Improved haemodynamic stability and cerebral tissue oxygenation after induction of anaesthesia with sufentanil compared to remifentanil: a randomised controlled trial.

BACKGROUND: Balanced anaesthesia with propofol and remifentanil, compared to sufentanil, often decreases mean arterial pressure (MAP), heart rate (HR) and cardiac index (CI), raising concerns on tissue-oxygenation. This distinct haemodynamic suppression might be attenuated by atropine. This double blinded RCT, investigates if induction with propofol-sufentanil results in higher CI and tissue-oxygenation than with propofol-remifentanil and if atropine has more pronounced beneficial effects on CI and tissue-oxygenation in a remifentanil-based anaesthesia. METHODS: In seventy patients scheduled for coronary bypass grafting (CABG), anaesthesia was induced and maintained with propofol target controlled infusion (TCI) with a target effect-site concentration (Cet) of 2.0 µg ml- 1 and either sufentanil (TCI Cet 0.48 ng ml- 1) or remifentanil (TCI Cet 8 ng ml- 1). If HR dropped below 60 bpm, methylatropine (1 mg) was administered intravenously. Relative changes (∆) in MAP, HR, stroke volume (SV), CI and cerebral (SctO2) and peripheral (SptO2) tissue-oxygenation during induction of anaesthesia and after atropine administration were analysed. RESULTS: The sufentanil group compared to the remifentanil group showed significantly less decrease in MAP (∆ = - 23 ± 13 vs. -36 ± 13 mmHg), HR (∆ = - 5 ± 7 vs. -10 ± 10 bpm), SV (∆ = - 23 ± 18 vs. -35 ± 19 ml) and CI (∆ = - 0.8 (- 1.5 to - 0.5) vs. -1.5 (- 2.0 to - 1.1) l min- 1 m- 2), while SctO2 (∆ = 9 ± 5 vs. 6 ± 4%) showed more increase with no difference in ∆SptO2 (∆ = 8 ± 7 vs. 8 ± 8%). Atropine caused higher ∆HR (13 (9 to 19) vs. 10 ± 6 bpm) and ∆CI (0.4 ± 0.4 vs. 0.2 ± 0.3 l min- 1 m- 2) in sufentanil vs. remifentanil-based anaesthesia, with no difference in ∆MAP, ∆SV and ∆SctO2 and ∆SptO2. CONCLUSION: Induction of anaesthesia with propofol and sufentanil results in improved haemodynamic stability and higher SctO2 compared to propofol and remifentanil in patients having CABG. Administration of atropine might be useful to counteract or prevent the haemodynamic suppression associated with these opioids. TRIAL REGISTRATION: Clinicaltrials.gov on June 7, 2013 (trial ID: NCT01871935 ).

Prophylactic atropine administration attenuates the negative haemodynamic effects of induction of anaesthesia with propofol and high-dose remifentanil: A randomised controlled trial.

BACKGROUND: Induction of anaesthesia with propofol and remifentanil often induces unwanted bradycardia and hypotension, raising concerns regarding tissue oxygenation. The electrophysiological cardiac effects of remifentanil can be reversed by atropine. OBJECTIVE: To investigate if prophylactic administration of atropine can attenuate the negative haemodynamic effects of propofol and a high dose of remifentanil during induction of anaesthesia. DESIGN: A double-blind, randomised controlled trial. SETTING: Single-centre, University Medical Center Groningen, The Netherlands. PATIENTS: Sixty euvolaemic patients scheduled for surgery under general anaesthesia. INTERVENTIONS: Anaesthesia was induced and maintained with a target-controlled infusion of propofol with a target effect-site concentration (Ce) of 2.5 µg ml, remifentanil (target-controlled infusion), (Ce 8 ng ml) and cis-atracurium. Methylatropine (500 µg) or 0.9% saline was administered at immediately before induction of anaesthesia. MAIN OUTCOME MEASURES: The changes (Δ) in mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), rate pressure product, cerebral tissue oxygenation and peripheral tissue oxygenation between induction of anaesthesia (T0) and 10 min later (T10). RESULTS: Atropine significantly attenuated the changes in the outcome measures between T0 and T10. Median (inter-quartile range) changes were MAP, Δ = -24 (-40 to -21) vs. Δ = -37 mmHg (-41 to -31) (P = 0.02); HR, Δ = 0 ±â€Š13 vs. -19 ±â€Š11 bpm (P < 0.01); CI, Δ = -0.4 ±â€Š0.7 vs. -0.9 ±â€Š0.6l min m (P < 0.01) and rate pressure product, Δ = -3241 (-5015 to -613) vs. Δ = -5712 mmHg min (-6715 to -3917) (P < 0.01). Cerebral tissue oxygenation and peripheral tissue oxygenation did not change in either group. Maximum HR after atropine was 102 (86 to 116) vs. 85 bpm (76 to 95). CONCLUSION: Administration of atropine, before induction of anaesthesia with propofol and high-dose remifentanil, can significantly reduce the decreases in HR, MAP and CI. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01871922.

Risk factors for postoperative delirium after colorectal operation.

BACKGROUND: A clear understanding of risk factors for postoperative delirium helps in the selection of individuals who might benefit from targeted perioperative intervention. The aim of this study was to identify risk factors for postoperative delirium after colorectal operation for malignancy. METHODS: All consecutive patients who underwent elective or emergency operation because of malignancy of the colon, sigmoid, or rectum between 2009 and 2012 were included in this study. Potential risk factors for postoperative delirium were selected based on previous studies. These candidate factors were analyzed using univariate and multivariate logistic regression analysis. Based on this analysis, odds ratios and 95% confidence intervals were estimated. RESULTS: A total of 436 patients underwent an oncologic resection of the colon, sigmoid, or rectum. Postoperative delirium was observed in 45 (10.3%) patients. Patients with a delirium had a greater in-hospital mortality rate (8.9% vs 3.6%, P = .09), spent more days in the intensive care unit, and had a longer total hospital stay. Variables associated with postoperative delirium in univariate analyses were age, American Society of Anesthesiologists classification, blood transfusion, history of psychiatric disease, history of cerebrovascular disease, postoperative pain management, postoperative renal impairment, C-reactive protein levels, leukocyte blood count, and postoperative complications. Independent risk factors were history of psychiatric disease (odds ratio 8.38, 95% confidence interval: 1.50-46.82), age (odds ratio 4.01, 95% confidence interval; 1.55-10.37), and perioperative blood transfusion (odds ratio 2.37, 95% confidence interval; 1.11-5.06). CONCLUSION: This study shows that postoperative delirium is a frequently encountered complication after colorectal operation. Three independent risk factors for postoperative delirium were identified (history of psychiatric disease, age, and perioperative transfusion) that may contribute to risk estimation in this patient population.