Training Requirements in Point-of-Care Ultrasonography of the Upper Airway: A Feasibility Study.

OBJECTIVES: Point-of-care ultrasonography of the upper airway can be a useful supplement to conventional pre-anesthetic clinical evaluations. However, the reliability of such examinations is highly operator-dependent and proper training in sonoanatomy and ultrasound operational skills are required. The objective of this study aims to assess the minimum training requirements for applying a predefined upper airway scanning protocol in healthy volunteers by anesthesia trainees. METHODS: Twenty-two healthy volunteer members of the Operating Room staff participated in the study. A predefined scanning protocol that included the identification of specific structures (hyoid bone, vocal cords, thyrohyoid membrane/epiglottis/pre-epiglottic space, cricothyroid membrane, and thyroid gland), as well as the performance of specific measurements (distance from the hyoid bone to skin, anterior commissure to skin, epiglottis to skin, and thyroid isthmus to skin) was taught in a single-day training course. The trainees' competence was assessed after multiple scanning repetitions performed over a week. Mixed effects regression models were applied for the trainee-instructor differences in all ultrasound measurements. RESULTS: Cricothyroid membrane visualization had the lowest success rate (88%). Trainee-instructor differences were statistically significant for hyoid bone-to-skin (P < .001) and epiglottis-to-skin distances (P = .016). Measurement of the distance from the epiglottis to the skin required more scanning repetitions to achieve minimum deviance compared with other measurements. Ten or fewer scanning repetitions were sufficient to achieve minimum deviance for all four measurements. CONCLUSIONS: At least 10 scanning repetitions of a pre-defined upper airway scanning protocol can be used as the minimum standard for training.

Long-term outcomes of thoracic endovascular aortic repair for the treatment of descending thoracic aortic aneurysms: a systematic review and meta-analysis.

INTRODUCTION: We undertook a systematic review of the currently published literature on TEVAR for DTAAs and we combined the eligible studies into a meta-analysis with the intention of evaluating the efficacy and the long-term durability of this treatment option. EVIDENCE ACQUISITION: A systematic search of the literature from January 2015 up to December 2022 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. For events during follow up we calculated the incidence rates (IRs) with 95% confidence intervals (95% CIs) per 100 patient-years (p-ys) as the number of patients with outcome events occurring during the specific time period divided by the total number of p-ys. EVIDENCE SYNTHESIS: A total of 4127 study titles were identified by the initial search strategy, of which 12 were considered eligible for inclusion in the meta-analysis. A Total of 1976 patients (62% male) were identified among the eligible studies. One-year survival was 90.1% (95% CI 86.3% to 93.0%), 3-year survival was estimated at 80.5% (95% CI 69.2% to 88.4%) and the 5-year survival was estimated at 73.2% (95%CI 64.3% to 80.5%) with significant heterogeneity among studies regarding these outcomes. Regarding freedom from reintervention analysis for 1 year and 5 years was 96.5% (95% CI 94.5% to 97.8%) and 85.4% (95% CI 56.7% to 96.3%) respectively. The pooled late complications IR per 100 p-ys was 55.0 (95% CI 39.1 to 70.9), whereas the pooled IR for late reinterventions per 100 p-ys was 21.2 (95% CI 26.0 to 87.5). Late type I endoleak was reported with a pooled IR of 26.7 per 100 p-ys (95% CI 19.8 to 33.6) and late type III endoleak with a pooled IR of 7.6 per 100 p-ys (95% CI 5.5 to 9.7). CONCLUSIONS: TEVAR presents a safe and feasible solution for the treatment of DTAA with sustained long-term effectivity. Current evidence supports a satisfactory 5-year survival with low rates of reinterventions.

GReek Anaesthesiologists's Burnout EPidemic within the COVID-19 pandemic (GRABEP study); a multicenter study on burn out prevalence among Greek anesthesiologists and association with personality traits.

COVID-19 pandemic resulted in an unprecedented crisis with extreme distress for the frontline physicians and increased risk of developing burnout. Burnout has a negative impact on patients and physicians, posing a substantial risk in patient safety, quality of care and physicians' overall wellbeing. We evaluated burnout prevalence and possible predisposing factors among anaesthesiologists in the COVID-19 referral university/tertiary hospitals in Greece. In this multicenter, cross-sectional study we have included anaesthesiologists, involved in the care of patients with COVID-19, during the fourth peak of the pandemic (11/2021), in the 7 referral hospitals in Greece. The validated Maslach Burnout Inventory (MBI) and Eysenck Personality Questionnaire (EPQ) were used. The response rate was 98% (116/118). More than half of the respondents were females (67.83%, median age 46 years). The overall Cronbach's alpha for MBI and EPQ was 0.894 and 0.877, respectively. The majority (67.24%) of anaesthesiologists were assessed as "high risk for burnout" and 21.55% were diagnosed with burnout syndrome. Almost half participants experienced high levels of all three dimensions of burnout; high emotional exhaustion (46.09%), high depersonalization (49.57%) and high levels of low personal accomplishment (43.49%). Multivariate logistic analysis revealed that neuroticism was an independent factor predicting "high risk for burnout" as well as burnout syndrome, whereas the "Lie scale" of EPQ exhibited a protective effect against burnout. Burnout prevalence in Greek anaesthesiologists working in COVID-19 referral hospitals during the fourth peak of the pandemic was high. Neuroticism was predictive of both "high risk for burnout" and "burnout syndrome".

Systemic Thrombolysis for Treatment of Acute Life-threatening Pulmonary Embolism During Cesarean Section Followed by Post-partum Rescue Hysterectomy: A Case Report and Review of the Literature.

BACKGROUND/AIM: Acute pulmonary embolism during cesarean section is extremely rare and only a limited number of cases have been reported in literature. The aim of this study was to report a case of acute high risk pulmonary embolism during elective cesarean section treated with systemic thrombolysis and discuss the multidisciplinary management in both early recognition and prompt treatment. CASE REPORT: A 39-year-old, G5P2, ASA II parturient presented for repeat cesarean section under general anesthesia. A sudden drop in end-tidal CO2 after placenta delivery combined with significant hemodynamic instability after an uneventful intraoperative course was strongly indicative of pulmonary embolism. Urgent transthoracic ultrasound revealed a sizable thrombus in the inferior vena cava and the right atrium. Thrombolysis was carried out intraoperatively using recombinant tissue plasminogen activator, which was administered under continuous US monitoring until thrombus resolution. This resulted in significant bleeding that was treated in a stepwise manner beginning with implementation of massive transfusion protocol, Bakri balloon placement, and rescue hysterectomy several hours after the event. Follow-up was uneventful and she was discharged on the 12th postoperative day. CONCLUSION: Though pregnancy is one of the major risk factors of the development of venous thromboembolism, acute intraoperative pulmonary embolism is extremely rare. Specific guidelines for the management of such cases are difficult to issue due to the paucity of relevant data. Thus, an individualized approach by a multidisciplinary team for diagnosis and intervention is mandated.

The Effect of Cell Salvage on Bleeding and Transfusion Needs in Cardiac Surgery.

Introduction: Cell salvaging is well established in the blood management of cardiac patients, but there remain some concerns about its effects on perioperative bleeding and transfusion variables. This randomized controlled study investigated the potential effects of the centrifuged end-product on bleeding, transfusion rates, and other transfusion-related variables in adult cardiac surgery patients submitted to extracorporeal circulation. Materials and Methods: Patients were randomly chosen to receive (cell-salvage group, 99 patients) or not to receive (control group, 110 patients) the centrifuged product of a cell salvage apparatus. Bleeding and transfusion rates according to the universal definition of perioperative bleeding (UDPB) classification, postoperative hemoglobin, coagulation, and oxygenation indices were recorded and compared between the groups. Results: Both groups had almost identical bleeding and transfusion rates (median value: 2 units of red blood cells (RBC) and no units of fresh frozen plasma (FFP) and platelets (PLT) for both groups, p > 0.05). Patients in the cell-salvage group presented slightly higher hemoglobin concentrations (10.6 ± 1.1 vs. 10.1 ± 1.7 g/dL, p < 0.05, respectively) and a tendency towards better oxygenation indices (PaO2/FiO2: 241 ± 94 vs. 207 ± 84, p=0.013) in the postoperative period albeit with a tendency for prolongation of prothrombin time (INR: 1.31 ± 0.18 vs. 1.26 ± 0.12, p=0.008). Conclusion: Within the study's constraints, the perioperative use of the cell salvage concentrate does not seem to affect bleeding or transfusion variables, although it could probably ameliorate postoperative oxygenation in adult cardiac surgery patients. A tendency to promote coagulation disturbances was detected.

Perioperative Coagulation Profile in Major Liver Resection for Cancer: A Prospective Observational Study.

Hepatectomy-induced coagulation disturbances have been well studied over the past decade. Cumulative evidence supports the superiority of global coagulation analysis compared with conventional coagulation tests (i.e., prothrombin time or activated partial thromboplastin time) for clinical decision making. Cancer, however, represents an acquired prothrombotic state and liver resection for cancer deserves a more thorough investigation. This prospective observational study was conducted to assess the perioperative coagulation status of patients undergoing major hepatectomies for primary or metastatic hepatic malignancy. Patients were followed up to the 10th post-operative day by serial measurements of conventional coagulation tests, plasma levels of coagulation factors, and thrombin generation assay parameters. An abnormal coagulation profile was detected at presentation and included elevated FVIII levels, decreased levels of antithrombin, and lag time prolongation in thrombin generation. Serial hematological data demonstrated increased Von Willebrand factor, FVIII, D-dimer, fibrinogen and decreased levels of natural anticoagulant proteins in the early post-operative period predisposing to a hyper-coagulable state. The ratio of the anticoagulant protein C to the procoagulant FVIII was low at baseline and further declined post-operatively, indicating a prothrombotic state. Though no bleeding complications were reported, one patient experienced pulmonary embolism while under thromboprophylaxis. Overall, patients with hepatic carcinoma presenting for elective major hepatectomy may have baseline malignancy-associated coagulation disturbances, aggravating the hyper-coagulable state documented in the early post-operative period.

Anesthetic Management of A Patient with Charcot-Marie-Tooth Disease for 2-stage Revision of Total Knee Replacement.

Charcot-Marie-Tooth disease is characterised by hereditary motor and sensory neuropathy. Its anaesthetic management is challenging owing to the unpredictable response observed in patients, especially to non-depolarising neuromuscular blocking drugs, and the risk of malignant hyperthermia and cardiorespiratory complications. A 66-year-old woman underwent anaesthesia for 2 different surgical procedures, a 2-stage revision of total knee replacement over a 4-month period. She presented with severe anatomic disorders, accompanied by severe motor and sensory impairment. An anaesthetic plan without neuromuscular blocking drugs or volatile anaesthetics, using a clean ventilator, with dantrolene available, was successfully used both times. There were no complications during the administration of general anaesthesia or postoperatively at the post-anaesthesia care unit, and the patient did not complain of pain at any time. General anaesthesia with a careful selection of anaesthetic drugs proved to be a safe option for the management of a patient with Charcot-Marie-Tooth disease.

Pulsed Radiofrequency of the Occipital Nerves: Results of a Standardized Protocol on Chronic Headache Management.

BACKGROUND: Pulsed radiofrequency (PRF) of the occipital nerves has neuromodulative properties and is used for chronic pain management. However, its role in various types of chronic headaches has not been adequately investigated so far. OBJECTIVES: Τhis was an observational, open-label, prospective study aiming to assess the efficacy of PRF of occipital nerves on various types of chronic headache management. METHODS: Patients with chronic headaches followed up at the pain management unit were scheduled for PRF of both occipital nerves after a positive diagnostic nerve block. PRF was applied following a standardized protocol at 42°C, and the number of headaches per month was assessed as a primary outcome at baseline (before treatment), as well as after 1, 3, and 6 months. Pain intensity during headache crises was recorded using the Numeric Rating Scale (NRS, 0 - 10). RESULTS: Fifty-seven patients suffering from chronic migraines, cluster headaches, tension-type headaches, and occipital neuralgia were studied. PRF significantly improved the number of headache episodes per month, as well as the pain intensity of the crises. The median number of headache episodes per month was significantly reduced in patients with migraine, from 14.5 to 4 after 1 month, and to 6.5 after 6 months. The same was seen for patients with clusters, who were also improved. A statistically significant reduction in NRS values over time was seen for all types of headaches. CONCLUSIONS: PRF of the occipital nerves can lead to a reduction of the number of headache episodes per month, improving the intensity of pain during each episode.

Patient-controlled epidural analgesia with and without basal infusion using ropivacaine 0.15% and fentanyl 2γ/mL for labor analgesia: a prospective comparative randomized trial.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is a common practice for labor pain relief. This study aimed to compare two different settings of a PCEA device using the same solution to obtain labor analgesia. METHODS: Fifty-two parturients were randomly allocated to receive ropivacaine 0.15% and fentanyl 2 γ/mL via a PCEA device either as a background infusion of 5 mL/h plus 5 mL demand bolus doses with 10-minute lockout (group B/D, N.=26) or as only demand bolus doses of 5 mL with 10-minute lockout (group D, N.=26). The primary outcome was the total volume of local anesthetic administrated during labor; secondary outcomes included the analgesic efficacy and the effects on maternal and neonatal outcomes. RESULTS: No statistical difference was observed between the groups concerning demographic characteristics, duration of first and second stages of labor, administration of oxytocin and ephedrine, rescue doses, instrumental delivery, Bromage Scale, maternal side effects and satisfaction, neonatal Apgar scores and pH. The total volume of local anesthetic was greater in group B/D compared to group D (P=0.015). A statistically significant difference was detected in VAS scores only at the end of the second stage (P=0.036) and at 60 minutes from the test dose administration (P=0.022) and with group D exhibited higher pain scores than group B/D. The incidence of breakthrough pain (VAS>4) was higher in group D compared with group B/D (P=0.035). CONCLUSIONS: The addition of background infusion plus PCEA demand bolus doses increased local anesthetic consumption and reduced breakthrough pain without affecting maternal satisfaction and neonatal outcomes.

Residual neuromuscular blockade in a real life clinical setting: correlation with sugammadex or neostigmine administration.

BACKGROUND: The aim of this study was to identify the frequency of residual neuromuscular blockade (RNMB) in the postanesthesia care unit (PACU) of a tertiary university hospital in Greece, and its correlation with reversal agents. The influence of other perioperative factors was assessed secondarily. METHODS: Patients >18 years old, undergoing surgery with general anesthesia were prospectively studied during a 6-month period. Immediately after arrival at the PACU, the train-of-four ratio (TOF) was assessed by independent investigators, using accelerometry 3 consecutive times, and the mean value was calculated. When TOF was <0.9, RNMB was diagnosed and further interventions were decided. All perioperative data, including history of patients, anesthetic drugs used and surgical details, were recorded from the patients' files. RESULTS: Five hundred twenty patients were studied; 90.4% received rocuronium, 9.2% cis-atracurium, and 0.4% succinylcholine. The prevalence of RNMB was 10.8%. A significant difference (P=0.0006) was detected between patients who received neostigmine versus sugammadex, with the latter showing higher TOF values postoperatively, although the actual incidence of RNMB did not differ between the two groups. Patients with coexisting diseases received sugammadex more frequently (P<0.001), while women, and patients ASA>III were more likely to exhibit RNMB (P=0.02 and P=0.05 respectively). CONCLUSIONS: The frequency of RNMB was 10.8%. Patients who received sugammadex presented with higher TOF values at the PACU, although no difference in RNMB was detected compared to neostigmine. Female gender and the presence of comorbidities increased the possibility to exhibit RNMB at the PACU.

The effect of 0.5 L 6% hydroxyethyl starch 130/0.42 versus 1 L Ringer's lactate preload on the hemodynamic status of parturients undergoing spinal anesthesia for elective cesarean delivery using arterial pulse contour analysis.

PURPOSE: Fluid loading attenuates the hypotensive response to spinal anesthesia (SA). This study aimed to compare the preload efficacy of 0.5 L hydroxyethyl starch (HES) versus 1 L Ringer's lactate (R/L) in the prevention of hypotension after SA for elective cesarean delivery (CD). Assessment of maternal hemodynamic variables using FloTrac/Vigileo™ and neonatal outcome constituted secondary outcomes. METHODS: Thirty-two ASA I/II parturients scheduled for elective CD were preloaded with either 1 L R/L (Group R/L, n = 16) or 0.5 L HES 6% 130/0.42 (Group T, n = 16) approximately 25 min before SA. Hypotension, defined as a 20% decrease of systolic arterial pressure (SAP) from baseline or SAP <100 mmHg, was treated with vasopressors according to a predetermined algorithm. The overall duration of hypotensive episodes and the total amount of vasopressors administered determined the severity of the hemodynamic instability. RESULTS: The incidence of hypotension was 73.3% in Group R/L and 46.7% in Group T. HES compared to R/L preload was associated with a shorter overall duration of hypotensive episodes (p < 0.001), a significantly less usage of ephedrine and phenylephrine (p = 0.015 and p = 0.029, respectively) and a greater impact, although not statistically significant, on cardiac index (CI) and stroke volume index (SVI). Although no statistical difference was detected between groups over time, there was a significant drop in CI, SVI and SAP within groups (p < 0.001) up to 14 min after SA. No difference was recorded in neonatal outcome. CONCLUSIONS: Preloading with 0.5 L HES 130/0.42 produced more stable hemodynamics compared to 1 L R/L solution in obstetric patients.

Association of gender, ABCA1 gene polymorphisms and lipid profile in Greek young nurses.

OBJECTIVE: One of the important proteins involved in lipid metabolism is the ATP-binding cassette transporter A1 (ABCA1) encoding by ABCA1 gene. In this study we evaluated the single nucleotide polymorphisms (SNPs) of ABCA1 gene. We analyzed SNPs in chromosome 9 such as rs2230806 (R219K) in the position 107620867, rs2230808 (R1587K) in the position 106602625 and rs4149313 (I883M) in the position 106626574 according to gender and lipid profile of Greek nurses. METHODS: The study population consisted of 447 (87 men) unrelated nurses who were genotyped for ABCA1 gene polymorphisms. Additionally, lipid profile [total cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol (LDL-C) and apolipoprotein A1] was evaluated. RESULTS: The distribution of all three studied ABCA1 gene polymorphisms did not differ according to gender. However, only R219K genotype distribution bared borderline statistical significance (p = 0.08) between the two studied groups. Moreover, allele frequencies of R219K, R1587K and I88M polymorphisms did not differ according to gender. In general, blood lipid levels did not seem to vary according to ABCA1 gene polymorphisms, when testing all subjects or when testing only men or only women. However, a significant difference of LDL-C distribution was detected in all subjects according to R1587K genotype, indicating lower LDL-C levels with KK polymorphism (p = 0.0025). The above difference was solely detected on female population (p = 0.0053). CONCLUSIONS: The ABCA1 gene polymorphisms frequency, distribution and lipid profile did not differ according to gender. However, in the female population the KK genotype of R1587K gene indicated lower LDL-C levels. Further studies, involving a higher number of individuals, are required to clarify genes and gender contribution.

CYP8A1 gene polymorphisms and left main coronary artery disease.

BACKGROUND: Left main (LM) disease is rare but the most hazardous phenotype of coronary artery disease (CAD). Thus, early detection of participants at high risk of developing left main coronary heart disease (LM-CAD) is crucial. The aim of this study was to identify gene polymorphisms which could distinguish participants who are at high risk of developing LM-CAD. Such a candidate can be the prostaglandin I(2) or prostacyclin (PGI(2)) gene. METHODS: The DNA of 254 participants (151 participants with angiographically documented LM-CAD and 103 healthy controls) was analyzed for the frequency of C1117A polymorphism in the gene coding CYP8A1. RESULTS: The genotype distribution was different between the LM-CAD and the control group. Particularly, the CC genotype of CYP8A1 was commoner in the LM-CAD than in the healthy group (P < .001). Allele frequencies were also differently distributed between the 2 groups. C allele frequency was higher in LM-CAD group (P = .016). CONCLUSIONS: The CC genotype of C1117A polymorphism is associated with higher risk of LM-CAD, which prospectively may have potential importance in screening high-risk populations. However, further investigations in larger populations are required to confirm these findings.

The role of common variants of the cholesteryl ester transfer protein gene in left main coronary artery disease.

BACKGROUND: The cholesteryl ester transfer protein (CETP) has a central role in the lipid metabolism and therefore may alter the susceptibility to atherosclerosis. METHODS: The DNA of 471 subjects [133 subjects with angiographically documented left main coronary artery disease (LMCAD), 241 subjects with more peripheral coronary artery disease (MPCAD) and 97 subjects self reported healthy (Controls)] was analyzed for the frequency of TaqIB and I405V polymorphisms in the gene coding CETP. RESULTS: There is no significant difference in CETP allele frequency or genotype distribution among LMCAD and MPCAD patients although there is statistical difference between LMCAD and Controls (p = 0.001). Specifically, patients with LMCAD and B1B1 genotype of TaqIB polymorphism were more frequent present compared to Controls (33.8% vs 22.9%, respectively). The frequency of B2B2 genotype was 3 times lower in the LMCAD group compared to Controls (10.5% vs 30.2%, respectively). In the LMCAD group the frequency of B1 allele compared to Controls was higher (62% vs 46%, respectively, p = 0.001). The relationship between TaqIB gene polymorphism and the LMCAD was independent of lipid profile, with the exception of apolipoprotein A. CONCLUSIONS: These findings indicate that the TaqIB polymorphism may have potential importance in screening individuals at high risk for developing CAD. However, this polymorphism cannot distinguish between LMCAD and MPCAD. Further prospective investigations in larger populations are required to confirm these findings.

ATP-binding cassette transporter A1 gene polymorphisms and serum lipid levels in young Greek nurses.

OBJECTIVE: The ATP-binding cassette transporter A1 (ABCA1) is essential protein involved in lipid metabolism. The present study was undertaken to detect the possible association of polymorphisms in the ABCA1 gene [rs2230806 (R219K) and rs2230808 (R1587K)] and lipid profile in Greek young nurses. METHODS: The study population consisted of 308 unrelated nurses who were genotyped and the ABCA1 polymorphisms were detected. Additionally, lipid profile [total cholesterol (TC), triglycerides (TGs), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and apolipoprotein (apo) A] was evaluated. RESULTS: There was no difference in the genotypic and allelic frequencies of the R219K polymorphism according to lipid profile. The R1587K genotypes differed significantly according to TC, LDL-C and TGs concentration (p = 0.023, p = 0.014 and p = 0.047, respectively). Particularly, significant difference in TC, LDL-C and TGs concentration was detected between RK and RR genotypes (p = 0.006, p = 0.004, p = 0.014, respectively). Women with RK genotype compared to RR genotype had higher concentration of TGs (134.25 mg/dl vs 108.89 mg/dl, p = 0.014, respectively), total cholesterol (207.41 mg/dl vs 187.69 mg/dl, p = 0.006, respectively), and LDL-C (110.6 mg/dl vs 96.9 mg/dl, p = 0.004, respectively). CONCLUSIONS: These findings suggest that the R1587K polymorphism of ABCA1 gene was associated with lipid profile of Greek nurses. Women with RK genotype had higher TGs, total and LDL-C concentration compared to RR genotype. These observations may be significant in assessing the risk of CAD since a 1% change in LDL-C is associated with a 1% change of cardiovascular events. Also, TGs concentration were documented to play a significant role in women. However, this needs to be confirmed by larger studies.

Flumazenil expedites recovery from sevoflurane/remifentanil anaesthesia when administered to healthy unpremedicated patients.

BACKGROUND AND OBJECTIVE: To investigate the hypothesis that 0.3 mg flumazenil administered to healthy unpremedicated patients at the end of deep surgical sevoflurane/remifentanil anaesthesia would expedite recovery. Flumazenil, an imidazobenzodiazepine derivative, antagonizes the hypnotic/sedative effects of benzodiazepines on γ-aminobutyric acid receptors. However, endogenous benzodiazepine ligands (endozepines) were isolated in mammalian tissues of individuals who had not received benzodiazepines. METHODS: Twenty-four healthy unpremedicated patients, scheduled to undergo elective surgery requiring general anaesthesia, were randomly allocated to receive either a single dose of 0.3 mg flumazenil (n = 14) or placebo (n = 10) intravenously at the end of the surgical procedure just before the discontinuation of the volatile anaesthetic. After study drug administration, the authors compared various recovery parameters in the flumazenil and control groups. RESULTS: Median time to spontaneous respiration, eye opening on verbal command, extubation and time to date of birth recollection was significantly shorter in the flumazenil group than in the control group [2.5 min (2.0-3.0) vs. 7.0 min (6.8-8.3), 3.4 min (3.0-4.0) vs. 8.1 min (6.9-10.2), 4.0 min (3.0-5.0) vs. 9.0 min (7.0-10.8) and 4.7 min (4.0-5.0) vs. 10.3 min (8.0-12.0), respectively]. CONCLUSION: Administration of a single dose of 0.3 mg flumazenil to healthy unpremedicated patients at the end of sevoflurane/remifentanil anaesthesia results in earlier emergence from anaesthesia and significantly expedites recovery. This could redefine the role of flumazenil in general anaesthesia, implicating endozepine-dependent mechanisms.