Gulden Ugur

Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade.

PurposeAdministration of remifentanii followed by propofol provides adequate conditions for tracheal intubation without muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. Intubating conditions with remifentanil followed by propofol, thiopentone or etomidate are compared in this study.MethodsIn a randomized, double-blind study 45 healthy males were assigned to one of three groups (n = 15). After iv atropine, remifentanil 3 μg· kg−1 were injected over 90 sec followed by propofol 2 mg· kg−1 (Group I), thiopentone 6 mg· kg−1 (Group II) or etomidate 0.3 mg· kg−1 (Group III), Ninety seconds after the administration of the hypnotic agent, laryngoscopy and intubation were attempted, Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff.ResultsOne patient in Group I, three patients in Group II and five patients in Group III could not be intubated on the first attempt. Clinically acceptable intubating conditions were observed in 93.3%, 66.7%, 40.0% of patients in Groups I, II and III, respectively. Overall conditions at intubation were significantly (P < 0,05) better, and the frequency of excellent conditions was significantly (P < 0.05) higher in the propofol group compared with the thiopentone and etomidate groups. No patient was treated for hypotension or bradycardia.ConclusionPropofol 2 mg· kg−1 was superior to thiopentone 6 mg· kg−1 and etomidate 0.3 mg· kg−1 for tracheal intubation when combined with remifentanil 3 μg· kg−1 and no muscle relaxant.RésuméObjectifL’administration de rémifentanil suivie de propofol permet des conditions satisfaisantes d’intubation endotrachéale sans myorelaxants. D’autres hypnotiques n’ont pas encore été testés dans ces circonstances. Nous avons donc voulu comparé les conditions d’intubation avec le rémifentanil suivi du propofol, du thiopental ou de l’étomidate.MéthodeL’étude randomisée et à double insu a été réalisée auprès de 45 hommes en bonne santé, répartis en trois groupes (n = 15). Après l’administration iv d’atropine, l’injection de 3 μg· kg−1 de rémifentanil, pendant 90 sec, a été suivie de 2 mg· kg−1 de propofol (Groupe I), de 6 mg· kg−1 de thiopentai (Groupe II) ou de 0,3 mg· kg−1 d’étomidate (Groupe III). Quatre-vingt-dix secondes après l’administration de l’agent hypnotique, la laryngoscope et l’intubation ont été tentées. Les conditions d’intubation ont été évaluées comme excellentes, bonnes ou pauvres d’après la facilité de ventilation, du relâchement de la mâchoire, la position des cordes vocales et la réponse du patient à l’intubation et au gonflement lent du ballonnet du tube endotrachéal.RésultatsUn patient du Groupe I, trois du Groupe II et cinq du Groupe III n’ont pu être intubés au premier essai. Des conditions d’intubation acceptables ont été observées chez 93,3 %, 66,7 % et 40,0 % des patients des Groupes I, II et III. Dans l’ensembie, les conditions d’intubation ont été signifiativement (P < 0,05) meilleures, et la fréquence de conditions excellentes a été signifeativement (P < 0,05) plus élevée, avec le propofol, comparé au thiopentai et à l’étomidate. Aucun patient n’a dû recevoir de traitement pour hypotension ou bradycardie.ConclusionLes conditions d’intubation endotrachéale ont été meilleures avec l’usage de 2 mg· kg−1 de propofoi, comparés à 6 mg· kg−1 de thiopental et à 0,3 mg· kg−1 d’étomidate, combinés à 3 μg· kg−1de remifentanil et sans myorelaxants.

Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol

Background and objective: In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 followed by propofol 2 mg kg−1. Methods: In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 were injected over 90 s followed by propofol 2 mg kg−1. Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. Results: Seven patients who received remifentanil 2 μg kg−1 and one patient who received remifentanil 3 μg kg−1 could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 μg kg−1 (45% of patients) or remifentanil in doses of 2 μg kg−1 (20%), 3 μg kg−1 (75%) or 4 μg kg−1 (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 μg kg−1 compared with those who received alfentanil 40 μg kg−1 or remifentanil 2 μg kg−1. No patient needed treatment for hypotension or bradycardia. Conclusions: Remifentanil 4 μg kg−1 and propofol 2 mg kg−1 administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.

Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery.

Background and objective: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. Methods: Patients in Group 1 (n = 20) received alfentanil 20 μg kg−1 followed by 2 μg kg−1 min−1 intravenously; patients in Group 2 (n = 20) received remifentanil 1 μg kg−1 followed by 0.5 μg kg−1 min−1 intravenously. Both groups then received propofol 2 mg kg−1 followed by 9 mg kg−1 h−1 intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). Results: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score ⩾9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores ⩾9 were similar. Conclusions: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.

Effects of preoperative gabapentin on postoperative pain after radical retropubic prostatectomy.

Objective: The impact of preoperative gabapentin on tramadol consumption using patient-controlled analgesia (PCA) and postoperative pain was assessed in patients undergoing radical retropubic prostatectomy (RRP). Methods: In this prospective, randomized trial, 51 patients undergoing RRP were randomized into two groups: the gabapentin group received 900 mg gabapentin orally 2 h before surgery; the control group did not receive gabapentin. Postoperative analgesia was provided by tramadol PCA. Pain was assessed using a visual analogue scale for 24 h, postoperatively. Results: Mean cumulative tramadol consumption at 24 h was comparable in the two groups. Pain scores at 45 min, 60 min and 2 h postoperatively, and the number of patients who required rescue analgesia, were significantly lower in the gabapentin group than in the control group. Side-effects were similar in the two groups. Conclusions: Preoperative administration of 900 mg gabapentin did not decrease tramadol consumption, but was associated with lower pain scores in the early postoperative phase and a reduced need for rescue analgesia, compared with controls, in patients undergoing RRP.

Sevoflurane vs ketamine-midazolam for the anesthetic management of children undergoing extracorporeal shock wave lithotripsy.

discontinued from the current dose of 0.4 lgÆkgÆh. Tachycardia, hypertension and emesis were observed immediately after discontinuation without any physiological explanation. These symptoms did not subside with lorazepam administration. Drug withdrawal was suspected, hence dexmedetomidine was restarted 3 h later with the loading dose of 1 lgÆkg and followed by continuous infusion at 0.4 lgÆkgÆh with good results (see Figure 1). The following day, the infusion was gradually weaned off by 0.1 lgÆkgÆh every 8 h without incident. The prolonged use of dexmedetomidine in the ICU has been a safe option in pediatric patients. Hammer et al. (1) reported the use of dexmedetomidine in a 9-year-old male for 4 days following a tracheal reconstruction. Their use of dexmedetomidine allowed for a decrease dose in fentanyl and midazolam combined with more periods of controlled wakefulness. Walker et al. (2) reported on prolonged dexmedetomidine infusions in 65 pediatric burn patients. There was an average of 11 days on the agent with a range of 2–50 days. The dosing ranges of dexmedetomidine were 0.1–2 lg kg h. The infusion of dexmedetomidine was weaned off on each patient over 12–24 h. There were no episodes of tachyphylaxis or withdrawals reported in both studies. In addition, Enomoto et al. (3) recently described the use of dexmedetomidine in an infant for more than 2 months following a liver transplant. The pediatric use of dexmedetomidine continues to increase. More research is needed in the prolonged use of dexmedetomidine to determine the safe maximal total dosing in pediatric population. As seen in our patient, protracted use of dexmedetomidine may lead to a physiologic dependence as seen in other classes of drugs. We propose that a gradual weaning is warranted after a prolonged use of dexmedetomidine to prevent withdrawal. Mark D. Weber R N C P N P* Satid Thammasitboon M D M H P E* David A. Rosen M D† *Department of Pediatrics †Department of Anesthesia, West Virginia University Children’s Hospital (email: mweber@hsc.wvu.edu)

Evaluation of a Multimodal Approach to Postoperative Pain in Patients Undergoing Flank Incision in the Urology Operating Room

OBJECTIVE In this study, we evaluated subcutaneous (sc) morphine in combination with multimodal analgesia for postoperative pain control after radical nephrectomy and pyeloplasty with flank incision. METHODS Forty-nine patients under The American Society of Anesthesiologists Physical Status classification (ASA) I-III aged 18-85 years undergoing radical nephrectomy and pyeloplasty with flank incision were included in this prospective, randomised study. The patients were divided into two groups (Group O [n=25] and Group M [n=24]) and received standard general anaesthesia. Tramadol (100 mg) and paracetamol (100 mg) were given intravenously before fascia closure and 20 mL of 0.25% levobupivacaine was injected locally at surgical incisions in all patients. Patients in Group M also received 0.1 mg kg(-1) morphine subcutaneously. Patient-controlled analgesia (PCA) with tramadol was used for postoperative pain control in both groups. Postoperative pain scores (VAS), vital parameters, side effects, the need for rescue analgesia during 24 hours postoperatively, and patient satisfaction were recorded. RESULTS Groups were comparable with respect to demographic data, ASA status, and duration of surgery. There were no significant differences between the groups in postoperative PCA tramadol consumption, rescue analgesia, side effects, or vital parameters. Postoperative pain scores (VAS) in Group M were significantly lower at 30, 45, 60, and 120 minutes compared to Group O (p<0.05). CONCLUSION In patients undergoing radical nephrectomy and pyeloplasty with flank incision, subcutaneous morphine in combination with multimodal analgesia decreases early postoperative pain scores compared to multimodal analgesia alone.

The Effect of EMLA Cream on Patient-Controlled Analgesia with Remifentanil in ESWL Procedure: A Placebo-Controlled Randomized Study

Background To alleviate stinging pain in the skin entry area and visceral discomfort in patients who are undergoing ESWL. Objectives This study was designed to investigate the effectiveness of the EMLA cream in combination with remifentanil patient-controlled analgesia (PCA) in patients undergoing ESWL treatment. Patients and Methods Sixty patients were divided into two double-blind randomized groups. Those in the first group were administered 3-5mm of EMLA 5% cream on a marked area; the second group received, as a placebo, a cream with no analgesic effect in the same amount. All patients were administered a remifentanil bolus with a PCA device. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; postoperative side effects, agitation, and respiratory depression were measured after. Visual Analogue Scale (VAS) scores were taken preoperatively, perioperatively, directly postoperatively, and 60 minutes subsequent to finishing the procedure. Results There were no statistically significant differences in the frequency of PCA demands and delivered boluses or among perioperative VAS. No significant side effects were noted. Patient satisfaction was recorded high in both groups. Conclusions EMLA cream offered no advantage over the placebo cream in patients undergoing ESWL with remifentanil PCA.

Superficial venous thrombophlebitis caused by rocuronium

Pain is one of the major disadvantages of rocuronium, which is used during induction of anesthesia. Even at subparalyzing doses, 50–100% of patients complain of intense pain. Sudden flexion and withdrawal movement in the wrist or arm have been reported following rocuronium use in many papers. No information about risk factors leading to this withdrawal movement or pain on injection is available and whether this reaction leads to erythema or to venous sequelae (i.e. thrombosis and thrombophlebitis) has not been systematically investigated. However, in both of our cases, visible reactions occurred and both patients were diagnosed with venous superficial thrombophlebitis. Therefore, we believe that rocuronium-related pain may, in part, be because of direct venous injury.

Randomised, cross-over comparison of sevoflurane and ketamine-midazolam anaesthesia in children undergoing extracorporeal shock-wave lithotripsy

IntroductionThe aim of this study was to assess the haemodynamic responses, adverse events and recovery characteristics associated with sevoflurane and ketamine-midazolam anaesthesia for paediatric extracorporeal shock-wave lithotripsy.MethodsTwenty children aged 2–11 years, who were undergoing two consecutive lithotripsy sessions at an interval of 4 weeks were enrolled and randomised to receive either inhalation or dissociative anaesthesia at their first session. The alternative anaesthesia protocol was used at their second session. Inhalation anaesthesia was induced with 8% sevoflurane and 70% N2O in oxygen; 10 μg/kg atropine and 2 μg/kg fentanyl were then administered. Anaesthesia was maintained with 2%–3% end-tidal sevoflurane and 70% N2O in oxygen via a laryngeal mask airway. Dissociative anaesthesia was induced intravenously with 10 μg/kg atropine, 0.05 mg/kg midazolam, 1.5 mg/kg ketamine and maintained with 0.5–1.0 mg/kg ketamine. Haemodynamic parameters were recorded before and after induction, after the start of the procedure, and every 10 minutes thereafter. Postoperatively, the times to responding to command, sitting, ambulating, achieving an Aldrete score ≥9, and achieving a post-anaesthetic discharge score ≥9 were recorded.ResultsSystolic and diastolic arterial pressures at all measurements throughout the procedure were higher with ketamine-midazolam than with sevoflurane (P<0.05). Heart rates were comparable between groups, except after induction and after start of the procedure in which they were higher with ketamine-midazolam (P<0.05). All recovery endpoints were achieved earlier with sevoflurane than with ketamine-midazolam (P<0.05). Nauseavomiting incidences were similar in both groups.ConclusionSevoflurane and ketamine-midazolam both provided effective anaesthesia for paediatric lithotripsy. The recovery and discharge times were shorter after anaesthesia with sevoflurane compared with ketamine-midazolam in children undergoing lithotripsy.