Propofol-remifentanil Total Intravenous Anesthesia Research Articles

Relationship between decrement time and recovery time in pediatric total intravenous anesthesia with propofol and remifentanil.

Propofol target-controlled infusion is now used in many countries for the administration of total intravenous anesthesia (TIVA) and uses population pharmacokinetic data incorporated into the target-controlled infusion pump to administer a dose which will achieve a target concentration selected by the practitioner. Modern target-controlled infusion pumps can include an estimate of how long it will take for the plasma propofol concentration to fall to a value programmed into the pump, once the propofol infusion is stopped. This is known as decrement time. Many users consider decrement time to be equivalent to recovery time for the patient, despite the several assumptions that makes. To determine if the decrement time estimated by the target-controlled infusion pumps at the end of anesthesia could be reliably used to predict recovery time for individual patients. Target-controlled infusion pumps at Birmingham Children's Hospital are programmed with a propofol decrement concentration of 1.5 μg.mL-1 . Patients for a variety of surgical procedures were anesthetised with propofol-remifentanil TIVA. Eye opening was used as a surrogate of recovery time. Data were analyzed using median absolute deviation, Mann-Whitney U test, and linear regression to see if there was any correlation with decrement time and recovery time, total dose of propofol administered, duration of anesthesia and patient age. A total of 55 patients were audited. Median age was 7.2 years (range 0.9-15.9), and median weight was 26 kg (range 8.5-77). Median decrement time was 11.8 min (IQR 8.3-21), while median recovery time was 15 min (IQR 9-20). Recovery time was the same as decrement time in 2% of patients, less than in 40% of patients and more in 58% of patients. Two thirds of patients opened eyes at an estimated plasma propofol concentration between 1.2 and 1.8 μg.mL-1 . The median absolute deviation for the difference between decrement time and recovery time was 5.7 min, from a median of 1 min. Analysis demonstrated there was no statistical correlation between decrement time to 1.5 μg.mL-1 and recovery time, age, total propofol dose administered, or duration of anesthesia, for individual patients. There was variation between decrement time to 1.5 μg.mL-1 and recovery time of over 5 min in nearly half of patients. Decrement time to 1.5 μg.mL-1 must be used with caution when trying to predict recovery time for individual patients following TIVA.

Effects of Volatile versus Total Intravenous Anesthesia on Occurrence of Myocardial Injury after Non-Cardiac Surgery.

The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into a volatile group. To balance the use of remifentanil between groups, a balanced group (n = 1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450–0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554–1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194–0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.

P4580The effect of anesthetic techniques on cardiac troponin-T after non-cardiac surgery

Abstract Background The effects of anesthetics on cardiac protection and clinical outcomes have shown conflicting results in patients undergoing non-cardiac surgery. Unlike cardiac surgeries in which cardio-protective effects of anesthetic techniques have been reported, it lacks evidence and reproducibility in non-cardiac surgery. A current generation high-sensitivity cardiac troponin (hs-cTnI) is known to detect perioperative myocardial injury in non-cardiac surgery which is closely related to clinical outcomes. In this study, we hypothesized that balanced anesthesia using both remifentanil and volatile agents is the most effective in reducing postoperative myocardial injury, and compared the incidence of postoperative myocardial injury among different types of general anesthesia. Methods We analyzed the data of 3555 patients who underwent general anesthesia for non-cardiac surgery in our hospital between February 2010 and December 2016. In all patients, hs-cTnI was detected in preoperative period and postoperative period within 48 hours. Major exclusion criteria was troponin elevation before surgery. Patients were stratified into three groups; 661 patients who were received propofol-remifentanil total intravenous anesthesia (TIVA group), 1279 patients who were received volatile anesthesia without remifentanil (Volatile group) and 1622 patients who were received volatile anesthesia with remifentanil (Balanced group). The Primary outcome was troponin elevation [hs-cTnI≥0.04 ng/mL] within post-operative within 48 hours, and the incidence of postoperative complications such as postoperative acute kidney injury, new-onset atrial fibrillation and in-hospital mortality were also compared. Results The occurrence of myocaridial injury were significant difference between three groups. The occurrence of myocardial injury was significantly lower in the Balanced group than in Volatile group after adjustment (Odds ratio (OR) = 0.727; 95% confidence interval (CI) = 0.59–0.89; P-value = 0.002). Balanced group and TIVA group showed comparable results in risk of postoperative troponin elevation after adjustment (OR 1.131; 95% CI 0.96–1.33; P-value = 0.133). The incidence of troponin elevation was significantly higher in Volatile group than TIVA group after adjustment (OR 1.6; 95% CI 0.52–0.96; P-value = 0.005). The incidence of AKI was significantly lower in Balanced group than Volatile group after adjustment (OR 0.637; 95% CI 0.49–0.81; P-value <0.001). Conclusion The remifentanil combination during general anesthesia may be associated with myocardial protection effect in patients undergoing non-cardiac surgery. Whether this impact leads to adverse long-term outcome remains unclear, and requires further investigation.

Comparison of the Effects of Total Intravenous Anesthesia and Intravenous Inhalational Anesthesia on Brain Metabolism during Surgery

To compare the effects on the brain metabolism of propofol-remifentanil total intravenous anesthesia and desflurane-remifentanil intravenous inhalational anesthesia in neurosurgery. Methods: Thirty-four neurosurgical patients with intracranial space-occupying surgery were randomly divided into two groups: Group A was conducted with the propofol-remifentanil total intravenous anesthesia and Group B with desflurane-remifentanil intravenous inhalational anesthesia. The patients were monitored for the brain metabolism prior to anesthesia, 1 hour after surgery, 2 hours after surgery, and half an hour after surgery. Results: The cerebral venous oxygen saturation, jugular bulb oxygen partial pressure, jugular vein oxygen content, and arterial oxygen content of the patients in group B were significantly higher than that of group A (P<0.001); arterial-jugular oxygen content difference and brain oxygen uptake rate of group B were lower than that in group A. Conclusions: (1) Both anesthesia methods can reduce the cerebral oxygen consumption and brain oxygen uptake, and thus reduce the cerebral oxygen metabolism.

Effects of surgery and propofol-remifentanil total intravenous anesthesia on cerebrospinal fluid biomarkers of inflammation, Alzheimer\u2019s disease, and neuronal injury in humans: a cohort study

BackgroundSurgery and anesthesia have been linked to postoperative cognitive disturbance and increased risk of Alzheimer’s disease. It is not clear by which mechanisms this increased risk for cognitive disease is mediated. Further, amyloid β production has been suggested to depend on the sleep-wake cycle and neuronal activity. The aim of the present study was to examine if cerebrospinal fluid (CSF) concentrations of a number of biomarkers for Alzheimer’s disease-related processes, including amyloid β, neuronal injury, and inflammation, changed over time during intravenous anesthesia in surgical patients.MethodsWe included patients scheduled for hysterectomy via laparotomy during general anesthesia with intravenous propofol and remifentanil. CSF samples were obtained before, during, and after surgery (5 h after induction) and tested for 27 biomarkers. Changes over time were tested with linear mixed effects models.ResultsA total of 22 patients, all females, were included. The mean age was 50 years (± 9 SD). The mean duration of the anesthesia was 145 min (± 40 SD).Interleukin (IL)-6, IL-8, monocyte chemoattractant protein 1, and vascular endothelial growth factor A increased over time. IL-15 and IL-7 decreased slightly over time. Macrophage inflammatory protein 1β and placental growth factor also changed significantly. There were no significant effects on amyloid β (Aβ) or tau biomarkers.ConclusionsSurgery and general anesthesia with intravenous propofol and remifentanil induce, during and in the short term after the procedure, a neuroinflammatory response which is dominated by monocyte attractants, without biomarker signs of the effects on Alzheimer’s disease pathology or neuronal injury.

Does the Type of Anesthetic Technique Affect In-Hospital and One-Year Outcomes after Off-Pump Coronary Arterial Bypass Surgery?

Despite numerous previous studies, there is little data on the effects of anesthetics on clinical outcome after off-pump coronary arterial bypass grafting (OPCAB). Therefore, we retrospectively compared the effects of anesthetic choice on in-hospital major adverse events (MAEs) and one-year major adverse cardiovascular and cerebral events (MACCEs) in patients undergoing OPCAB. Electronic medical records were reviewed in 192 patients who received propofol-remifenanil total intravenous anesthesia (TIVA) and propensity score-matched 662 patients who received isoflurane anesthesia. The primary endpoints were in-hospital MAEs and one-year MACCEs. The components of in-hospital MAEs were in-hospital death, myocardial infarction (MI), coronary revascularization, stroke, renal failure, prolonged mechanical ventilation longer than 72 h, and postoperative new cardiac arrhythmia requiring treatment. One-year MACCEs was defined as a composite of all-cause mortality, MI, coronary revascularization, and stroke. There was no significant difference in risk of in-hospital MAEs (OR = 1.29, 95% CI = 0.88–1.88, P = 0.20) or one-year MACCEs (OR = 0.81; 95% CI = 0.46–1.42, P = 0.46) between the groups. The risk of postoperative new arrhythmia including new atrial fibrillation significantly increased in the TIVA group compared to the isoflurane anesthesia group (OR = 1.72, 95% CI = 1.12–2.63, P = 0.01). In conclusion, the choice between propofol-remifentanil TIVA and isoflurane anesthesia did not show differences in incidence of in-hospital MAEs or one-year MACCEs in patients undergoing OPCAB. However, further studies on the effects of anesthetics on development of in-hospital new arrhythmia will be needed.

Total intravenous anesthesia of propofol-remifentanil for patients of cosmetic surgery

Objective To explore the effect of propofol-remifentanil total intravenous anesthesia in cosmetic surgery and the controllability of anesthesia. Methods According to the American Society of Anesthesiologists (ASA), levelsⅠ-Ⅱ hospitalized patients for elective cosmetic surgery (100 cases) were randomly divided into two groups, namely propofol-remifentanil total intravenous anesthesia group (Group T) and combined intravenous inhalational anesthesia group (Group C), 50 cases each. Observatory items of patients included intraoperative cardiovascular drug use, body movement, waking-up time, extubation time, leaving time from operation theatre, postoperative adverse reaction, hypoxemia (SpO2<95%) and anesthesia satisfaction. Results In Group C, waking-up time, extubation time and leaving time from operation theatre were (12.2±3.6), (13.8±4.6) and (4.6±5.8) min, respectively, which were longer than those (6.7±2.6), (7.8±3.3) and (3.3±3.8) min in Group T (P 0.05). Satisfactory rate with anesthesia was 84.0% (42/50) in Group T that was higher than 52.0% (26/50) in Group C (P<0.05). Conclusions Propofol-remifentanil intravenous anesthesia has definite effects with faster postoperative recovery, less adverse reaction and complications, safety and operablity. Key words: Propofol; Remifentanil; Total intravenous anesthesia; Combined intravenous inhalational anesthesia; Cosmetic surgery

Emergence delirium in children: a randomized trial to compare total intravenous anesthesia with propofol and remifentanil to inhalational sevoflurane anesthesia

Emergence delirium (ED) refers to a variety of behavioral disturbances commonly seen in children following emergence from anesthesia. Vapor-based anesthesia with sevoflurane, the most common pediatric anesthetic technique, is associated with the highest incidence of ED. Propofol has been shown to reduce ED, but these studies have been methodologically limited. To conduct a randomized-controlled trial comparing the incidence of ED in children following sevoflurane (SEVO) anesthesia and propofol-remifentanil total intravenous anesthesia (TIVA). One hundred and twelve children, ASA I-II, aged ≥ 2 and ≤ 6 years, undergoing strabismus repair, were assigned to receive TIVA (intravenous induction and maintenance of anesthesia with propofol and remifentanil) or SEVO (inhalational induction and maintenance of anesthesia with sevoflurane). Parent-child induction behavior was scored using the Perioperative Adult Child Behavior Interaction Scale (PACBIS). Postoperatively, ED was assessed by a masked investigator using the Pediatric Anesthesia Emergence Delirium (PAED) Scale and pain using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale every 5 min. Data are reported for 94 subjects. Incidence of ED was higher with SEVO (38.3% vs 14.9%, P = 0.018). There was no difference in the median PACBIS score. A higher FLACC score was seen with SEVO (median 3 vs 1, P = 0.033). Subjects experiencing ED had higher FLACC scores vs those unaffected by ED (median 7 vs 1, P < 0.0001). There was a lower incidence of ED after TIVA. Both intravenous and inhalational inductions were similarly well-tolerated. The use of TIVA was associated with reduced postoperative pain as measured using FLACC scores.

The effects of secondhand smoke on postoperative pain and fentanyl consumption

Although the need for increased postoperative analgesia in smokers has been described, the effect of secondhand smoke on postoperative analgesia requirements has not been studied. We examined the effects of secondhand smoke on fentanyl consumption and postoperative pain. In this study, 101 patients (American Society of Anesthesiology physical status I and II) who underwent abdominal hysterectomy were divided into 3 groups according to history of exposure to cigarette smoke as per medical records which was retrospectively confirmed by measurement of serum cotinine: smokers (n = 28), nonsmokers (n = 31), and secondhand smokers (n = 32). All patients received propofol-remifentanil total intravenous anesthesia and used fentanyl patient controlled analgesia for postoperative pain. The fentanyl consumption visual analogue scale-pain intensity (VAS-PI) score and side effects were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 h after surgery. Fentanyl consumption at all the evaluation time points was significantly higher in secondhand smokers than in nonsmokers (P < 0.05). However, fentanyl consumption in secondhand smokers was lower than that in smokers in the PACU and at 24 h (P < 0.05). VAS-PI scores during movement and at rest in the PACU and at 4, 6, and 24 h after surgery were higher in secondhand smokers than in nonsmokers (P < 0.05). There were no statistically significant differences between the groups with regard to side effects such as nausea, vomiting, and dizziness (P > 0.05). Secondhand smoking was associated with increased postoperative fentanyl consumption, and increased VAS-PI scores. These findings may be beneficial for managing postoperative pain in secondhand smokers.

Propofol–remifentanil intravenous anesthesia and spontaneous ventilation for airway foreign body removal in children with preoperative respiratory impairment

To investigate the efficacy and safety of propofol-remifentanil total intravenous anesthesia (TIVA) and spontaneous ventilation for foreign body (FB) removal in pediatric patients with preoperative respiratory impairment. We carried out a prospective observational clinical study of FB removal using a rigid bronchoscope under propofol-remifentanil TIVA and spontaneous ventilation in 65 pediatric patients who presented with preoperative respiratory impairment. Heart rate, blood pressure, pulse oxygen saturation (SpO(2)), respiratory rate, endtidal CO(2) (ETCO(2))(ETCO2), induction time, and remifentanil rate were recorded. Adverse events, the intervention for these events, and the duration of postoperative care were also of interest. Sixty children completed the study. The mean induction time was 12.3 min. During the procedure, the maximum remifentanil rate was 0.14 μg · kg(-1) · min(-1). Light breath holding occurred in 16 (26.7%) patients. No severe breath holding or body movements were observed. An SpO(2) below 90% occurred in 10 (16.7%) cases. No progressive desaturation was observed. The mean ETCO(2) at the end of the procedures was 7.91 KPa and returned to normal 5 min after the procedure. In the postanesthesia care unit (PACU), no hypoxemia was observed and the mean recovery time was 23.4 min. No laryngospasm, pneumothorax, or arrhythmias were observed. Propofol-remifentanil TIVA and spontaneous ventilation are effective and safe techniques to manage anesthesia during airway FB removal in children with preoperative respiratory impairment.

Esmolol blunts postoperative hemodynamic changes after propofol-remifentanil total intravenous fast-track neuroanesthesia for intracranial surgery

Study Objective To investigate whether esmolol is effective in attenuating postoperative hemodynamic changes related to sympathetic overdrive. Design Clinical study. Setting Operating room of a university hospital. Patients 60 ASA physical status I, II, and III patients, age 18 to 65 years, scheduled for elective craniotomy for supratentorial neurosurgery. Interventions Patients were given total intravenous anesthesia (TIVA) during emergence from anesthesia and up to 60 minutes after extubation. Those patients who had hypertension (defined as an increase in systolic blood pressure >20% from baseline values) and tachycardia (defined as an increase >20% in heart rate from baseline) received a loading dose of 500 μg/kg esmolol in one minute, followed by an infusion titrated stepwise (50, 100, 200, and 300 μg/kg per min) every two minutes. Measurements The mean dose and duration of esmolol therapy were measured. Main Results Of 60 patients, 49 (82%) who received propofol-remifentanil TIVA developed significant tachycardia and hypertension soon after extubation. Treatment with esmolol (500 μg/kg in bolus maintained at a mean rate of 200 ± 50 μg/kg per min) effectively controlled hypertension and tachycardia in 45 of 49 patients (92%; P < 0.05) within a mean 4.30 ± 2.20 minutes. After extubation, mean esmolol infusion time was 29 ± 8 minutes. Conclusion In patients undergoing elective neurosurgery with propofol-remifentanil TIVA, a relatively small esmolol dose and short infusion time effectively blunts early postoperative arterial hypertension and tachycardia.

The Effects of Propofol-remifentanil Total Intravenous Anesthesia on Platelet Function

Background: The majority of anesthetic agents, including inhalation anesthetics, inhibit platelet function, but the effect of propofol on platelets is controversial. This study was designed to compare the effects of propofol-remifentanil total intravenous anesthesia and sevoflurane inhalation anesthesia on platelet function. Methods: Patients undergoing major hip surgery were divided into two groups: inhalation anesthesia with sevoflurane or total intravenous anesthesia with propofol and remifentanil. Hemoglobin, hematocrit, platelet count, prothrombin time, activated partial thromboplastin time, and platelet aggregation were measured 5 minutes before induction, the first hour intra-operatively, and the first hour postoperatively. Results: Total intravenous anesthesia with propofol and remifentanil significantly diminished collagen-induced platelet aggregation values intraoperatively compared with preoperative values. Also, intraoperative collagen- and adenosine diphosphate (ADP)-induced platelet aggregation was significantly lower in anesthesia with propofol and remifentanil compared with sevoflurane anesthesia. Sevoflurane did not induce significant changes in collagen- or ADP-induced platelet aggregation. Conclusions: Total intravenous anesthesia with propofol and remifentanil significantly reduced collagen-induced platelet aggregation intraoperatively, while inhalation anesthesia with sevoflurane did not reduce collagen-or ADP-induced platelet aggregation at all. (Korean J Anesthesiol 2008; 54: 134～8)

The Effect-Site Concentration of Remifentanil for Prevention of Increase of Blood Pressure and Heart Rate to Tracheal Intubation during Propofol-Remifentanil Total Intravenous Anesthesia in Korean

Background: Combination of propofol and remifentanil is an ideal regimen for total intravenous anesthesia. The purpose of this study is to determine the effect-site concentration of remifentanil for prevention of hemodynamic responses to tracheal intubation during fixed propofol infusion (4g/ml) and to find any sexual differences. Methods: Thirty ASA physical status I-II patients undergoing general anesthesia were assigned to male (n = 15), and female (n = 15) group. All patients received a target controlled infusion (TCI) of propofol with a fixed effect-site concentration of 4g/ml. After target effect-site concentration of propofol and remifentanil was reached, tracheal intubation was performed. The hemodynamic changes (systolic/diastolic blood pressure, mean arterial pressure, and heart rate) were measured at 1 and 2 min before tracheal intubation (baseline), immediately after, 1, 2, 3, 4 and 5 min following tracheal intubation. In both groups, effect-site concentration of remifentanil was initiated with 3 ng/ml. Subsequent concentration of remifentanil was determined by hemodynamic responses of the previous patient to tracheal intubation based on up and down sequential allocation. Results: The mean EC50 of remifentanil for prevention of hemodynamic responses to tracheal intubation were 1.37 ng/ml (95% CI, 0.95-1.81 ng/ml) in male group and 1.05 ng/ml (95% CI, 0.68-1.40 ng/ml) in female group, respectively. In addition, there were no statistical significant differences between two groups. Conclusions: Relatively small dosages of remifentanil (0.68-1.81 ng/ml) for attenuation of hemodynamic responses to tracheal intubation was needed in Korean population in propofol TCI and there were no sexual differences.