Effectiveness of high dose remifentanil in preventing coughing and laryngospasm in non-paralyzed patients for advanced bronchoscopic procedures

Anesthesia for bronchoscopy presents unique challenges, as constant stimulus due to bronchoscope needs to be obtunded using drugs with a minimal post-procedure residual effect. Remifentanil for maintenance is an ideal choice, but optimal doses are yet to be determined. Bronchoscopic procedures were prospectively evaluated for 4 months studying the frequency of complications and anesthesia techniques. Anesthesia was maintained on remifentanil/propofol infusion avoiding neuromuscular blockers. Laryngeal mask airway was used for the controlled ventilation [with high oxygen concentration] that also served as a conduit for bronchoscope insertions. Anesthesiologists were blinded to the study [avoiding performance bias] and the Pulmonologist was blinded to the anesthesia technique [to document unbiased procedural satisfaction scores]. Procedures were divided into 2 groups based on the dose of remifentanil used for maintenance: Group-H [high dose -0.26 to 0.5 micro g/kg/min and Group-NH [non-high dose <0.25 micro,g/kg/min]. Observed 75 procedures were divided into Group-H [42] and Group-NH [33]. Number of statistical difference was found in demography, procedural profile, hemodynamic parameters and total phenylephrine used. Chi-square test showed Group-NH had significantly higher frequency of laryngospasm [P= 0.047] and coughing [F= 0.002]. The likelihood ratio of patient coughing and developing laryngospasm in Group-NH was found to be 4.56 and 10.97 times respectively. Minimum pulse-oximeter saturation was statistically higher in Group-H [98.80% vs. 96.50% P= 0.009]. Pulmonologist satisfaction scores were significantly better in Group-H. High dose of remifentanil infusion is associated with a lower incidence of coughing and laryngospasms during bronchoscopy. Simultaneously, it improves Pulmonologist's satisfaction and procedural conditions

Outpatient endoscopic retrograde cholangiopancreatography: safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures

Endoscopic retrograde cholangiopancreatography [ERCP] is a unique diagnostic and therapeutic procedure performed in high risk patients in prone/semi-prone position. Propofol based deep sedation has emerged as the method of choice however, the ability to predict possible complications is yet un-explored. The present study aimed to evaluate known high risk-factors for general anesthesia [American Society of Anesthesiologists [ASA] status, body mass index [BMI], and Mallampati class] for their ability to affect outcomes in ERCP patients. Retrospective data of 653 patients who underwent ERCP during a period of 26 months at university hospital of Pennsylvania was reviewed. Patient-specific and procedure specific data was extracted. Desaturation was defined by fall of pulse oximeter saturation below 95% and its relation to patient specific high risk-factors was analyzed. Only 45 patients had transient de-saturation below 95% without any residual sequlae. No statistically significant relation between desaturation episodes and patients higher ASA status or BMI or modified Mallampati [MMP] class was found. Despite 60% patients being ASA III/IV none required emergency intubation or procedural interruption. Optimal oxygenation and airway patency was maintained with high degree of success using simple airway maneuvers or conduit devices [nasal/oral trumpet] with oxygen supplementation in all patients. Unlike general anesthesia, pre-operative patient ASA status, higher MMP or increasing BMI does not bear relation with likelihood of patients desaturating during ERCP. In presence of vigilant apnea monitoring and careful dose titration of maintenance anesthetics with airway conduits, general anesthesia, emergency intubations, and procedure interruptions can be avoided