from general anaesthesia.12 In our study, post operative cough response were nil,mild and moderate category.with a prevalence of mild category in 60%,75%,15%,and 10% among 2% lignocaine group,4% lignocaine group, 0.25% Ropivacaine and 0.5% Ropivacaine respectively, moderate catagory in 10% in 2% lignocaine group and 5% in 4% lignocaine group and 0.25% ropivicaine, none in 0.5% ropivicaine respectively.Nil in the severe group. 30% of lignocaine 2% group,20% of subjects in 4%ligncaine group,80% of 0.25% Ropivacaine group and 90% of 0.5% of Ropivacaine group respectively.This difference was statistically significant as the p value was 0.002.

We conclude that Ropivacaine showed better results in comparison to lignocaine in attenuation of hemodynamic pressor response and decreased incidence of post operative cough, which was statistically significant with p value of 0.005.

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