Continuous Infusion Of Sufentanil Research Articles

Effects of S(+)-ketamine combined with sufentanil for patient-controlled intravenous analgesia on the early recovery in elderly patients undergoing laparoscopic radical resection of rectal cancer

Objective: To observe the efficacy and safety of S(+)-ketamine combined with sufentanil for patient-controlled intravenous analgesia (PCIA) in elderly patients undergoing laparoscopic radical resection of rectal cancer and explore its impact on patients' early recovery. Methods: One hundred and ten patients undergoing laparoscopic radical resection of rectal cancer in Affiliated Cancer Hospital of Zhengzhou University from December 2020 to March 2021, were divided into two groups (n=55) using a random number table: group S received PCIA, with continuous infusion of S(+)-ketamine combined with sufentanil, while group C received PCIA, with continuous infusion of sufentanil. PCIA was initiated at the end of the surgery, and the formulations were as follows: group S, S(+)-ketamine (1.44 mg/kg), sufentanil (1.05 μg/kg), ketorolac tromethamine (2.0 mg/kg) and tropisetron (5 mg), in 100 ml of normal saline; group C: sufentanil (1.50 μg/kg), ketorolac tromethamine (2.0 mg/kg) and tropisetron (5 mg), in 100 ml of normal saline. Postoperative visual analogue scale (VAS) and Ramsay sedation scale were recorded at 6, 12, 24, 36, 48 h after the surgery. The incidence of remedial analgesia, the effective compressions number of PCI during 48 h after the operation. Time to first ambulation, time to first anal exhaust, time to resume oral feeding were recorded. The occurrence of adverse effects was compared between the two groups. Results: A total of 10 patients were excluded during the study, including 4 cases of conversion to laparotomy, 3 cases of dropping out of the study, and 3 cases with operation time more than 4 hours. Finally, 50 cases in group S and 50 cases in group C completed the study. There were no significant differences in VAS scores and Ramsay sedation sores at all time points between two groups (all P>0.05). Likewise, there were also no significant differences in the number of remedial analgesia and effective compressions of PCIA during 48 h after the operation between the two groups (both P>0.05). The total dosage of sufentanil consumption in group S [(64±9) μg] was lower than that in group C [(95±12) μg] within 48 h of PCIA, with a statistically significant difference (P<0.001). Time to first ambulation in group S was (1.1±0.2) d, which was shorter than that in group C [(1.6±0.5) d], and the difference was statistically significant (P<0.001). Likewise, time to first anal exhaust in group S [(1.3±0.4) d] was shorter than that in group C [(1.8±0.6) d], with a statistically significant difference (P<0.001). Additionally, time to resume oral feeding in group S was (2.5±0.6) d, which was shorter than that in group C [(3.1±0.7) d], and there was a statistically significant difference (P<0.001). The incidence of nausea, vomiting and pruritus in group S were 4.0%, 2.0% and 0, which were lower than that in group C (16.0%, 10% and 8.0%, respectively), with statistically significant differences (all P<0.05). No case with psychiatric symptoms was found in both groups. Conclusion: When used for postoperative intravenous analgesia in elderly patients undergoing laparoscopic radical resection of rectal cancer, S(+)-ketamine combined with sufentanil can provide satisfactory analgesic effects, decrease total consumption of sufentanil and the incidence of adverse effects, and thus facilitate patients' early recovery.

INTRAOPERATIVE MANAGEMENT OF A NEWBORN WITH COR TRIATRIUM DEXTRUM: A CHALLENGING CASE

Introduction Cor triatrium dextrum is an extremely rare cardiac condition with an incidence of Methods CASE REPORT: Informed parental consent was obtained to present this case. A 20-day-old term infant weighing 2.8 kg was admitted for progressive cyanosis and difficulties to thrive. At physical examination the newborn had a peripheral oxygen saturation of 75%. Preoperative chest X-ray showed a clog-shaped heart. Preoperative NT pro-BNP was 2311 ng/L. Repeated transthoracic echocardiography confirmed the diagnosis of cor triatrium dextrum and a R-to-L shunt through a patent foramen ovale. Distal pulmonary arteries were small for age. Surgery was scheduled. At the induction of anesthesia specific attention was paid to maintain normovolemia and a blood pressure and heart rate as compared to baseline values. Induction of anesthesia was performed with 2 mg Ketamine, 0.2 mg midazolam and 2 µg sufentanil. Tracheal intubation was facilitated with cisatracurium. Anesthesia was maintained with 1% Sevoflurane and a continuous infusion of sufentanil. Intraoperative transesophageal echocardiography (TEE) confirmed the diagnosis. The TEE 4 chamber view showed a membrane within the RA (Figure 1A) with a spinnaker movement in diastole when it was bulging into the TV (Figure 2). Laterally, there was an opening within the membrane permitting turbulent blood flow from the RA through the TV (Figure 1B). Resection of the membrane was uneventful and the foramen ovale was closed. Weaning from cardiopulmonary bypass (CPB) was facilitated with a continuous infusion of milrinone. Results Figures 1A and 1B: Intraoperative TEE view of the membrane. Discussion Cor triatrium dextrum being an extremely rare CHD, anesthesiologists may not be familiar with its clinical presentations. Depending on the degree of the RA obstruction, poor right ventricle (RV) filling and compromised pulmonary blood flow may occur. Neonatal cyanosis may appear due to streaming of the blood from the RA across the atrial septum to the left atrium. Intraoperative actions need to be taken in order to increase RV filling. In this case the opening from the RA to the RV resulted in turbulent flow but intraoperative hemodynamic optimization increased this forward flow and prevented any oxygen saturation concentrations LEARNING POINTS 1. Anesthesiologists need to be aware of intraoperative hemodynamic instability and cyanosis due to the obstructive membrane within RA in case of cor triatrium dextrum. 2. Pre CPB TEE should carefully evaluate the TV that may mimick an Ebstein anomaly as the membrane may bulge into the TV.

Application of continuous serratus plane block with patient-controlled analgesia on postoperation analgesia after thoracoscopic surgery

Objective: To investigate the application of ultrasound-guided continuous serratus plane block with patient-controlled analgesia on postoperation analgesia after thoracoscopic surgery, and influence on postoperative rehabilitation. Methods: Sixty patients scheduled for thoracoscopic surgery were randomly divided into two groups. PCNA group (n=30) received ultrasound guided continuous serratus plane block with patient-controlled nerve analgesia, with continuous infusion of 0.2% ropivacaine and 30 ml of 0.3% ropivacaine for the first does. PCIA group(n=30) received patient-controlled intravenous analgesia, with continuous infusion of sufentanil. Postoperative visual analogue scale (VAS) and prince henry pain scale (PHPS) were recorded at 1 hour (T(1)), 4 hour (T(2)), 8 hour (T(3)), 24 hour (T(4)), 2 days (T(5)), 3 days (T(6)), 4 days (T(7)), before discharge (T(8)), 30 days (T(9)) after surgery. Adverse reactions and the time of postoperative first out-of-bed activity, passage of gas by anus, bowel movement, chest tube removal, discharge was also recorded. Results: The resting VAS score of T(3), T(4), T(5) in group PCNA and group PCIA were 0(0) vs 0(2.0), 0(0) vs 2.0(2.0), 0(0) vs 0(2.0), the resting VAS score was lower in group PCNA than in group PCIA (Z=-2.524, -3.944, -3.652, P<0.05 or P<0.01). The upper arm activity VAS score of T(2), T(3), T(4), T(5), T(6), T(7) in group PCNA and group PCIA were 0(0) vs 0(2.0), 0(0) vs 2.0(2.5), 0(2.0) vs 2.0(2.0), 0(2.0) vs 2.0(2.0), 0(0) vs 2.0(2.0), 0(0) vs 0(2.0), the upper arm activity VAS score was lower in group PCNA compared with group PCIA (Z=-2.984, -3.915, -4.484, -4.450, -3.422, -2.456, P<0.05 or P<0.01). The coughing VAS score T(3), T(4), T(5), T(6), T(7) in group PCNA and group PCIA were 2.0(2.0) vs 2.0(2.5), 2.0(2.5) vs 4.0(4.0), 2.0(2.5) vs 4.0(4.0), 2.0(2.0) vs 3.0(2.0), 2.0(2.0) vs 2.0(2.0), the coughing VAS score was lower in group PCNA compared with group PCIA (Z=-3.432, -3.410, -2.643, -3.210, -2.746, P<0.05 or P<0.01). The PHPS score was significantly lower in group PCNA at T(3)[1.0(1.3) vs 2.0(2.0)], T(4)[1.0(2.0) vs 3.0(1.0)], T(5)[1.0(1.3) vs 2.0(1.3)], T(6)[1.0(1.3) vs 2.0(2.0)], T(7)[1.0(1.0) vs 1.0(2.0)] compared to group PCIA (Z=-3.149, -3.662, -3.369, -3.681, -2.815, all P<0.01). And the time of out-of-bed activity, passage of gas by anus of the PCNA group were (20.0± 6.9)h, ( 16.0± 8.0)h, which was advanced more than PCIA group [(23.9± 7.1)h, (34.3± 13.2)h, t=-2.20, -6.47, all P<0.05]. Furthermore, PCNA group had better sleep quality from the 2nd night to the 4th night , and with lower adverse reactions (all P<0.05). Conclusion: The application of ultrasound-guided continuous serratus plane block after thoracoscopic surgery can reduce postoperative pain and enhance recovery after surgery.

Comparison of the effect of different infusion rates of sufentanil on surgical stress index during cranial pinning in children under general anaesthesia: a randomized controlled study

BackgroundSurgical stress index (SSI) is an established indicator for intraoperative nociception. Opioids are used to block stimulus of cranial pinning in neurosurgery. We investigated the effect of different infusion rates of sufentanil on SSI during cranial pinning in children under general anaesthesia.MethodsForty-nine children (2–12 years of age) underwent neurosurgery with pinning. The children were randomized into three groups based on the rate of sufentanil infusion: 0.2, 0.5, and 0.8 μg·kg−1·hr.−1. Continuous sufentanil infusion began following neuromuscular blockade administration, at a rate determined by each patient’s assigned treatment group. Following preparation for surgery, cranial pinning was performed. Systolic, diastolic, and mean blood pressures, along with heart rate and photoplethysmographic data, were continuously recorded from 1 min prior to cranial pinning through 5 min after cranial pinning, in 1-min intervals. SSI was calculated following the completion of surgery. Differences in measured outcomes over time among the three groups were evaluated using a generalized estimation equation. Differences in pinning outcomes in the same group were evaluated with Freidman test.ResultsWe found no statistical differences in long-term SSI that were associated with different infusion rates of sufentanil during cranial pinning. Blood pressures in all groups increased for 2 min after cranial pinning, and then decreased; we found no statistical difference in long-term blood pressure values among the groups. Heart rate increased after pinning in the group that received a low-dose infusion of sufentanil.ConclusionsSince SSI was intended to measure the blunting effects of sufentanil towards the noxious stimulus of cranial pinning, our results suggest that SSI might not be sufficiently sensitive to monitor the nociceptive response in children.Trial registration(KCT0000978, Jan-07, 2014).

The Conversion from Continuous Sufentanil Infusion to Oral Retarded Opioid Medication: Beware of the Equi-Analgesic Opioid Ratios - A Case Series

The Conversion from Continuous Sufentanil Infusion to Oral Retarded Opioid Medication: Beware of the Equi-Analgesic Opioid Ratios - A Case Series

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*.

Coronary artery bypass surgery, performed with or without cardiopulmonary bypass, is frequently followed by postoperative cognitive decline. Near-infrared spectroscopy is commonly used to assess cerebral tissue oxygenation, especially during cardiac surgery. Recent studies have suggested an association between cerebral desaturation and postoperative cognitive dysfunction. We therefore studied cerebral oxygen desaturation, defined as area under the cerebral oxygenation curve < 40% of > 10 min.%, with respect to cognitive performance at 4 days (early) and 3 months (late) postoperatively, compared with baseline, using a computerised cognitive test battery. We included 60 patients, of mean (SD) age 62.8 (9.4) years, scheduled for elective coronary artery bypass grafting, who were randomly allocated to surgery with or without cardiopulmonary bypass. Cerebral desaturation occurred in only three patients and there was no difference in cerebral oxygenation between the two groups at any time. Among patients who received cardiopulmonary bypass, 18 (62%) had early cognitive decline, compared with 16 (53%) in the group without cardiopulmonary bypass (p = 0.50). Three months after surgery, 11 patients (39%) in the cardiopulmonary bypass group displayed cognitive dysfunction, compared with four (14%) in the non-cardiopulmonary bypass group (p = 0.03). The use of cardiopulmonary bypass was identified as an independent risk factor for the development of late cognitive dysfunction (OR 6.4 (95% CI 1.2-33.0) p = 0.027. In conclusion, although cerebral oxygen desaturation was rare in our population, postoperative cognitive decline was common in both groups, suggesting that factors other than hypoxic neuronal injury are responsible.

Intrathecal Catheter Granuloma Associated with Continuous Sufentanil Infusion

Intrathecal sufentanil is a minimally utilized opioid for patients with intractable pain refractory to traditional intrathecal medications. We present an 86-year-old female with a history of multiple spine surgeries who eventually progressed to having chronic, intractable, and diffuse low back pain. After failing medical management, she underwent a successful intrathecal trial of opioid therapy and was subsequently treated with an implantable drug delivery system (IDDS) or intrathecal pump. We describe the first reported case of formation of a catheter tip granuloma associated with intrathecal infusion of sufentanil. Due to increasing opioid requirements and gradually escalating pain, a computed tomography myelogram was performed to explore neuraxial etiologies of her symptoms. This investigation revealed the presence of a catheter tip-associated inflammatory mass (granuloma). All patients receiving intrathecal medications, including sufentanil, must be considered for the possibility of catheter-associated granuloma, particularly with symptoms of altered neurological function and/or increasing medication requirements associated with worsening pain.

Intraoperative Methadone Improves Postoperative Pain Control in Patients Undergoing Complex Spine Surgery

Patients undergoing complex spine surgery frequently experience severe pain in the postoperative period. The combined opiate receptor agonist/N-methyl-d-aspartate receptor antagonist methadone may be an optimal drug for these patients given the probable involvement of N-methyl-d-aspartate systems in the mechanism of opioid tolerance and hyperalgesia. Twenty-nine patients undergoing multilevel thoracolumbar spine surgery with instrumentation and fusion were enrolled in this prospective study and randomized to receive either methadone (0.2 mg/kg) before surgical incision or a continuous sufentanil infusion of 0.25 μg/kg/h after a load of 0.75 μg/kg. Postoperative analgesia was provided using IV opioids by patient-controlled analgesia. Patients were assessed with respect to pain scores (visual analog scale from 0 to 10), cumulative opioid requirement, and side effects at 24, 48, and 72 hours after surgery. Demographic data, duration, and type of surgery were comparable between the groups. Methadone reduced postoperative opioid requirement by approximately 50% at 48 hours (sufentanil versus methadone group, median [25%/75% interquartile range]: 63 mg [27.3/86.1] vs 25 mg [16.5/31.5] morphine equivalents, P = 0.023; and 72 hours: 34 mg [19.9/91.5] vs 15 mg [8.8/27.8] morphine equivalents, P = 0.024) after surgery. In addition, pain scores were lower by approximately 50% in the methadone group at 48 hours after surgery (sufentanil versus methadone group [mean ± SD] 4.8 ± 2.4 vs 2.8 ± 2.0, P = 0.026). The incidence of side effects was comparable in both groups. Perioperative treatment with a single bolus of methadone improves postoperative pain control for patients undergoing complex spine surgery.

Remifentanil versus sufentanil em infusão contínua em intervenções cirúrgicas videolaparoscópicas: estudo comparativo

BACKGROUND AND OBJECTIVES: Continuous infusion (CI) of remifentanil is common in total intravenous anesthesia. On the other hand, CI of sufentanil for short/medium-term surgeries has not been widely used. The objective of this study was to compare two techniques of total intravenous anesthesia, using CI of remifentanil or sufentanil, regarding their intraoperative behavior and characteristics of recovery of patients undergoing videolaparoscopic surgeries. METHODS: Sixty patients, equally divided in 2 groups (RG and SG), participated in this study. Continuous infusion of remifentanil was used for anesthetic induction in RG, while a bolus of sufentanil associated with CI of this drug was used in SG. The CI of remifentanil was discontinued at the end of the surgery, while the CI of sufentanil was discontinued 20 minutes before the end of the surgery. Patients received ketoprofen and dypirone intraoperatively. Tramadol was used for rescue analgesia in the recovery room. Variations of mean arterial pressure (MAP) and hard reate (HR), time for awakening, propofol consumption, intercurrences in the recovery room, and time of stay in the recovery room were analyzed. RESULTS: Mean MAP was greater in SG than in RG (91.9 × 77.6, p < 0.0001). The incidence of pain was significantly greater in RG than on SG (22 × 1 patient, p < 0.0001). The incidence of postoperative nausea and vomiting (PONV) was greater in RG than in SG (10 × 2 patients, p < 0.0098). The mean time of stay in the recovery room was greater in RG than in SG (76 × 49 min, p < 0.0001). CONCLUSIONS: Hemodynamic control was satisfactory in both groups. Continuous infusion of sufentanil promoted better postoperative pain control with decreased consumption of rescue analgesic and, consequently, reduced incidence of PONV and reduced time of stay in the recovery room.

Remifentanil versus Sufentanil em infusão contínua em intervenções cirúrgicas videolaparoscópicas: estudo comparativo

Continuous infusion (CI) of remifentanil is common in total intravenous anesthesia. On the other hand, CI of sufentanil for short/medium-term surgeries has not been widely used. The objective of this study was to compare two techniques of total intravenous anesthesia, using CI of remifentanil or sufentanil, regarding their intraoperative behavior and characteristics of recovery of patients undergoing videolaparoscopic surgeries.Sixty patients, equally divided in 2 groups (RG, and SG), participated in this study. Continuous infusion of remifentanil was used for anesthetic induction in RG, while a bolus of sufentanil associated with CI of this drug was used in SG. The CI of remifentanil was discontinued at the end of the surgery, while the CI of sufentanil was discontinued 20 minutes before the end of the surgery. Patients received ketoprofen and dypirone intraoperatively. Tramadol was used for rescue analgesia in the recovery room. Variations of mean arterial pressure (MAP) and hard reate (HR), time for awakening, propofol consumption, intercurrences in the recovery room, and time of stay in the recovery room were analyzed.Mean MAP was greater in SG than in RG (91.9 x 77.6, p < 0.0001). The incidence of pain was significantly greater in RG than on SG (22 x 1 patient, p < 0.0001). The incidence of postoperative nausea and vomiting (PONV) was greater in RG than in SG (10 x 2 patients, p < 0.0098). The mean time of stay in the recovery room was greater in RG than in SG (76 x 49 min, p < 0.0001).Hemodynamic control was satisfactory in both groups. Continuous infusion of sufentanil promoted better postoperative pain control with decreased consumption of rescue analgesic and, consequently, reduced incidence of PONV and reduced time of stay in the recovery room.

Inflammation affects sufentanil consumption in ulcerative colitis

Previous studies have demonstrated an increased perioperative opioid requirement during inflammatory disease. To evaluate the influence of the inflammatory process, we studied in the same patient the sufentanil requirement during procedures that occur during two distinct phases of ulcerative colitis with different inflammatory profiles: (1) left colectomy for major colitis unresponsive to medical treatment during acute inflammation and (2) coloprotectomy with ileoanal anastomosis, three months after recovery of the acute inflammatory episode. Sixteen patients with clinical and histological evidence of ulcerative colitis scheduled for colectomy with ileoanal anastomosis were included. For each surgical procedure, anaesthesia was induced with sufentanil 0.5 microg kg(-1) and propofol 2 mg kg(-1). Patients were ventilated with 50% nitrous oxide and oxygen, and tidal volume was adjusted to keep end-tidal CO2 at 30 mmHg. Anaesthesia was maintained with end-tidal isoflurane at 0.5%. Analgesia was achieved with continuous infusion of sufentanil at 0.3 microg kg(-1) h(-1). Additional boluses of sufentanil and increases in infusion rates were used when haemodynamic variables increased to more than 20% of preoperative values. Sufentanil consumption during surgery was analysed by Wilcoxon signed rank sum test. P < 0.05 was considered significant. Total intra-operative sufentanil requirement was significantly larger during colectomy performed for acute inflammatory colitis than during ileoanal anastomosis performed after the inflammatory process (1.24 +/- 0.48 microg kg(-1) h(-1) vs. 0.62 +/- 0.3 microg kg(-1) h(-1); P < 0.05). For the same patient, inflammatory status influences opioid requirements during surgery for ulcerative colitis.

Instructions for Obtaining Journal CME Credit

Anesthesiology’s journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.The American Society of Anesthesiologists designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading this article, participants should understand the risks and benefits of intrathecal microcatheters versus continuous epidural catheters for labor analgesia.Authors – Valerie A. Arkoosh, M.D., M.P.H., Craig M. Palmer, M.D., Esther M. Yun, M.D., Shiv K. Sharma, M.D., F.R.C.A., James N. Bates, Ph.D., M.D., Richard N. Wissler, M.D., Ph.D., Jodie L. Buxbaum, M.D., Wallace M. Nogami, M.D., and Edward J. Gracely, Ph.D.Grants or research support: Supported by Ballard Medical Inc., Salt Lake City, Utah (successor to Preferred Medical Products, Inc.), a division of Kimberly-Clark.Consultantships or honoraria: NoneAuthors – Kenneth Drasner, M.D., and Richard Smiley, M.D., Ph.D.Grants or research support: NoneConsultantships or honoraria: The article authored by Drs. Drasner and Smiley was supported solely from institutional and/or departmental sources.Question Writer – Leslie C. Jameson, M.D.Dr. Jameson has no grants, research support, or consultant positions, nor does she receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Arkoosh et al . entitled “A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia” and its accompanying editorial by Drasner and Smiley entitled “Continuous spinal analgesia for labor and delivery: A born-again technique?” in the February issue of Anesthesiology, choose the one correct answer for each question:1. Which of the following statements about case reports in 1992 of neurologic injury associated with the use of intrathecal microcatheters (27–32 gauge) introduced through a 22–26 gauge needle is most likely true?A. All affected patients experienced an intrathecal hematoma.B. Complications occurred exclusively in obstetric patients.C. The Food and Drug Administration withdrew approval of all catheters in the intrathecal space.D. A neurologic complication occurred primarily with the use of a hyperbaric solution of 5% lidocaine.2. The authors of the current study compared neurologic complications, analgesic effectiveness, and neonatal outcome between standard continuous epidural (CEPI) analgesia and continuous intrathecal (CIT) analgesia administered through a 28-gauge microcatheter. Which of the following statements about their research protocol is most likely true?A. CIT patients received a continuous infusion of sufentanil and a bupivacaine bolus for breakthrough pain.B. Patients with preeclampsia were allowed to enroll in the study.C. To detect a permanent neurologic deficit rate for CIT patients equivalent to that reported with CEPI patients would require study enrollment of 100 patients.D. Patient assessment only occurred 24 h after delivery.3. When comparing the neurologic outcomes of the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques, which of the following statements is most likely true?A. Postpartum weakness or loss of sensation occurred at the same frequency in both groups.B. CIT patients were significantly more likely to require a blood patch to treat a postpartum headache.C. CIT patients had less effective pain relief.D. Motor blockade caused fewer CEPI patients to have successful vaginal deliveries.4. When comparing outcomes of the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques, which of the following statements is most likely true?A. CIT patients were more likely to require treatment for systemic hypotension.B. CEPI patients reported a higher pruritus score.C. Fetal bradycardia was more frequent in the CEPI-treated mothers.D. Twenty-four hours after delivery, patient satisfaction was significantly greater in the CIT group.5. Which of the following statements about the catheters used in the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques is most likely true?A. Tensile strength of a 28-gauge microcatheter is the same as a standard 22-gauge epidural catheter.B. CIT catheters are significantly more difficult to remove than CEPI catheters.C. The CIT catheters were placed with a midline approach to improve ease of removal.D. One CEPI catheter broke inside the patient’s body.

Pilot study on the effect of tourniquet use on sufentanil pharmacokinetics

Study objective To test our hypothesis that sequestration of sufentanil can occur during surgery when a pneumatic tourniquet is used. Design Prospective, randomized study. Setting Operating room and recovery room of a university hospital. Patients 16 ASA physical status I and II patients scheduled for orthopedic surgery with pneumatic tourniquet use. Intervention Patients were randomized to three groups. Sufentanil was given intravenously at 0.5 μg kg −1 bolus at the same time that a constant infusion was started at 0.5 μg kg h −1. In Group 1, continuous infusion of sufentanil was stopped when the tourniquet was released (n = 6). In Group 2, continuous infusion of sufentanil was stopped 15 minutes after tourniquet release (n = 6). In Group 3, as a control group, the sufentanil bolus was started after tourniquet inflation (n = 4). Measurements Plasma sufentanil concentrations were determined by radioimmunoassay. To compare pharmacokinetic results, a simulation of the sufentanil plasma concentrations was achieved. Main results Exsanguination and inflation of the pneumatic tourniquet had no significant effect on pharmacokinetic results. In 75% of patients, a significant increase in sufentanil plasma concentration occurred between 30 and 60 minutes after tourniquet deflation in all three groups, probably as a result of patient mobilization. One respiratory distress event occurred in a Group 2 patient following extubation at 55 minutes after the end of the sufentanil infusion. The rebound of sufentanil concentration was higher in Group 2; it may be due to a reduced effect of the restoring circulation in the ischemic leg by a prolonged infusion after tourniquet deflation. Conclusions Using a pneumatic tourniquet induces transient changes in the pharmacokinetics of sufentanil. These changes may have clinical relevance during the first hour after tourniquet release.

Induction and maintenance of anaesthesia with sevoflurane in comparison to high dose opioid during coronary artery bypass surgery

Induction and maintenance of anaesthesia with sevoflurane in comparison to high dose opioid during coronary artery bypass surgery

COST COMPARISON OF PROPOFOL VS SEVOFLURANE ACCORDING TO BIS-MONITORED ANESTHESIA

S50 INTRODUCTION: Cost-analysis studies, comparing the consumption of sevoflurane and propofol during maintenance of anesthesia, titrate depth of anesthesia by using classical monitoring [1]. Since this technique is found inaccurate, an objective measurement of anesthetic depth is required [2]. The bispectral Index (BIS), a processed EEG variable, is provenly correlated with hypnotic drug effect [3,4]. This study was designed to compare the cost of propofol vs. sevoflurane during BIS monitored depth of anesthesia. METHODS: After Ethics' Committee approval and informed consent, 20 female patients, aged 18-65 years, ASA I-II, undergoing elective breast surgery, were randomly included in two groups. Classical and BIS monitoring (F7-Cz, F8-Cz) were applied. All patients were premedicated and received a bolus + continuous infusion of sufentanil (0.2 [micro sign]g/kg + 0.3 [micro sign]g/kg/h). Induction was performed with propofol at a rate of 400 ml/h until loss of consciousness. For maintenance, group I patients received propofol (10 mg/kg/h) which was increased or decreased with 2 mg/kg/h, according to a BIS value higher than 60 or lower than 40, respectively. In group II, patients received sevoflurane, initially set at FD = 2 vol%, via a face mask using a fresh gas flow of 6L/min O2 before intubation (5 min after induction) and via a ET-tube using a fresh gas flow of 2 L/min O2/air after intubation. Sevoflurane was increased or decreased (with steps of FET = 0.2-0.4 %) to maintain a BIS between 40 and 60. Sufentanil was stopped 30 min before and hypnotics at the end of surgery. The amount of propofol was automatically recorded using Rugloop [registered sign] and sevoflurane consumption was measured using the Record keeper [registered sign] from the ADU apparatus(Datex, Finland). Cost was calculated in BEF and converted into US$. For statistical analysis, summary statistics and Student t-test were applied. Significance level was set at 5 %. RESULTS: Antropometric data were similar between groups. Propofol consumption, used for induction was (I: 1.8 +/- 0.6 mg/kg; II: 1.7 +/- 0.5 mg/kg, NS). The amount of propofol given for maintenance in group I was 7.6 mg/kg/h. In group II, the amount of liquid sevoflurane given during maintenance was 0.2 ml/kg/h. In group I, 78.1 +/- 25.5 ml propofol and in group II: 11.2 +/- 3.0 ml propofol was given for induction + maintenance. In group I, we used 2 (1-3) propofol prefilled syringes of 50 ml. In group II, 1 (1-1) propofol ampulle of 20 ml was used. The amount of wasted propofol in group I was 21.8 +/- 13.4 ml and in group II, 11.2 +/- 3.0 ml (p<0.05). The costs for induction was similar in both groups. The cost for maintenance per hour was significant higher in the propofol group (563.5 +/- 168 BEF/h or 15.65 +/- 4.6 US$/h) compared with the sevoflurane group (321.6 +/- 130.5 BEF/h or 8.93 +/- 3.6 US$/h). CONCLUSION: When using the BIS for titrating an identical depth of anesthesia, the cost for maintenance of anesthesia with propofol is statistically higher than when using sevoflurane with fresh gas flows of 6 and 2 L/min, respectively before and after intubation. The cost for wasted drugs was higher in the propofol-propofol group than in the propofol-sevoflurane group.

Infusion of Propofol, Sufentanil, or Midazolam for Sedation After Aortic Surgery

We conducted a prospective, randomized study to compare quality of sedation, hemodynamic stability, and oxygen consumption of three different drugs for continuous IV sedation in the immediate postoperative period in patients scheduled for aortic surgery (propofol [n = 12], sufentanil [n = 12], or midazolam [n = 12]).After arrival in the recovery room, patients were randomized into one of the following groups: Group P (continuous infusion of propofol 2 mg [center dot] kg-1 [center dot] h-1), Group S (continuous infusion of sufentanil 0.25 [micro sign]g [center dot] kg-1 [center dot] h-1, with bolus doses of midazolam 2 mg to maintain sedation at 3-4 on the Ramsay scale), and Group M (continuous infusion of midazolam 0.07-0.15 [micro sign]g [center dot] kg-1 [center dot] h-1 to maintain sedation at 3-4 on the Ramsay scale). The three drugs were associated with similar hemodynamic stability, incidence of myocardial ischemia, and comparable kinetics and mean values for VO2, but a significant higher number of peaks for VO2 in Group S during the period of rewarming. To obtain an appropriate Ramsay score, we needed to increase the rate of administration of the drug in Group P, and to decrease this rate in Group M. After the drugs were discontinued, Group P required mechanical ventilation for less time. In conclusion, propofol is as effective as sufentanil or midazolam in controlling increased VO2 postoperatively. The initial dose of 2 mg [center dot] kg-1 [center dot] h-1 had to be increased for most patients. In addition, propofol sedation is associated with a quicker recovery compared with midazolam and sufentanil. Implications: A prospective, randomized comparison of propofol, sufentanil and midazolam infusions revealed similar effects on hemodynamics, oxygen consumption, and rate of myocardial ischemia after aortic surgery, although propofol was associated with a quicker recovery compared with midazolam and sufentanil.

Early extubation after mitral valve surgery: A target-controlled infusion of propofol and low-dose sufentanil

Objective: In the current study, the use of a target-controlled infusion of low-dose propofol was combined with a continuous infusion of sufentanil for patients undergoing mitral valve surgery. The purpose of the study was to evaluate the hemodynamic stability, the time to awakening and spontaneous ventilation, and the feasibility in an early extubation setting of a total intravenous anesthetic technique. Design: Prospective study. Setting: University hospital. Participants: Fifteen patients scheduled for elective mitral valve surgery. Interventions: Induction of anesthesia consisted of sufentanil (1 μg/kg), propofol (1 μg/mL) target plasma concentration achieved over 3 minutes, and atracurium (0.5 mg/kg). The propofol target-controlled infusion was maintained at 1 μg/mL throughout surgery and stopped at skin closure. A continuous infusion of sufentanil at 1.8 μg/kg/hr was started after induction and reduced to 0.9 μg/kg/hr at the start of cardiopulmonary bypass and stopped at the end of bypass. Atracurium was infused at a rate of 0.5 mg/kg/hr up to sternal closure. No inhalation agents were used. Measurements and Main Results: Hemodynamic data were within normal limits. Six patients (40%) responded to verbal commands within 15 minutes postoperatively, 10 (67%) within the first hour, and all patients recovered within 2 hours. Four patients (27%) resumed spontaneous ventilation within the first 15 postoperative minutes. The time to successful spontaneous ventilation was 169 ± 42 minutes. Spontaneous ventilation was associated with a 21% increase in cardiac index. Total sufentanil dose was 328 ± 28 μg (4.6 ± 0.2 μg/kg), whereas total propofol dose was 862 ± 44 mg (13.1 ± 1.2 mg/kg). No patient required reintubation. Conclusion: The simplicity of the method with only one change in infusion rate is a major advantage. The technique permits predictable recovery and return to spontaneous ventilation in all patients. Its use in patients entering early extubation protocols is appealing for its reproducibility, simplicity, and safety.

Case 5—1996 thrombosis after the use of a heparin-coated cardiopulmonary bypass circuit in a patient with heparin-induced thrombocytopenia

A 64-year-old, 165-cm, 58-kg woman was admitted to the hospital with an inferior myocardial infarction. She underwent an emergent percutaneous transluminal coronary angioplasty (PTCA) complicated by an early reocclusion necessitating a second PTCA. The second PTCA complicated itself by the dissection of the right coronary artery (RCA), necessitating the placement of four stents in the RCA. The patient was then treated with porcine heparin (H) for 7 days. Warfarin was progressively titrated to a prothrombin time of 23% (international normalized ratio = 3.8), and heparin was then stopped. After 3 days of effectwe warfarin treatment, she suddenly developed cardiogenic shock with third-degree atrioventricular block, necessitating resuscitation maneuvers, intubation, placement of an intra-aortic balloon pump, and a pacemaker. After this resuscitation, she recovered well except for a right hemiparesis that was attributed to a prolonged hypotensive state. Coronary angiography disclosed a reocclusion of the RCA. Fibrinolytic therapy was then administered, and a continuous infusion of heparin was reintroduced. Forty-eight hours after her ischemic event, a cerebral computed tomography (CT) scan was normal, and she had no neurologic sequelae. Nine days later, despite receiving a continuous infusion of heparin, she became ischemic in the right coronary artery territory, and an emergent coronary revascularization was planned. While evaluating the patient's files, the attending anesthesiologist found that the platelet level was below 35,000/mm 3 from the beginning of the second heparin administration 10 days earlier (Fig 1), and he suspected a syndrome of heparin-induced thrombocytopenia (HIT). Because of the presence of four stents in the patient's RCA and owing to her history of the repetitive coronary occlusions, the cardiologists refused to stop the heparin infusion. This infusion was therefore stopped in the operating room. A central venous catheter was already in place, a radial arterial catheter was then placed under local anesthesia, and both were flushed with 0.9% saline without heparin. Anesthesia was induced with etomidate and sufentanil, and muscle paralysis achieved with pancuronium. Anesthesia was maintained with midazolam, and a continuous infusion of sufentanil, 2 Ixg/kg/hr. Iloprost is not available in Belgium; neither are the heparin substitutes proposed in the literature. The anesthesiologist had no experience with the use of low-molecularweight heparin (LMWH) during bypass. Therefore, he elected to use a heparin-coated cardiopulmonary bypass (CPB) circuit (HC-CPB) (Durafio II; Bentley [Englewood, CO], because of its theoretical advantages of biocompatibility and protection of platelets against activation caused by contact with the artificial surfaces. Only 50 IU/kg of porcine heparin were administered in place of the usual 300 IU/kg. Two saphenous grafts were sutured on the RCA. The procedure was performed under normothermia and intermittent antegrade warm blood cardioplegia. Aortic crossclamp time was 34 minutes, and CPB lasted 55 minutes. No pharmacologic support was needed to come off bypass. The platelet level was 34,000/mm 3 before surgery and 39,000/mm 3 after 50 IU/kg of H. It decreased to 22,000/ mm 3 after 7 minutes of CPB, possibly because of hemodilution, and returned to 39,000/mm 3 after discontinuation of CPB. Activated coagulation times with kaolin (ACT) (Hemotec; Medtronic [Uden, The Netherlands]) were 151 seconds before heparin administration, 231 seconds after 50 IU/kg of H, 445 and 443 seconds during CPB, and 295 seconds after CPB. Only 10 mg (2,000 IU) of protamine were then administered, and ACT returned to 148 seconds (Fig 2). After administration of another 1,000 IU of protamine, the ACT was 82 seconds. Despite this, the patient was still bleeding actwely. It was then judged that no more heparin was circulating at that time, and it was decided that it would

Skin Burn Associated with Pulse Oximetry during Perioperative Photodynamic Therapy

IT was reported in 1967 that tumor destruction could be accomplished with the use of a porphyrin substance when exposed to light 1 . Individually, the light and the chemical may be relatively innocuous, whereas the combination can have significant effects. This principle has been applied to cancer treatment with a technique called photodynamic therapy (PDT). 2,3 PDT is a relatively new cancer treatment modality undergoing clinical trials in the United States. The treatment involves a drug (photosensitizer) that accumulates preferentially in tumor cells and subsequently kills cells on activation by light. We present a case in which the use of conventional perioperative monitoring with a pulse oximeter during PDT resulted in the loss of skin integrity at the site of the pulse oximeter probe.

Continuous Spinal Analgesia with Sufentanil for Labor and Delivery in a Parturient with Severe Pulmonary Stenosis

Continuous Spinal Analgesia with Sufentanil for Labor and Delivery in a Parturient with Severe Pulmonary Stenosis