Continuous Infusion Of Remifentanil Research Articles

Remimazolam for general anesthesia in a patient with aortic stenosis and severe obesity undergoing transcatheter aortic valve implantation

IntroductionThere is currently limited research on the clinical use of remimazolam in severely obese patients. In this report, we describe the anesthesia management of transcatheter aortic valve implantation (TAVI) in a severely obese patient using remimazolam.Case descriptionA 76-year-old woman (height 1.54 m; total body weight 104 kg; body mass index 43.9 kg/m2) was scheduled for TAVI via the femoral artery approach for aortic valve stenosis. Preoperative echocardiography showed an aortic valve peak flow of 4.0 m/s and an effective orifice area of 0.75 cm2. Anesthesia induction was performed with a bolus dose of 100 μg fentanyl, 15 mg remimazolam, 60 mg rocuronium, and a continuous infusion of remifentanil at 0.4 mg/h. Intraoperatively, remimazolam was administered at a rate of 35 mg/h. General anesthesia management was completed without any complications, although the patient required temporary catecholamine and inhalation anesthesia assistance due to hemodynamic changes.ConclusionOwing to its pharmacological advantages, remimazolam may be an option for anesthesia induction and maintenance in severely obese patients with unstable circulation.

Feasibility of opioid-free anesthesia in laparoscopic radical prostatectomy: A retrospective, quasi-experimental study

Abstract Background and Aims: Opioid-free anesthesia (OFA) provides adequate analgesia minimizing opioids. OFA has not been evaluated in laparoscopic radical prostatectomy (LRP). Our aim was to evaluate OFA feasibility and its effectiveness in LRP. Material and Methods: A quasi-experimental retrospective study of 55 adult patients undergoing LRP was performed from September 2020 until December 20223. Predefined protocols for either opioid-based anesthesia (OBA; with continuous remifentanil infusion) or OFA (continuous lidocaine, dexmedetomidine, and ketamine infusion) were followed. In both groups, wound infiltration was performed before skin incision. Primary outcome was postoperative pain management (numerical rating scale [NRS]) in the first 24 postoperative hours. Secondary outcomes were opioid consumption, start to sitting and ambulation, postoperative complications, and length of hospital stay. Results: OFA protocol patients had better median pain scores during movement at 1, 18 and 24 h, that is, 1 (interquartile range [IQR] 0–3) versus 2.5 (IQR 0–4), P = 0.047; 0 (IQR 0–1) versus 1 (IQR 0–2), P = 0.017; and 0 (IQR 0–0.25) versus 1 (IQR 0–2), P = 0.013, respectively. At 6 and 12 h, there were no statistically significant differences, that is, 0.5 (IQR 0–2) versus 1 (IQR 0–2), P = 0.908 and 1 (IQR 0–2) versus 0.5 (IQR 0–2), P = 0.929, respectively. Lower morphine requirements were recorded in the first 18 and 24 postoperative hours, that is, 0 (IQR 0–0) versus 1 (IQR 0–2.75) mg, P = 0.028 and 0 (IQR 0–2) versus 1.5 (IQR 0–3) mg, P = 0.012, respectively. Start to sitting and ambulation occurred earlier in the OFA group (P = 0.030 and P = 0.002, respectively). Linear regression showed that ambulation was independently associated with the analgesic technique (P = 0.034). Only one patient had postoperative nausea and vomiting (PONV) and belonged to the OBA group. There was no difference in total complications or the length of stay. Conclusion: In this study, OFA strategy was found to be safe, feasible, and provided adequate analgesia, minimizing the use of postoperative opioids, and was independently associated with earlier ambulation.

(167) Penile Plication is Well Tolerated Under Conscious Sedation: A Prospective Comparison of Deep Intravenous Vs. Nursing Administered Conscious Sedation

Abstract Introduction Penile plication is a common and effective surgical treatment for Peyronie's Disease. Although generally performed under general or spinal anesthesia, patient tolerability of penile plication under conscious sedation (CS) has several advantages: reduced anesthetic risk, health care cost savings, decrease wait times, and the ability conduct in outpatient facilities. While CS would provide significant potential benefit, there have been no evaluations of patient-reported tolerability to penile plication completed under conscious sedation nor comparisons with varying administrations. Objective To evaluate and compare patient-reported tolerability of penile plication performed under two CS sedation approaches: (1) deep intravenous conscious sedation (IVCS) administered by anesthesiologists and (2) nursing administered conscious sedation (NACS). Methods We evaluated procedure tolerability in a prospective cohort of 40 adult patients (23 IVCS; 17 NACS) undergoing primary penile plication between August 2022 and May 2023. Revision surgeries, and those with hourglass or hinge deformities were excluded. IVCS patients were administered midazolam (5mg) and ketamine (20mg) along with a continuous infusion of propofol (25-50 mcg/kg/min) and remifentanil (0.05 mcg/kg/min). NACS sedation protocol consisted of midazolam (1-2 mg) and fentanyl (50-100 ug). Patient baseline characteristics, procedure information, pain assessments (Likert scale; 0 [no pain]-10[most pain]) made by the patient and surgeon before during and after the procedure were collected. Following a post-surgical healing period, patients were contacted and administered an evaluated standardized patient tolerability questionnaire. Overall patient tolerability, pain assessments, and complication rates were compared descriptively, and using Wilcoxon sign-rank tests and McNemar tests. Results Baseline characteristics were similar between IVSC and NACS groups. Median pre-operative curvature of the IVCS cohort was 55 degrees (IQR=43.75-76.25) whereas the NACS curvature was 45 degrees (IQR=45-60). There was a 100% procedural success rate with no intra-operative concerns leading to the abortion of the procedure or conversion to general anesthetic. At six-week post-operative follow up, all patients had functional curvature. 100% of patients in the IVCS and NACS cohorts reported that they would recommend CS to others. Additionally, 95% (19/20; CI95=75.3%-99.0%) of those undergoing IVCS and 93.3% (14/15; CI95=70.2-98.8%) of the NACS cohort would choose CS over general anesthetic if they had to undergo the same surgery again. Sedation choice did not differ between CS groups (p=1.0). Most patients reported no pain pre-operatively (IVCS:[18/20]; NACS:[13/15]; p=1.0), peri-operatively (IVCS:[16/20]; NACS:[13/15]; p=0.68), or immediately post-operatively (IVCS:[14/20]; NACS:[14/15]; p=0.20). Two-hour post-operative pain did not differ between groups (p=0.89). Median two-hour post-operative IVCS pain was 2.5 (IQR=0-5.0) whereas median NACS pain was 3.0 (IQR=1.5-3.0). Conclusions Penile plication is exceptionally well tolerated when completed under either anesthesiologist administered intravenous conscious sedation or nursing administered conscious sedation. Most patients would choose conscious sedation over general anesthetic for the procedure in the future and all would recommend conscious sedation to others. Self-reported pain did not differ between groups and most patients reported no pain pre-, peri-, or immediately post-operatively. These results suggest that penile plication surgery can be completed in an outpatient setting under conscious sedation administered by trained nursing staff, which is expected to decrease costs, risks and wait-times of the procedure. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Target-controlled infusion of remimazolam effect-site concentration for total intravenous anesthesia in patients undergoing minimal invasive surgeries.

Although pharmacokinetic and pharmacodynamic models of remimazolam have been developed, their clinical application remains limited. This study aimed to administer a target-controlled infusion (TCI) of remimazolam at the effect-site concentration (Ce) in patients undergoing general anesthesia and to investigate the relationship of the remimazolam Ce with sedative effects and with recovery from general anesthesia. Fifty patients aged 20-75 years, scheduled for minimally invasive surgery under general anesthesia for less than 2 h, were enrolled. Anesthesia was induced and maintained using Schüttler's model for effect-site TCI of remimazolam. During induction, the remimazolam Ce was increased stepwise, and sedation levels were assessed using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale and bispectral index (BIS). Following attainment of MOAA/S scale 1, continuous infusion of remifentanil was commenced, and rocuronium (0.6 mg/kg) was administered for endotracheal intubation. The target Ce of remimazolam and the remifentanil infusion rate were adjusted to maintain a BIS between 40 and 70 and a heart rate within 20% of the baseline value. Approximately 5 min before surgery completion, the target Ce of remimazolam was reduced by 20-30%, and anesthetic infusion ceased at the end of surgery. Nonlinear mixed-effects modeling was employed to develop pharmacodynamic models for each sedation level as well as emergence from anesthesia. The remimazolam Ces associated with 50% probability (Ce50) of reaching MOAA/S scale ≤4, 3, 2, and 1 were 0.302, 0.397, 0.483, and 0.654 μg/mL, respectively. The Ce50 values for recovery of responsiveness (ROR) and endotracheal extubation were 0.368 and 0.345 μg/mL, respectively. The prediction probabilities of Ce and BIS for detecting changes in sedation level were 0.797 and 0.756, respectively. The sedation scale significantly correlated with remimazolam Ce (r = -0.793, P < 0.0001) and BIS (r = 0.914, P < 0.0001). Age significantly correlated with Ce at MOAA/S1 and ROR. Effect-site TCI of remimazolam was successfully performed in patients undergoing general anesthesia. The remimazolam Ce significantly correlated with sedation depth. The Ce50 for MOAA/S scale ≤1 and ROR were determined to be 0.654 and 0.368 μg/mL, respectively.

Comparison of propofol vs. remimazolam on emergence profiles after general anesthesia: A randomized clinical trial

Study objectiveThe emergence profiles in patients undergoing total intravenous anesthesia with either propofol or remimazolam with flumazenil reversal were compared. DesignA prospective, double-blind, randomized trial. SettingAn operating room and a post-anesthesia care unit (PACU). PatientsAdult patients (n = 100) having American Society of Anesthesiologists (ASA) physical status of I-III undergoing general anesthesia were enrolled and randomly assigned to the propofol or the remimazolam group. InterventionsThe propofol group received target-controlled infusion of propofol, and the remimazolam group received continuous infusion of remimazolam. Continuous infusion of remifentanil was used in both groups. For emergence, flumazenil was used in increments of 0.2 mg in the remimazolam group. MeasurementsThe primary outcome was the time required for the patient to obey verbal commands. The secondary outcomes included the time to bispectral index (BIS) over 80, the time to laryngeal mask airway (LMA) removal, the Richmond Agitation-Sedation Scale (RASS) scores in the PACU, and adverse events throughout the study period. Main resultsThe time taken to obey verbal commands was significantly longer in the propofol group than the remimazolam group (14 [9, 19]) vs. 5 [3, 7]) minutes, P < 0.001; median difference -9, 95% confidence interval -11 to -6). The times to BIS over 80 and to LMA removal were also significantly longer in the propofol group. In addition, the RASS score upon arrival to the PACU differed significantly between the two groups (P = 0.006). Re-sedation in the PACU was observed in 11 (22%) of the patients in the remimazolam group. ConclusionsRemimazolam-based total intravenous anesthesia with flumazenil reversal may be effective in reducing emergence time, but a significant incidence of re-sedation was observed in the PACU. Further studies are needed to determine adequate dose and timing of routine flumazenil use and minimize the risk of re-sedation.

Determination of the effective dose of dexmedetomidine to achieve loss of consciousness during anesthesia induction.

Dexmedetomidine (DEX) is a sedative with greater preservation of cognitive function, reduced respiratory depression, and improved patient arousability. This study was designed to investigate the performance of DEX during anesthesia induction and to establish an effective DEX induction strategy, which could be valuable for multiple clinical conditions. Patients undergoing abdominal surgery were involved in this dose-finding trial. Dixon's up-and-down sequential method was employed to determine the effective dose of DEX to achieve the state of "loss of consciousness", and an effective induction strategy was established with continuous infusion of DEX and remifentanil. The effects of DEX on hemodynamics, respiratory state, EEG, and anesthetic depth were monitored and analyzed. Through the strategy mentioned, the depth of surgical anesthesia was successfully achieved by DEX-led anesthesia induction. The ED50 and ED95 of the initial infusion rate of DEX were 0.115 and 0.200 μg/kg/min, respectively, and the mean induction time was 18.3 min. The ED50 and ED95 of DEX to achieve the state of "loss of consciousness" were 2.899 (95% CI: 2.703-3.115) and 5.001 (95% CI: 4.544-5.700) μg/kg, respectively. The mean PSI on the loss of consciousness was 42.8 among the patients. During anesthesia induction, the hemodynamics including BP and HR were stable, and the EEG monitor showed decreased α and β powers and increased θ and δ in the frontal and pre-frontal cortices of the brain. This study indicated that continuous infusion of combined DEX and remifentanil could be an effective strategy for anesthesia induction. The EEG during the induction was similar to the physiological sleep process.

Hemodynamic responses to 1 MAC desflurane inhalation during anesthesia induction with propofol bolus and remifentanil continuous infusion: a prospective randomized single-blind clinical investigation

BackgroundDesflurane is not recommended during anesthesia induction because of its sympathetic stimulation effect, particularly in patients with myocardial ischemic disease. To date, the hemodynamic response to 1 MAC desflurane inhalation in combination with remifentanil infusion during anesthesia induction has rarely been reported.MethodsThis investigation was designed to compare hemodynamic responses to 1 MAC desflurane (group D, n = 200) with sevoflurane (group S, n = 200) during anesthesia induction and endotracheal intubation in adult patients undergoing elective spine surgery. Subgroup analysis of the different age subgroups was also performed. With continuous infusion of remifentanil 0.1 μg/kg/min, anesthesia was induced with propofol bolus, and endotracheal intubation was performed after muscle relaxation. Heart rate (HR) and mean arterial blood pressure (MAP) were measured every minute for 5 min after anesthesia induction (T1-5) and after endotracheal intubation (T6-10).ResultsHR was significantly higher in group D (n = 182) than in group S (n = 173) at T3-10 except at T6 (1 min after intubation) (all P < 0.05). In the age-based subgroup analyses, which subdivided the group D and S into four subgroups based on patient’s age, the changes in HR from baseline values were significantly different between the coeval subgroups of patients in their 20–29 years and 30–39 years of age (all P < 0.05). MAP was reduced from baseline value, irrespective of group and age.ConclusionInhalation of 1 MAC desflurane during anesthesia induction with propofol bolus and remifentanil continuous infusion and during endotracheal intubation was more likely to induce elevations in HR more likely than 1 MAC sevoflurane, especially in younger patients.Trial registrationThis study was registered in the Clinical Research Information Service (CRIS, http://cris.nih.go.kr) of the Republic of Korea on Feb 12, 2016 (Registration No. KCT 0,001,813).

The effects of intravenous remifentanil on umbilical artery serum-derived exosomes in parturients undergoing epidural anesthesia: a randomized trial

BackgroundUmbilical artery serum-derived exosomes (UEs) serve as messengers for maternal–fetal information exchange and cellular regulation. Intravenous remifentanil could be considered as an effective adjunct to epidural anesthesia in providing a favorable analgesia effect for cesarean section (C-section), but its effects on UEs are currently unknown.MethodsFrom 01/12/2021 to 30/06/2022, eligible parturients scheduled for repeated C-section at the First Affiliated Hospital of Wenzhou Medical University were randomized to receive either an intravenous bolus (0.15 μg/kg) followed by a continuous infusion (0.075 μg/kg/min) of remifentanil or normal saline throughout the procedure. The primary outcome was the number of UEs. Secondary outcomes included the size and protein amount of UEs, the vital signs, visceral pain score, sedation score, maternal satisfaction score, Apgar score, the incidence of neonatal asphyxia, umbilical arterial pH, and the presence of complications.ResultsNanoparticle tracking analysis indicated similar size of UEs between the two groups, but the number and protein amount of UEs were increased in the remifentanil group compared to the control group (P < 0.05). In parturients receiving remifentanil, visceral pain scores were decreased, which was accompanied by the increased scores of maternal satisfaction with the anesthetic method (P < 0.05). Other maternal and neonatal outcomes were comparable between the two groups (P > 0.05).ConclusionThe intravenous administration of remifentanil increased the number of UEs in parturients undergoing repeated C-section under epidural anesthesia, with improved birth experience and minimal neonatal complications.

USE OF VIDEO LARYNGOSCOPE FOR DIFFICULT AIRWAY MANAGEMENT IN THORACIC SURGERY: A CASE STUDY

We present the clinical case of a 76-year-old male with the following medical history: Active smoker (2 packs/day),moderate obesity, moderate COPD. arterial hypertension, mellitus diabetes 2, dyslipidemia. Lacunar stroke without neurological damage, infrarenal abdominal aortic aneurysm of 40 mm, under follow-up in policlinic of Vascular Surgery, 1st degree atrioventricular block, under follow-up by Cardiology. Normal Echocardiography. PET-CT: Hypermetabolic pulmonary nodule in RUL, suggestive of cancer. FUNCTIONAL TESTS: Moderate obstructive pattern. FEV1 2.20 (72%), FEV1/FVC 58. DLCO 5.80 (64%). AIRWAY EXPLORATION: Retrognatia, Mallampati III, significant cervical stiffness, thick neck and degree of movement of head and neck < 80°. Case Management: Placement of thoracic epidural catheter (T5-T6) prior to induction for analgesic control during intraoperative and postoperativeperiod. Non-invasive blood pressure monitoring, 5-lead ECG, temperature, peripheral oxygen saturation (SpO2), Bispectral Index (BIS) and Train-of-four (TOF). In the presence of predictors of possible difficult airway and ventilation, material is prepared for management of possible difficult airway Pre-oxygenation with face mask and FiO2 1 until EtO2 85 mmHg is reached. Rapid sequence induction was performed with intravenous midazolam, fentanyl, propofol and 1,2 mg/kg of rocuronium. After reaching TOF 0, direct laryngoscopy was initially performed but a Cormark-Lehane (CL) III was observed.Indirect laryngoscopy was then performed with a McGrath video laryngoscope with a n°4 disposable blade, showing a CL I. Subsequently, an 11 Fr airway exchange catheter was introduced through the vocal cords into the trachea; then, the proximal end of the airway exchange catheter was inserted into the endobronchial lumen of the 37Fr Vivasight DL, to permet its insertion into the trachea guided by this airway exchange catheter under the vision of the McGrath videolaryngoscope. Once the VivaSight DL was inserted into the trachea, the airway exchange catheter was removed and the VivaSight DL tube was turned left 90° and was inserted successful into the left main bronchus guided by embedded camera of this special type of DLT. Anesthesia maintenance was performed with inhalated sevoflurane and continuous intravenous infusion of remifentanil and rocuronium. Epidural elastomer of levobupivacaine 0.125% at 7 ml/h. Controlled ventilation is maintained in volume control mode, with Tidal Volume (TV) at 7 ml/kg ideal weight in two-lung ventilation and 5 ml/kg ideal weight in one-lung ventilation. Alveolar Recruitment Maneouvres (ARM) after intubation and at start of one-lung ventilation (OLV) were performed. Good mechanics and adequate gas exchange throughout the procedure, with no episodes of desaturation. After completion of surgery, reversal of neuromuscular blockade was achieved with sugammadex at 2 mg/kg. After checking TOF ratio> 90% and adequate level of consciousness, optimal respiratory mechanics and a 100% SpO2, extubation was performed without incident. He was transferred to the intensive care unit for post-surgical control during the first 24 hours.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block in dogs undergoing ovariectomy.

In medicine, the transversus abdominis plane (TAP) block has been shown as an effective method of analgesia in several surgical procedures. In this context, this prospective, randomized, blinded study aimed to evaluate the analgesic efficacy of TAP block, guided by ultrasound in female dogs submitted to ovariectomy. Therefore, 32 animals randomly assigned in two groups (n = 16) were used. Groups consisted of TAP block control (TBC) which received water injection (0.2 ml kg-1 point), and TAP block bupivacaine (TBB) which received bupivacaine (0.2 ml kg-1 point at 0.25%); both groups were submitted to four-point approach. Animals were pre-medicated with acepromazine (0.03 mg kg-1) and meperidine (2 mg kg-1) IM, propofol was used as anesthetic induction (3-5 mg kg-1) IV, and isoflurane was used to maintain. To standardize groups, the animals received a continuous infusion of remifentanil (0.2μg kg-1 min) and rocuronium (0.6 mg kg-1) IV in the intraoperative period. Variables measured were the heart and respiratory rates, blood pressure, temperature, peripheral oxyhemoglobin saturation, exhaled carbon dioxide concentration, exhaled isoflurane concentration, serum cortisol, analgesia, and sedation. Before the pre-anesthetic medication (Baseline) and 1, 2, 4, 6, and 8 h after extubation, pain and sedation were assessed using a numeric rating scale (NRS), Glasgow composite measure pain scale (GCMPS-SF), and sedation scale. Moreover, serum cortisol was measured at different moments. The results show that in the intraoperative period, there was no significant difference between groups. After surgery, in TBC, 13 out of 16 animals required analgesic rescue, whereas, in TBB, this occurred only in one animal. Regarding the measurement of serum cortisol, the TBC group showed a significant difference when compared to the baseline time in the traction of the first ovary (p < 0.0001), 2 h (p = 0.0441), and 8 h (p = 0.0384) after extubation. In TBB, cortisol showed a significant increase only in the traction of the first ovary and 2 h after extubation (p < 0.0001). The technique using ultrasound-guided TAP block in two points approach by hemiabdomen with 0.2 ml kg-1 bupivacaine 0.25% was effective in providing post-operative analgesia in dogs undergoing ovariectomy.

Influence of genetic variants on remifentanil sensitivity in Chinese women.

Significant individual differences have been observed in pain sensitivity and analgesic effect of opioids. Previous studies have shown that genetic factors contributed to analgesics requirement obviously. Therefore, we investigated the role of genetic polymorphisms in the sensitivity to the analgesic effect of remifentanil in this study. One hundred thirty-seven patients undergoing gynaecological surgery were observed. Before procedures, we measured the basal pain threshold of each patient, including the pressure pain threshold and pressure pain tolerance threshold. Subsequently, patients received a continuous remifentanil infusion for 15 min at a constant rate of 0.2μg/(kg min). The pain thresholds were measured again after the remifentanil infusion. Moreover, respiratory depression was estimated using oxygen saturation during infusion. DNA was extracted from peripheral venous blood and genotyped using SNaPshot technology. Polymorphisms were found in genes associated with the individual variation in analgesia. Participants carrying OPRM1 rs9397685 AA, ADRB1 rs1801253 CC, and GCH1 rs8007267 CC polymorphisms showed higher sensitivity to analgesic effect induced by remifentanil, and the participants carrying the OPRD1 rs2234918 TT showed lower sensitivity to remifentanil-related respiratory depression. Moreover, individual susceptibility to remifentanil increases with age. Gene variation in OPRM1 rs9397685 AA, ADRB1 rs1801253 CC, GCH1 rs8007267 CC, and OPRD1 rs2234918 TT were related to the conspicuous interindividual differences in the analgesia and respiratory depression of remifentanil, mainly by affecting the target protein receptors and relative metabolic enzymes.

ED50 value of remifentanil in inhibiting coughing during extubation in children with snoring

Objective: This study aimed to determine the effective dose 50% (ED50) value of remifentanil in inhibiting coughing during extubation in children with snoring. Methods: The subjects were children who scored a grade I in the American Society of Anesthesiology (ASA) metric and who were undergoing tonsillectomy (with or without adenoidectomy) under general anesthesia. Using Dixon’s up-and-down sequential method, the initial infusion rate of remifentanil was 0.06 μg/kg/min, and the difference between the infusion rates of the two adjacent groups was 0.01 μg/kg/min. If a child had no cough response during extubation, the infusion rate for the next child was reduced by 0.01 μg/kg/min. If that child had cough response, the infusion rate for the next child was increased by 0.01 μg/kg/min, and the test was terminated when seven pairs of children with positive-negative alternating results were obtained. The ED50 value and its 95% confidence interval (CI) were calculated by probit regression. The times for extubation, awakening, agitation, and respiratory complications after extubation were compared between the two groups. Results: 1) The ED50 value of a continuous infusion of remifentanil required to inhibit the cough response of children during extubation was 0.042 μg/kg/min, and the 95% confidence interval was 0.025–0.062 μg/kg/min. 2) The total dosage and infusion rate of remifentanil in the cough suppression group were higher than those in the cough group (p < 0.05), but the differences in the times for extubating and awakening between the two groups were not statistically significant (p > 0.05). 3) There was no correlation between the infusion rate of remifentanil and the time for extubating and awakening in the cough suppression group; the r values were 0.13 and 0.12, respectively, and p > 0.05. 4) The differences in postoperative respiratory complications between the two groups were not statistically significant (p > 0.05). Conclusion: The ED50 value of a continuous infusion of remifentanil required to inhibit the cough response of children during extubation after tonsillectomy (with or without adenoidectomy) was 0.042 μg/kg/min, and a low-dose infusion of remifentanil does not affect the times for awakening and extubating in children.

The use of Esketamine in CT-guided percutaneous liver tumor ablation reduces the consumption of remifentanil: a randomized, controlled, double-blind trial.

BackgroundIn the anesthesia management of percutaneous liver tumor ablation, the requirement of analgesia is very strict. Currently, intravenous anesthesia is commonly used, such as remifentanil combined with sedative drugs. However, the pain relief is not instantaneous after increasing the dosage of remifentanil. Esketamine, a medium- or long-term analgesic drug, does not inhibit respiration to maintain patient comfort during the ablation and reduces the consumption of remifentanil. Therefore, this experiment was designed to investigate the potential of combinational therapy and the most appropriate dose of esketamine.MethodsA total of 120 patients were randomly divided into three groups by SPSS. The regular anesthesia model included dexmedetomidine 0.5 µg/kg, intravenous glucose tolerance test, remifentanil continuous infusion, flurbiprofen 50 mg, i.v., palonosetron 0.225 mg, i.v., and 1% lidocaine for local anesthesia. Group A was the regular control group, only using the regular model; Group B also received with 0.1 mg/kg esketamine, i.v.; and Group C also received 0.2 mg/kg esketamine, i.v.. The whole experiment was double-blind.ResultsFrom December 2020 to March 2021, 120 patients were randomized in total, and 108 were included in the analysis: 36, 37, 35 were allocated to Group A, Group B, and Group C, respectively. The total dosage of remifentanil in Group A, Group B, Group C was 179.38±123.37, 120.31±57.96 and 115.91±62.42 µg, respectively. We found the total dosage of remifentanil in Group B and Group C were significantly decreased in comparison to that of Group A (P=0.004, P=0.003, respectively). The maximum dosage of remifentanil in Group A, Group B, and Group C was 1.76±0.62, 1.37±0.47, and 1.33±0.56 ng/mL, respectively. The maximum dosage of remifentanil in Group B and Group C were significantly decreased in comparison to that of Group A (P=0.003, P=0.001, respectively). The incidence of severe pain during the ablation in Group B was significantly lower than that in Group A (3 vs. 12, P<0.05).ConclusionsThe use of esketamine can reduce the dosage of opioids for liver tumor ablation and reduce the occurrence of severe pain. We found that 0.1 mg/kg esketamine, i.v. is the most suitable dose for liver tumor ablation.Trial RegistrationChinese Clinical Trial Registry ChiCTR2100049152.

The Effects of Remifentanil and Fentanyl on Emergence Agitation in Pediatric Strabismus Surgery.

Emergence agitation (EA) is one of the main concerns in the field of pediatric anesthesia using sevoflurane. We investigated the effects of remifentanil and fentanyl on the incidence of EA in pediatric patients undergoing strabismus surgery. Ninety children were randomly allocated into two groups and received either remifentanil (group R: intraoperatively remifentanil 0.2 μg/kg/min) or fentanyl (group F: fentanyl 2 μg/kg at anesthetic induction) intraoperatively. After surgery, EA incidence was assessed using a four-point agitation scale and Pediatric Anesthesia Emergence Delirium (PAED) scale in the post-anesthesia care unit. Face, leg, activity, cry, and consolability (FLACC) scores for postoperative pain were also assessed. The incidence of EA using the four-point agitation scale (scores ≥ 3) was similar in both groups (remifentanil group, 28.89% vs. fentanyl group, 24.44%). Similar results were obtained using the PAED scale (scores > 12), with an incidence of 33.33% in the remifentanil group and 26.67% in the fentanyl group. Differences in FLACC scores were not found to be statistically significant. A single bolus administration of fentanyl during anesthetic induction and continuous infusion of remifentanil during surgery had similar effects on the EA incidence in these pediatric patients.

Effect of Remifentanil on Postoperative Vomiting After Strabismus Surgery in Preschool Children: A Prospective Randomized Controlled Trial.

BackgroundStrabismus surgery and the use of opioid are risk factors of postoperative vomiting. We evaluated whether there is a dose-dependent effect of remifentanil on the incidence of postoperative vomiting.MethodsSixty pediatric patients who were scheduled for strabismus surgery were enrolled. Patients were randomly divided into three groups; Group H (high-dose remifentanil group), Group L (low-dose remifentanil group), and Group C (control group). After endotracheal intubation, patients in the Group H and L received an intravenous bolus dose of remifentanil of 1.0 μg/kg and 0.5 μg/kg over 2 min, respectively. Group H and L patients received a continuous infusion of remifentanil (0.1 μg/kg/min) during the surgery. The patients in Group C did not have any dose of remifentanil. Intravenous fentanyl (1 µg/kg) was administered to the patients for postoperative pain control.ResultsThe primary outcome was a difference of the incidence of postoperative vomiting within 24 hours after surgery. There was no significant difference in incidence of postoperative vomiting between three groups. The degree of emergence agitation and postoperative pain did not show any significant difference between three groups.ConclusionsThe intraoperative administration of remifentanil did not show dose-dependent effect on postoperative vomiting in pediatric strabismus surgery.

Cardiovascular Safety and Hemostatic Efficacy of Topical Epinephrine in Children Receiving Zirconia Crowns.

The primary aim of this study was to determine the cardiovascular safety of topical racemic epinephrine pellets by measuring heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure in children receiving dental care under general anesthesia. The secondary aim was to assess clinical efficacy by measuring time to reach adequate hemostasis. For this pilot study utilizing a split-mouth randomized design, 13 patients requiring prefabricated zirconia crowns on both primary maxillary first molars were recruited. Patients received continuous infusions of propofol and remifentanil with 50-70% inhaled nitrous oxide and oxygen. After randomization and tooth preparation, either saline pellets (control) or racemic epinephrine pellets (experimental) were applied directly to gingival tissue. Vital signs were recorded for 5 minutes. The procedure was repeated on the contralateral side using the alternative (control or experimental) treatment. Topical racemic epinephrine compared to saline produced a significantly larger decrease in mean diastolic blood pressure (-11.1% vs -3.9%; P < .01) and mean arterial pressure (-8.1% vs -2.1%; P < .01), although all noted decreases in cardiovascular variables were clinically insignificant. All experimental treatment teeth achieved adequate hemostasis after 2.2 minutes. Only 5 of the 13 control treatment teeth achieved adequate hemostasis during the 5-minute observation period (1.6 vs 4.2 minutes; P = .01). Overall, we conclude that use of topical racemic epinephrine pellets did not result in adverse cardiovascular effects and hemostasis was reached more quickly and predictably compared to saline pellets.

Anesthesia for Transoral Endoscopic Parathyroidectomy by Vestibular Approach (TOEPVA)

BackgroundAfter thyroid diseases, hyperparathyroidism is one of the most common endocrine surgical diseases. The increasing diagnosis of thyroid pathologies in early stages and a societal emphasis on physical appearances, especially in young women, have led to the development of new surgical techniques alternative to conventional transcervical incision consistently. Here, we describe our anesthesia experience for parathyroidectomy with Transoral Endoscopic Parathyroidectomy by Vestibular Approach (TOEPVA). Patients who undergo TOEPVA at our institution between November 2018 and April 2019 were reviewed. Demographic data and hemodynamic parameters were reported.ResultsSeven patients were operated successfully by this technique, none of which required conversion to conventional open surgery. Two patients required atropine and one patient required ephedrine during insufflation.ConclusionAfter induction of anesthesia with propofol, remifentanil, and rocuronium and anesthesia managed by desflurane co-administered with continuous infusion of remifentanil provide feasible and safe anesthesia for TOEPVA. However, especially during hydrodissection and insufflation, a close cooperation between surgeon and anesthetist has a great value to improve patient management.

Prophylactic administration of diphenhydramine/paracetamol reduced emergence agitation and postoperative pain following maxillofacial surgeries: a randomized controlled trial.

Emergence agitation after maxillofacial surgeries is an anxious and problematic complication for the surgeon and anesthesiologist that may lead to self-extubation, haemorrhage, and surgical destruction. In this study, we investigated the effects of preemptive administration of diphenhydramine on emergence agitation and quality of recovery after maxillofacial surgery in adult patients. Eighty-five patients undergoing maxillofacial surgery were randomized into two groups. The diphenhydramine group (Group D, n = 40) received diphenhydramine premedication 0.5mg/kg before anesthesia induction, while the control group (Group C, n = 40) received volume-matched normal saline as a placebo. Before incision, all patients receive 0.1mg/kg morphine sulfate slowly intravenously within 5min. Continuous infusion of remifentanil 0.2μg/kg/h and inhalation of isoflurane was maintained during the anesthesia period. Paracetamol 1g was infused 15min before extubation. We evaluated the incidence of agitation during the extubation period after general anesthesia, hemodynamic parameters, and recovery characteristics during the postoperative period. During extubation time, the incidence of emergence agitation was lower in Group D than in Group C (16% vs. 49%, P = 0.041). The time from isoflurane discontinuation to extubation (7.7min in Group D vs. 6.8min in Group C, P = 0.082) was not different. Grade of cough during emergence, the severity of pain, analgesic requirements, and hemodynamic changes were lower in group D compared with Group C. Preemptive administration of diphenhydramine provided smooth emergence from anesthesia. It also improved the quality of recovery after maxillofacial surgery. This study was registered at http://irct.ir (registration number IRCT20130304012695N3).

Havayolunun Uyanık Video Laringoskopik Değerlendirmesi Öngörülmeyeni Öngörmekte Yeni Araç Olabilir mi?: Randomize Çapraz Geçişli Çalışma

Objective: Even with worldwide acceptance and obedience to airway evaluation tests, there have not been enough tests performed to predict a difficult intubation with 100% accuracy. The Cochrane database published a review about the insufficiency of airway examination tests. For decades, anesthesiologists have tried to identify these issues. Material and Methods: After ethics committee approval and written informed consent had been obtained, 20 patients were enrolled to this prospective randomised study. All patients were oxygenated before and during the procedure. Standard anesthesia monitoring and 0.05 mg.kg-1 midazolam was administered intravenously. The nasopharynx was prepared with a topical 10% lidocaine spray then a continuous remifentanil infusion was given at a rate of 0.07 μ.kg.min-1 at least for 3 minutes. Awake videolaryngoscopy with Storz C-MAC, Storz D-Blade, McGrath MAC X-Blade and Airtraq was performed in random order to the same patient. Results: Two women denied participation and we analysed 18 patients. One patient did not allow the Airtraq to be inserted deeper and so we had 17 analyses for awake assessment for the Airtraq. Demographic and airway variables of patients were similar. The duration to obtain the optimal view was similar among the videolaryngoscopes. The comfort rating of patient and the observer were lower in the C-MAC (p<0.001). The Cormack-Lehane grades were worse in the C-MAC when compared to the others (p=0.006). Gag reflex occurred more in the Airtraq and the C-MAC videolaryngoscopes (p=0.007). Conclusion: Airtraq, McGrath MAC X-Blade, Storz D-Blade was superior to Storz C-MAC for awake videolaryngoscopic assessment of the airway as a new tool to predict a difficult laryngoscopy.

Intraoperative Remifentanil Infusion and Postoperative Pain Outcomes After Cardiac Surgery—Results from Secondary Analysis of a Randomized, Open-Label Clinical Trial

Report of secondary pain outcomes from a prospective, randomized, open-label clinical trial that compared remifentanil and fentanyl on perioperative hyperglycemic response in cardiac surgery. Single institution, tertiary university hospital. The study comprised 116 adult elective cardiac surgical patients. Participants were randomly assigned to receive either intermittent fentanyl boluses (F) or continuous remifentanil infusion (R) intraoperatively. Postoperative pain was evaluated with pain scores every 6 hours for 48 hours. Pain threshold to mechanical stimuli was measured around the sternotomy incision at 48 and 96 hours. The development of chronic pain was assessed using the numeric rating scale at 1, 3, 6, and 12 months after discharge. The final analysis included 106 patients. Pain scores and wound hyperalgesia were not significantly different postoperatively between the groups. The incidence of chronic pain at 3 months was comparable in both groups (61% in group F v 58% in group R; p = 0.79). Pain of more-than-mild degree was seen in 13 (32%) patients in group F and 8 (19%) in group R (p = 0.25) at 3 months. Median pain scores were not significantly different between the groups at 1, 3, 6, and 12 months after discharge from the hospital. The present study's findings suggested that intraoperative remifentanil infusion does not significantly worsen pain outcomes in patients undergoing elective cardiac surgery.