The optimal anesthetic depth for interventional neuroradiology: comparisons between light anesthesia and deep anesthesia / 대한마취과학회지

BACKGROUND: This study was designed to determine the optimal anesthetic depth for the maintenance and recovery in interventional neuroradiology. METHODS: Eighty-eight patients undergoing interventional neuroradiology were randomly allocated to light anesthesia (n = 44) or deep anesthesia (n = 44) groups based on the value of the bispectral index (BIS). Anesthesia was induced with propofol, alfentanil, and rocuronium and maintained with 1-3% sevoflurane. The concentration of sevoflurane was titrated to maintain BIS at 40-49 (deep anesthesia group) or 50-59 (light anesthesia group). Phenylephrine was used to maintain the mean arterial pressure within 20% of preinduction values. Recovery times were recorded. RESULTS: The light anesthesia group had a more rapid recovery to spontaneous ventilation, eye opening, extubation, and orientation (4.1 +/- 2.3 vs. 5.3 +/- 1.8 min, 6.9 +/- 3.2 min vs. 9.1 +/- 3.2 min, 8.2 +/- 3.1 min vs. 10.7 +/- 3.3 min, 10.0 +/- 3.9 min vs. 12.9 +/- 5.5 min, all P < 0.01) compared to the deep anesthesia group. The use of phenylephrine was significantly increased in the deep anesthesia group (768 +/- 184 vs. 320 +/- 82 microg, P < 0.01). More patients moved during the procedure in the light anesthesia group (6/44 [14%] vs. 0/44 [0%], P = 0.026). CONCLUSIONS: BIS values between 50 and 59 for interventional neuroradiology were associated with a more rapid recovery and favorable hemodynamic response, but also with more patient movement. We suggest that maintaining BIS values between 40 and 49 is preferable for the prevention of patient movement during anesthesia for interventional neuroradiology.

Current Evidence for Spinal Opioid Selection in Postoperative Pain

BACKGROUND: Spinal opioid administration is an excellent option to separate the desirable analgesic effects of opioids from their expected dose-limiting side effects to improve postoperative analgesia. Therefore, physicians must better identify either specific opioids or adequate doses and routes of administration that result in a mainly spinal site of action rather than a cerebral analgesic one. METHODS: The purpose of this topical review is to describe current available clinical evidence to determine what opioids reach high enough concentrations to produce spinally selective analgesia when given by epidural or intrathecal routes and also to make recommendations regarding their rational and safety use for the best management of postoperative pain. To this end, a search of Medline/Embase was conducted to identify all articles published up to December 2013 on this topic. RESULTS: Recent advances in spinal opioid bioavailability, based on both animals and humans trials support the theory that spinal opioid bioavailability is inversely proportional to the drug lipid solubility, which is higher in hydrophilic opioids like morphine, diamorphine and hydromorphone than lipophilic ones like alfentanil, fentanyl and sufentanil. CONCLUSIONS: Results obtained from meta-analyses of RTCs is considered to be the 'highest' level and support their use. However, it's a fact that meta-analyses based on studies about treatment of postoperative pain should explore clinical surgery heterogeneity to improve patient's outcome. This observation forces physicians to use of a specific procedure surgical-based practical guideline. A vigilance protocol is also needed to achieve a good postoperative analgesia in terms of efficacy and security.

Effect of pneumoperitoneum on the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic surgery / 대한마취과학회지

BACKGROUND: This study investigated the effect of pneumoperitoneum on the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery. METHODS: Thirty adult patients undergoing laparoscopic abdominal surgery were studied. Anesthesia was induced with 1.5 mg/kg of propofol, 12 ug/kg of alfentanil and 0.6 mg/kg of rocuronium and maintained with 2 vol% of sevoflurane and 0.05-0.2 microg/kg/min remifentanil. The neuromuscular relaxation was monitored by Train-of-Four (TOF) and post-tetanic count (PTC). Additional rocuronium of 0.2 mg/kg was administered for deep neuromuscular blockade at 30 min after pneumoperitoneum. Before (PPpre) and 30 min after pneumoperitoneum (PPpost), PTC was measured at 6 min intervals. The relationship between PTC and the time interval to reappearance of T1 response was observed. RESULTS: The mean +/- SD of the intervals between the detection of 4 counts of the PTC and the first response to TOF stimulation was 13.0 +/- 1.1 min and 16.4 +/- 6.3 min PPpre and PPpost, respectively (P = 0.20). There were significant negative relationships between PTC observed and the time interval to reappearance of T1 response (adjusted R2 = 0.869, P < 0.001 for PPpre data, and adjusted R2 = 0.561, P < 0.001 for PPpost data). Comparing the difference of regression equation between PPpre and PPpost data using a parallelism test, there was no statistically significant difference (P = 0.193). CONCLUSIONS: This study showed that PP with intra-abdominal pressure at the level of 13-14 mmHg did not affect the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery.

Sevoflurane versus propofol for interventional neuroradiology: a comparison of the maintenance and recovery profiles at comparable depths of anesthesia / 대한마취과학회지

BACKGROUND: Sevoflurane and propofol are used widely for interventional neuroradiology (INR). Using the bispectral index (BIS), we compared the clinical properties of sevoflurane and propofol anesthesia in patients undergoing INR at comparable depths of anesthesia. METHODS: The patients were allocated randomly into two groups. The sevoflurane group received propofol (1.5 mg/kg), alfentanil (5 microg/kg), and rocuronium (0.6 mg/kg) for induction, and the propofol group was induced with a target effect-site concentration of propofol (4 microg/ml), alfentanil (5 microg/kg), and rocuronium (0.6 mg/kg). After intubation, anesthesia was maintained with sevoflurane or propofol with 67% nitrous oxide in 33% oxygen. Sevoflurane and propofol concentrations were titrated to maintain the BIS at 50-60. Phenylephrine or opioid was used to maintain the mean arterial pressure within 20% of the baseline values. The amounts of phenylephrine or alfentanil used, the number of patients showing movement during the procedure, and the recovery times were recorded. RESULTS: Compared to the propofol group, the sevoflurane group showed faster recovery in spontaneous ventilation, eye opening, extubation, and orientation (4 vs. 7 min, 7 vs. 9 min, 8 vs. 10 min, 10 vs. 14 min, respectively; P < 0.01). In the propofol group, significantly greater amounts phenylephrine were used (P < 0.05), and more patients moved during the procedure (P < 0.05). CONCLUSIONS: The use of sevoflurane in maintaining anesthesia during INR was associated with faster recovery, less patient movement during the procedure, and a more stable hemodynamic response when compared to propofol.

A comparison of general anesthesia versus axillary brachial plexus block for hand and wrist surgery in the view of patient satisfaction

BACKGROUND: We evaluated whether the analgesic superiority of regional block over general anesthesia improves patient satisfaction. METHODS: Patients were anesthetized with either general anesthesia (GA) (n = 30) or axillary brachial plexus block (BPB) (n = 30). GA was standardized to include induction with propofol and alfentanil and maintenance with desflurane in an oxygen/nitrous oxide mixture. BPB was performed using an axillary perivascular approach, and 1.5% lidocaine 20 ml with epinephrine (1 : 200,000) and 0.5% levobupivacaine 20 ml were injected. Pain scores and numbers of times pushing the patient-controlled analgesia (PCA) button were measured preoperatively and at 2, 6, and 24 hours after the end of surgery. On the first day after the operation, one of our researchers visited the patients to document their opinions of their anesthetic experiences and their satisfaction scores. RESULTS: Group BPB had lower visual analog scale scores at 2 hours and 6 hours postoperatively. Numbers of times pushing the PCA button was also lower in Group BPB within the first 2 hours and between 2-6 hours postoperatively. However, patient satisfaction scores were not statistically different between the two groups (84 +/- 11 vs. 88 +/- 12, P = 0.177). CONCLUSIONS: BPB provided superior analgesia after upper limb surgery compared to GA, but for a complete understanding of patients' satisfaction, detailed consideration of factors such as sedation would be necessary.

Sedação e analgesia em colonoscopia eletiva: propofol-fentanil versus propofol-alfentanil / Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil / Sedación y analgesia en colonoscopia electiva: propofol-fentanilo versus propofol-alfentanilo

JUSTIFICATIVA E OBJETIVO: Sedação e analgesia são recomendadas em colonoscopia para propiciar conforto, pois são procedimentos invasivos e podem ser dolorosos. Este estudo teve como objetivo comparar as combinações de propofol-alfentanil e propofol-fentanil para sedação e analgesia em pacientes submetidos à colonoscopia eletiva. MÉTODOS: Estudo prospectivo e randomizado. Participaram do estudo 80 pacientes, ASA I-II, entre 18 e 65 anos. A indução de sedação e a analgesia foram feitas com propofol (1 mg.kg-1) e fentanil (1 µg.kg-1) no grupo propofol-fentanil (PF) e com propofol (1 mg.kg-1) e alfentanil (10 µg.kg-1) no grupo propofol-alfentanil (PA). Para manutenção, doses adicionais de propofol foram administradas em bolus de 0,5 mg.kg-1 para obter escores de 3-4 na Escala de Sedação de Ramsey (ESR). Registrados os dados demográficos, a frequência cardíaca, a pressão arterial média (PAM), a saturação de oxigênio da hemoglobina (SpO2), os valores da ESR, o tempo de colonoscopia, a dose total de propofol, as complicações, o tempo de recuperação e o tempo para alta, bem como os escores de satisfação do colonoscopista e do paciente. RESULTADOS: A PAM aos 15 minutos no Grupo PA foi significativamente maior do que no Grupo PF (p = 0,037). A frequência cardíaca média do grupo PA foi maior no início do que nas mensurações subsequentes (p = 0,012, p = 0,002). A média da dose total de propofol do Grupo PA foi significativamente maior do que a do Grupo PF (p = 0,028). O tempo médio de recuperação do grupo PA foi significativamente maior do que o do grupo PF (p = 0,032). CONCLUSÃO: Fentanil proporciona melhores condições de operação e reduz a necessidade de doses adicionais de propofol. Essas vantagens diminuem o tempo de recuperação. Portanto, propofol-fentanil é superior ao propofol-alfentanil para sedação e analgesia em colonoscopia.

BACKGROUND AND OBJECTIVES: Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS: This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 µg.kg-1 fentanyl, 1 mg.kg-1 propofol in the propofol-fentanyl group (Group PF) and 10 µg.kg-1 alfentanil, 1 mg.kg-1 propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5 mg.kg-1 bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS: MAP at the 15th minute in Group PA was significantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was significantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was significantly longer than that of Group PF (p = 0.032). CONCLUSION: Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.

JUSTIFICATIVA Y OBJETIVO: La sedación y la analgesia están recomendadas en la colonoscopia para propiciar la comodidad, porque son procedimientos invasivos y pueden ser dolorosos. Este estudio tuvo el objetivo de comparar las combinaciones de propofol-alfentanilo y propofol-fentanilo para la sedación y la analgesia en pacientes sometidos a la colonoscopia electiva. MÉTODOS: Estudio prospectivo y aleatorio. Participaron en el estudio 80 pacientes, ASA I-II, entre 18 y 65 años. La inducción de sedación y la analgesia fue hecha con propofol (1 mg.kg-1) y fentanilo (1 µg.kg-1) en el grupo propofol-fentanilo (PF) y con propofol (1 mg.kg-1) y alfentanilo (10 µg.kg-1) en el grupo propofol-alfentanilo (PA). Para el mantenimiento, dosis adicionales de propofol se administraron en bolos de 0,5 mg.kg-1 para obtener las puntuaciones de 3-4 en la Escala de Sedación de Ramsey (ESR). Se registraron los datos demográficos, la frecuencia cardíaca, la presión arterial promedio (PAP), la saturación de oxígeno de la hemoglobina (SpO2), los valores de la ESR, el tiempo de colonoscopia, la dosis total de propofol, las complicaciones, el tiempo de recuperación y el tiempo para el alta, como también las puntuaciones de satisfacción del colonoscopista y del paciente. RESULTADOS: La PAP a los 15 minutos en el Grupo PA fue significativamente mayor que en el Grupo PF (p = 0,037). La frecuencia cardíaca promedio del grupo PA fue mayor al inicio que en las mensuraciones posteriores (p = 0,012, p = 0,002). El promedio de la dosis total de propofol del Grupo PA fue significativamente mayor que la del Grupo PF (p = 0,028). El tiempo promedio de recuperación del grupo PA fue significativamente mayor que el del grupo PF (p = 0,032). CONCLUSIONES: El Fentanilo proporciona mejores condiciones de operación y reduce la necesidad de dosis adicionales de propofol. Esas ventajas reducen el tiempo de recuperación. Por tanto, el propofol-fentanilo es superior al propofol-alfentanilo para la sedación y la analgesia en la colonoscopia.

Comparison of the effects of remifentanil and alfentanil on intraocular pressure in cataract surgery

Anesthesia for ophthalmic surgery requires management of intraocular pressure [IOP] during perioperative period. In an open eye, in conditions such as after traumatic injury or during cataract surgery, IOP increase can lead to permanent vision loss. Administration of narcotics concomitant with anesthetics has the ability to reduce this increase of IOP. This clinical trial aims to compare the efficacy of remifentanil and alfentanil in preventing an increase in IOP after administration of succinylcholine, intubation and during anesthesia. This double-blind clinical trial was conducted on 50 patients undergoing elective general surgery for cataracts. Patients were randomly divided into two groups. Alfentanil [20 microg/kg in 30 s] for group 1 and remifentanil [1 microg/kg in 30 s] for group 2 were injected before induction of anesthesia, and 0.5 microg/kg/min alfentanil for group 1 and 0.1 microg/kg/min remifentanil for group 2 were infused during the anesthesia. Systolic and diastolic blood pressure, heart rate, and IOP from normal eye were measured before the induction, after administration of thiopental and succinylcholine, after tracheal intubation, and 2 min later, and were repeated in 2-min intervals until the end of operation. IOP decreased after injection of anesthetics and remained lower all through the operation in both groups, but IOP decreased after injection of succinylcholine in remifentanil group while it increased in alfentanil group [P<0.05]. Results of this study indicate benefits of both remifentanil and alfentanil in managing IOP after induction and during anesthesia. It seems that remifentanil is better than alfentanil in controlling the IOP after injection of succinylcholine

Pretreatment of magnesium sulphate improves intubating conditions of rapid sequence tracheal intubation using alfentanil, propofol, and rocuronium: a randomized trial / 대한마취과학회지

BACKGROUND: We investigated the effects of a magnesium sulfate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI) in this double-blind randomized study. METHODS: Adult patients (n = 154) were randomly allocated to a rocuronium-0.6, rocuronium-0.9, or magnesium group. The magnesium group was pretreated with 50 mg/kg MgSO4, and the other two groups received the same volume of isotonic saline. Anesthesia was induced with alfentanil, propofol, and either 0.6 mg/kg (rocuronium-0.6 and magnesium groups) or 0.9 mg/kg (rocuronium-0.9 group) rocuronium. An anesthesiologist, blinded to the group assignments, performed RSI and assessed the intubating conditions. Systolic arterial pressure (SAP) and heart rate (HR) were recorded before the magnesium sulfate or normal saline was administered, before anesthesia induction, before intubation, and every minute after intubation for 5 min. RESULTS: Airway features were similar among the three groups. The intubating conditions were improved significantly in the magnesium group (P 0.05). No hypertensive episode occurred during the immediate post-intubation period in the magnesium group (P = 0.001), and tachycardia occurred most frequently in the rocuronium-0.6 group (P < 0.05). CONCLUSIONS: MgSO4 administered prior to RSI using alfentanil, propofol, and rocuronium may improve intubating conditions and prevent post-intubation hypertension.

Comparison of the effect of fentanyl, sufentanil, alfentanil and remifentanil on cardiovascular response to tracheal intubation in children

Laryngoscopy and tracheal intubation may cause significant cerebral and systemic hemodynamic responses. Many drugs have been shown to be effective in modifying these hemodynamic responses, including fentanyl, sufentanil, alfentanil and remifentanil. The purpose of the current study was to compare the efficacy of fentanyl, sufentanil, alfentanil and remifentanil on blunting cardiovascular changes during laryngoscopy and intubation in children. Eighty children, 1-6 years old, classified as American Society of Anesthesiologists physical status I and II who were scheduled for elective surgery with general anesthesia and orotracheal intubation, were enrolled in this randomized and double-blinded study. Patients were randomly assigned into four groups of 20 patients. Group F received fentanyl 1 micro g/kg[-1], group S received sufentanil 0.1 micro g/kg[-1], group A received alfentanil 10 micro g/kg[-1] and group Rreceived remifentanil 1 micro g/kg[-1] intravenously. After establishment of neuromuscular blockade confirmed with a nerve stimulator, laryngoscopy and orotracheal intubation were performed 3 min after induction. Hemodynamic variables including systolic and diastolic blood pressure [SAP, DAP] and heart rate [HR] were recorded at base line [before opioid administration], before laryngoscopy and one minute after orotracheal intubation. The patients' characteristics and laryngoscopy grade were similar in all groups. There was no significant difference in the mean values of SAP, DAP and HR at each measured time between the four groups. There was significant difference in the mean values of SAP, DAP and HR measured over time in each group. The intravenous fentanyl attenuated laryngoscopy-induced SAP, DAP and HR increases better than sufentanil, alfentanil or remifentanil and hemodynamic stability is better preserved with fentanyl

Bonfils fiberscope: intubating conditions and hemodynamic changes without neuromuscular blockade

To compare intubating conditions and hemodynamic changes between Bonfils Intubation Fiberscope and Macintosh laryngoscopy without administering neuromuscular blocking drugs [NMBDs]. In this randomized controlled trial, 80 male and female patients, scheduled for elective surgery, aged 15 to 60 years, ASA class II or I, non-obese, non smokers, without anticipated difficult intubation; were randomly allocated into two groups of 40: Bonfils and Macintosh. Following adequate hydration and preoxygenation, midazolam 0.03 mg.kg[-1] was administered, followed by intravenous alfentanil 20 microg.kg[-1], lidocaine 1.0 mg.kg[-1], and propofol 2 mg.kg[-1] sequentially. Trachea was then intubated using Bonfils Intubation Fiberscope in the Bonfils group and conventional Macintosh laryngoscopy in the Macintosh group. Intubating condition, mean arterial blood pressure, heart rate, pulse oximetry, and success rate were measured. Clinically acceptable intubating condition scores did not differ significantly between the groups [P=0.465]. Compared to the baseline values, heart rate rose significantly after intubation only in the Macintosh group [P<0.001]. Although mean arterial blood pressure increased immediately after intubation in the Macintosh group [P=0.022], its post-intubation values were significantly less than baseline in both groups [P<0.001]. Intubation time took much longer in the Bonfils group [40 s] than the Macintosh group [11 s], P<0.001. In the absence of NMBDs, Bonfils Intubation Fiberscope compares well with Macintosh laryngoscopy in terms of success rate and intubating conditions, but with less mechanical stress and hemodynamic compromise and longer intubation time

A comparison of sufentanil and fentanyl for patient-controlled epidural analgesia in arthroplasty / 대한마취과학회지

BACKGROUND: The use of lipid soluble opioids such as fentanyl, alfentanil and sufentanil are recently on the increase for patient-controlled epidural analgesia (PCEA). In this study, the effects and adequate dose of sufentanil in arthroplasty were investigated. METHODS: Eighty patients scheduled for arthroplasty were enrolled for the study. Seventy-one patients (ASA physical status I-III) were randomly allocated into four groups. All groups received 0.1% ropivacaine through PCEA and each group received either fentanyl (group F: fentanyl 4 microg/ml) or sufentanil (group S1: sufentanil 0.5 microg/ml, group S2: sufentanil 0.75 microg/ml, and group S3: sufentanil 1.0 microg/ml). Postoperative pain scores were evaluated using VAS (visual analog scale, 0-10) and side effects such as hypotension, nausea/vomiting, pruritus and the degree of satisfaction were evaluated at 1, 6, 12, 24, 48 hours after surgery. RESULTS: Postoperative pain score (VAS) decreased gradually and the highest VAS score was recorded at 1 hour postoperative for all four groups. There were no differences in the degree of satisfaction and postoperative pain score between all groups. The incidence of pruritus was significantly lower in group S1 than in groups S2 and S3. CONCLUSIONS: The incidence of side effects were significantly lower in group S1 (0.1% ropivacaine plus sufentanil 0.5 microg/ml). Therefore, 0.5 microg/ml of sufentanil through PCEA is the recommended dose for postoperative pain control in arthroplasty.

The effects of peripheral hypothermia on monitoring the recovery from deep neuromuscular blockade with rocuronium

BACKGROUND: The skin temperature is often decreased during anesthesia because of a cool ambient temperature in the operating room. Contractility of the muscles may be affected by lowering the muscle temperature. This study was designed to verify that efforts to maintain normothermia on the monitored arm can make recovery from deep neuromuscular blockade more reliable. METHODS: A total of 60 patients were enrolled in this study. Each patient was randomly assigned to group 1 (the monitored arm was shielded with a passive warming protector) or group 2 (the monitored arm was was exposed to the ambient operating room temperature). Conventional inhalation anesthesia was induced with propofol and alfentanil, and this was maintained with O2, N2O and isoflurane. The twitch response of the adductor pollicis muscle was recorded. After calibration of the TOF watch(R), 0.6 mg/kg of rocuronium was injected. During anesthesia, the post tetanic count (PTC) was checked every 5 to 6 minutes until the first response to a train-of-four (TOF) stimulations appeared. The ambient operating room temperature, the core temperature and the skin temperature were checked simultaneously. RESULTS: The skin temperature of group 2 was lower than that of group 1 (33.89 +/- 0.81 degreesC and 35.41 +/- 0.45 degreesC, respectively, P < 0.05). When the data was plotted with the equation y=be(-ax), this equation well represented the data of group 1 (R2 = 0.82), but it did not well represent the data of group 2 (R2 = 0.54). CONCLUSIONS: During recovery from deep neuromuscular blockade with using rocuronium, it may be desirable to maintain normothermia at the thenar area for a better recovery time from a given PTC.

Dexmedetomidine is effective for monitored anesthesia care in outpatients undergoing cataract surgery / 대한마취과학회지

BACKGROUND: Dexmedetomidine has a sedative analgesic property without respiratory depression. This study evaluated the efficacy of dexmedetomidine as an appropriate sedative drug for monitored anesthesia care (MAC) in outpatients undergoing cataract surgery on both eyes compared with combination of propofol and alfentanil. METHODS: Thirty-one eligible patients were randomly divided into two groups on the first operation day. Dexmedetomidine was administered in group D at 0.6 microg/kg/h, and propofol and alfentanil was infused concomitantly in group P at a rate of 2 mg/kg/h and 20 microg/kg/h, respectively. Sedation was titrated at Ramsay sedation score 3. Iowa satisfaction with anesthesia scale (ISAS) of the patients was evaluated postoperatively. Systolic blood pressure (SBP), heart rate (HR), respiration rate (RR), and peripheral oxygen saturation (SpO2) were recorded throughout the surgery. For the second operation, the group assignments were exchanged. RESULTS: Postoperative ISAS was 50.3 (6.2) in group D and 42.7 (8.7) in group P, which was statistically significant (P < 0.001). SBP was significantly lower in group D compared with group P from the beginning of the operation. HR, RR, and SpO2 were comparable between the two groups. There were 8 cases (25.8%) of hypertension in group P, and 1 case (3.2%) in group D (P < 0.05). In contrast, 1 case (3.2%) of hypotension and 1 case (3.2%) of bradycardia occurred in group D. CONCLUSIONS: Compared with the combined use of propofol and alfentanil, dexmedetomidine could be used appropriately for MAC in cataract surgery with better satisfaction from the patients and a more stable cardiovascular state.

The clinical effective dose of alfentanil for suppressing cough during emergence from desflurane anesthesia / 대한마취과학회지

BACKGROUND: The administration of short-acting opioids before emergence is useful for preventing emergence cough induced by an endotracheal tube. This study examined the clinically effective dose of alfentanil for suppressing cough during emergence from desflurane anesthesia. METHODS: Twenty-nine adult patients undergoing elective oral surgery were enrolled in this study. During emergence from anesthesia, the patients received alfentanil diluted in 10 ml normal saline when the end-tidal vol% of desflurane decreased to 3%. The initial alfentanil dose was 16 microg/kg. The alfentanil dose for consecutive patients, determined by Dixon's up-and-down method, increased or decreased by 2 microg/kg according to a previous patient's result. RESULTS: The 50% effective dose (ED50) of alfentanil for suppressing cough during emergence from desflurane anaesthesia was 9.3 +/- 1.5 microg/kg according to Dixon's up-and-down method. Isotonic regression revealed an ED50 and ED95 (95% confidence interval) of alfentanil 10.0 microg/kg (6.8-13.2 microg/kg) and 14.0 microg/kg (7.7-19.4 microg/kg), respectively. CONCLUSIONS: The ED95 of alfentanil for suppressing emergence cough was 14.0 microg/kg. A single bolus administration of alfentanil during emergence from anesthesia was useful for suppressing emergence cough.

The clinical effective dose of rocuronium for lightwand tracheal intubation after induction with alfentanil, propofol, and low concentrations of sevoflurane / 대한마취과학회지

BACKGROUND: The aim of this study was to determine the clinical effective dose of rocuronium for tracheal intubation using a lightwand after induction with propofol, alfentanil, and a low concentration of sevoflurane. METHODS: Twenty-eight adults scheduled to undergo elective surgery lasting less than one hour were enrolled in this study. All patients received alfentanil (10 microgram/kg) and propofol (1.5 mg/kg) for the induction of anesthesia. Tracheal intubation using a lightwand was attempted 3 minutes after administering rocuronium and mask ventilation with 2 vol% of sevoflurane. The initial rocuronium dose was 0.5 mg/kg. The rocuronium dose for consecutive patients, determined by Dixon's up-and-down method, was increased or decreased by 0.05 mg/kg according to the result of the previous patient. The mean arterial pressure and heart rate were recorded before induction, 1 min before intubation, 1 and 2 min after intubation. RESULTS: The 50% clinical effective dose (cED(50)) of rocuronium for tracheal intubation using a lightwand was 0.20 +/- 0.05 mg/kg according to Dixon's up and down method. Isotonic regression revealed the cED(50) and cED(95) (95% confidence intervals) to be 0.20 mg/kg (0.10-0.3 mg/kg) and 0.35 mg/kg (0.16-0.49 mg/kg), respectively. CONCLUSIONS: The cED(50) and cED(95) of rocuronium for tracheal intubation using the lightwand were 0.20 mg/kg and 0.35 mg/kg, respectively, after induction with alfentanil, propofol, and a low concentration of sevoflurane.

The optimal clinical dose of alfentanil for tracheal intubation during inhalation induction with sevoflurane after sedation with ketamine in children

BACKGROUND: The purpose of this study was to determine the clinical effective dose of alfentanil required for successful tracheal intubation during inhalation induction using 5% sevoflurane without neuromuscular blockade in children sedated with ketamine. METHODS: Twenty-one children, aged 3-10 years, undergoing surgeries under general anesthesia were enrolled into the study. All patients were premedicated with 0.004 mg/kg glycopyrrolate intramuscularly 30 min before anesthesia.To facilitate separation of the child from the parents, intravenous 1 mg/kg ketamine was given prior to transfer into the operating room.After inhalation induction with 5% sevoflurane and 100% oxygen, pre-determined dose of alfentanil was injected over 20 sec. The dose of alfentanil was determined by modified Dixon's up-and-down method (2microgramkg as a step size starting from 12microgramkg).The study ended when six independent pairs of patients, who manifested cross over from 'failure' to 'success' for tracheal intubation, were recruited. RESULTS: In 50% of children, the effective bolus dose (ED50) (95% confidence intervals) of alfentanil for successful tracheal intubation was 7.2microgram/kg (6.3-8.1microgram/kg) during sevoflurane inhalation induction.From isotonic regression, 95% effective dose (ED95) (95% confidence intervals) of alfentanil was 9.9microgram/kg (2.2-16.0microgram/kg). CONCLUSIONS: During inhalation induction using 5% sevoflurane without neuromuscular blockade after ketamine sedation, the ED50 and ED95 of alfentanil for successful tracheal intubation were 7.2 microgram/kg and 9.9microgram/kg in children, respectively.

Comparing the combination effect of propofol-ketamine and propofol-alfentanil on hemodynamic stability during induction of general anesthesia in the elderly

Propofol [Diprivan], a modern intravenous hypnotic drug, produces a reduction in both cardiac index [CI] and mean arterial pressure [MAP] due to its sympatholytic activity. S-Ketamine [Ketanest], a potent analgesic, in contrast, causes an increase in both CI and MAP due to its sympathomimetic activity. This study was performed to compare the combination effects of propofol-ketamine and propofol-alfentanil on hemodynamic stability during induction of general anesthesia. In a prospective study, 100 patients over 60 [ASA I, II] scheduled for elective lower abdominal interventions were randomly divided into two groups. For induction of general anesthesia, after injection of midazolam, the first group [A] received alfentanil and propofol and the second group [B] received S-ketamine and propofol. Each group received atracurium as muscle relaxant. Blood pressure [BP] and heart rate [HR] were measured before and 1 and 5 minutes after induction of anesthesia. The increase in HR and decrease in MAP were statistically significant in both groups 1 and 5 minutes after general anesthesia. The increase in HR and decrease in MAP were significantly more in Group A, 1 and 5 minutes after general anesthesia. The dose of S-ketamine administered during induction of general anesthesia may not be enough to neutralize the cardio-depressant effect of propofol. A better hemodynamic activity was observed in Group B compared to Group A due to partial neutralization of the opposing action

Comparison of alfentanil and remifentanil for the use of patient controlled sedation under local anesthesia during ear, nose and throat surgery / 대한마취과학회지

BACKGROUND: This study was conducted to compare the effects of alfentanil and remifentanil on patient controlled sedation (PCS). METHODS: 60 patients scheduled for ear, nose and throat surgery under local anesthesia were randomly allocated to Group P (n = 20, propofol 10 mg/ml), Group A (n = 20, propofol 10 mg/ml with alfentanil 500 microg/ml) and Group R (n = 20, propofol 10 mg/ml with remifentanil 10 microg/ml). Without a basal rate, bolus was set to 2 ml with one minute of lockout time. RESULTS: A total of 57 patients were included in this study. Group A was found to have a lower blood pressure and pulse rate than group R. Group R showed a lower PCS dose upto an OAA/S (Observer's Assessment of Alertness/Sedation Scale) value of 4 and a higher OAA/S prior to surgery than group P. Group P was found to have a higher blood pressure and respiration rate than Group A. During PCS, patient anxiety was significantly decreased in all groups. In addition, there was no differences among groups in the level of pain during the perioperative period, delivery/attempt ratio, satisfaction of the patient and surgeon, and number of patients required to undergo the same PCS technique again. The frequency of side effects of PCS, which included pain on injection, transient hypertension, hypotension, desaturation and oversedation, were similar among groups. CONCLUSIONS: Evaluation of patients who underwent ear, nose and throat surgery under local anesthesia using PCS with propofol alone or alfentanil or remifentanil revealed no differences in safety, effectiveness, complications or satisfaction of the patients and surgeons.

The effect of midazolam premedication on patient satisfaction during fiberoptic bronchoscopy under patient-controlled sedation / 대한마취과학회지

BACKGROUND: Patient-controlled sedation (PCS) with propofol is a safe and effective method of attenuating discomfort during fiberoptic bronchoscopy. The purpose was to evaluate the usefulness of midazolam in addition to PCS for fiberoptic bronchoscopy. METHODS: We randomly assigned 155 patients undergoing diagnostic bronchoscopy to two groups. Group M (n = 79) received 0.03 mg/kg of midazolam for premedication while group P (n = 76) received a loading dose (0.05 ml/kg) of PCS solution composed of 200 mg (20 ml) of propofol and 1 mg (2 ml) of alfentanil. Both groups received the PCS solution 0.2 ml/kg/hr with a bolus of 1 ml and a lockout time of 1 min. Vital signs, pulmonologist satisfaction, patient satisfaction and amnesia were evaluated. RESULTS: After the insertion of the bronchoscope, there was a slight decrease of SpO2 and an increase of blood pressure and heart rate in both groups with no significant differences between the two groups. The group P required more bolus injections (1.6 +/- 1.7 in the group M vs 2.5 +/- 2.2 in group P; P < 0.05). There was no difference in the satisfaction of pulmonologists, but the satisfaction of patients was higher in the group M (P < 0.05). More patients in the group P (93%) remembered the procedure than in the group M (70%) (P < 0.05). CONCLUSIONS: PCS is an effective method for sedating patients undergoing fiberoptic bronchoscopy and midazolam provides more patient satisfaction and amnesia.

The dose-dependent effect of alfentanil on the rocuronium induced withdrawal in children

BACKGROUND: The injection of rocuronium causes pain and withdrawal responses.This study was designed to determine an optimal dose of alfentanil to prevent the withdrawal responses associated with injection of rocuronium in children. METHODS: One hundred and ten ASA physical status I and II pediatric patients were randomly allocated into four groups; Group C (control; normal saline 3 ml, n = 28), Group A5 (alfentanil 5microgram/kg, n = 28), Group A10 (alfentanil 10microgram/kg, n = 27) and Group A15 (alfentanil 15microgram/kg, n = 27). After the induction of anesthesia with 5 mg/kg of thiopental sodium, the test drug was injected over 20 seconds, respectively. After one minute, rocuronium 0.6 mg/kg was injected over 5 seconds. The patient's response after injection was graded using a four-point scale. Additionally, the mean arterial pressure and heart rate were recorded upon arrival in the operating room, as well as 1 min before and 1 min after tracheal intubation. RESULTS: The incidence of withdrawal responses was 96%, 61%, 19% and 19% in groups C, A5, A10 and A15, respectively. The incidence and severity of withdrawal responses in group A10 and A15 were lower than group C and A5. CONCLUSIONS: After thiopental injection, alfentanil 10microgram/kg prevent the withdrawal responses on injecting rocuronium in pediatric patients.