Comparison of adenosine and remifentanil infusions as adjuvants to desflurane anesthesia.

BACKGROUND: Because adenosine has been alleged to produce both anesthetic and analgesic sparing effects, a randomized, double-blinded study was designed to compare the perioperative effects of adenosine and remifentanil when administered as intravenous adjuvants during general anesthesia for major gynecologic procedures. METHODS: Thirty-two women were assigned randomly to one of two drug treatment groups. After premedication with 0.04 mg/kg intravenous midazolam, anesthesia was induced with 2 micro/kg intravenous fentanyl, 1.5 mg/kg intravenous propofol, and 0.6 mg/kg intravenous rocuronium, and maintained with desflurane, 2%, and nitrous oxide, 65%, in oxygen. Before skin incision, an infusion of either remifentanil (0.02 microg x kg(-1) x min(-1)) or adenosine (25 microg x kg(-1) x min(-1)) was started and subsequently titrated to maintain systolic blood pressure, heart rate, or both within 10-15% of the preincision values. RESULTS: Adenosine and remifentanil infusions were effective anesthetic adjuvants during lower abdominal surgery. Use of adenosine (mean +/- SEM, 166+/-17 microg x kg(-1) x min(-1)) was associated with a significantly greater decrease in systolic blood pressure and higher heart rate values compared with remifentanil (mean +/- SEM, 0.2+/-0.03 microg kg(-1) x min(-1)). Total postoperative opioid analgesic use was 45% and 27% lower in the adenosine group at 0-2 h and 2-24 h after surgery, respectively. CONCLUSIONS: Adjunctive use of a variable-rate infusion of adenosine during desflurane-nitrous oxide anesthesia was associated with acceptable hemodynamic stability during the intraoperative period. Compared with remifentanil, intraoperative use of adenosine was associated with a decreased requirement for opioid analgesics during the first 24 h after operation.

The cost-effectiveness of methohexital versus propofol for sedation during monitored anesthesia care.

UNLABELLED: We designed this study to test the hypothesis that methohexital is a cost-effective alternative to propofol for sedation during local anesthesia. Sixty consenting women undergoing breast biopsy procedures under local anesthesia were randomly assigned to receive an infusion of either propofol (50 microg x kg(-1) x min(-1)) or methohexital (40 microg x kg(-1) x min(-1)). The sedative infusion rate was titrated to maintain an observer's assessment of alertness/sedation (OAA/S) score of 3 (with 1 = awake/alert to 5 = asleep). Fentanyl 25 microg i.v. was administered as a "rescue" analgesic during the operation. We assessed the level of sedation (OAA/S score), vital signs, time to achieve an OAA/S score of 3 at the onset and a score of 1 after discontinuing the infusion, discharge times, perioperative side effects, and patient satisfaction. The direct cost of methohexital was lower than that of propofol, based on the milligram dosage infused during the operation. The sedative onset (to achieve an OAA/S score of 3) and the recovery (to return to an OAA/S score of 1) times, as well as discharge times, did not differ between the two groups. Patients receiving methohexital had a significantly lower incidence of pain on initial injection compared with those receiving propofol (10% vs 23%). Because the use of methohexital (29.4 +/- 2.7 microg x kg(-1) x min(-1)) for sedation during breast biopsy procedures has a similar efficacy and recovery profile to that of propofol (36.8 +/- 15.9 microg x kg(-1) x min(-1)) and is less costly based on the amount infused, it seems to be a cost-effective alternative to propofol for sedation during local anesthesia. However, when the cost of the drug infused and drug wasted was calculated, there was no difference in the overall drug cost. IMPLICATIONS: When administered to maintain a stable level of sedation during local anesthesia, methohexital is an acceptable alternative to propofol. However, the overall drug costs were similar with the two drugs.

Remifentanil administration during monitored anesthesia care: are intermittent boluses an effective alternative to a continuous infusion?

UNLABELLED: This randomized, double-blind study was designed to evaluate the analgesic effectiveness and respiratory stability of remifentanil when administered as intermittent bolus injections, a variable-rate infusion, or a combination of a constant basal infusion supplemented with intermittent boluses during monitored anesthesia care (MAC). Forty-five patients undergoing extracorporeal shock wave lithotripsy (ESWL) procedures were randomly assigned to one of the three modes of remifentanil administration. All patients received midazolam 2 mg i.v., followed by a propofol infusion at 50 microg x kg(-1) x min(-1). Two minutes before administering a series of test shock waves: Group I received a remifentanil infusion of 0.1 microg x kg(-1) x min(-1), and a saline bolus (5 mL); Group II received a saline infusion and a remifentanil bolus (25 microg in 5 mL); and Group III received a remifentanil infusion of 0.05 microg x kg(-1) x min(-1), and a remifentanil bolus (12.5 microg in 5 mL). The average pain intensity was scored on an 11-point scale, with 0 = no pain to 10 = severe pain. During the ESWL procedure, pain was treated by increasing the study drug infusion rate by 25%-50% and administering 5-mL bolus injections of the study medication in Groups I (saline) and II (remifentanil 25 microg). In Group III, intermittent 5-mL boluses (remifentanil 12.5 microg) were administered as needed. Patients in Groups II and III reported lower pain scores in response to the test shocks. Significantly more remifentanil was administered in Group I (379 +/- 207 microg) than in Group II (201 +/- 136 microg). However, more interventions were required for the treatment of intraoperative pain in the intermittent bolus group (Group II). When remifentanil is administered as the analgesic component of a MAC technique, these data support the use of intermittent bolus doses (12.5-25 microg) alone or in combination with a basal infusion (0.05 microg x kg(-1) x min(-1)) as alternatives to a variable-rate continuous infusion. IMPLICATIONS: In this study, three different modes of remifentanil administration were used during monitored anesthesia care for extracorporeal shock wave lithotripsy procedures. These results suggest that using intermittent bolus injections of remifentanil (25 microg) or a continuous infusion (0.05 microg x kg(-1) x min(-1)) supplemented with intermittent bolus (12.5 microg) injections may be more effective than a variable-rate infusion of remifentanil during propofol sedation.

Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy procedures?

BACKGROUND: Women awaiting needle-guided breast biopsy procedures may experience high anxiety levels. A randomized, double-blind, placebo-controlled study was designed to evaluate the ability of midazolam and diazepam (in a lipid emulsion [Dizac]) to improve patient comfort during needle localization and breast biopsy procedures. METHODS: Ninety women received two consecutive doses of a study medication, one before the mammographic needle localization and a second before entering the operating room. Patients were assigned randomly to receive saline, 2.0 ml intravenously, at the two time points; midazolam, 1.0 mg intravenously and 2.0 mg intravenously; or diazepam emulsion, 2.0 mg intravenously and 5.0 mg intravenously, respectively. Patients assessed their anxiety levels before the needle localization, before entering the operating room, and on arrival in the operating room. Patients completed a questionnaire evaluating their perioperative experience at the time of discharge. RESULTS: Patient satisfaction during needle localization was significantly improved in both benzodiazepine treatment groups (vs. saline). The incidence of moderate-to-severe discomfort during needle localization was lower in the midazolam (20%) and diazepam emulsion (6%) groups compared with the saline group (70%) (P<0.05). The preoperative visual analogue scale anxiety scores were similar in all three groups. In the operating room, however, anxiety scores were 55% and 68% lower after midazolam (21+/-19) and diazepam emulsion (15+/-14) compared with saline (46+/-28). Finally, there was no difference in the time to achieve home-readiness or actual discharge time among the three groups. CONCLUSIONS: Premedication with midazolam or diazepam emulsion improved patients' comfort during needle localization procedures and significantly reduced intraoperative anxiety levels before breast biopsy procedures without prolonging discharge times. Use of diazepam emulsion may be an effective alternative to midazolam in this population.

What is new in monitored anesthesia care?

The use of monitored anesthesia care (MAC) techniques is increasing in popularity because recovery profiles seem to be improved compared with general and regional anesthesia. This article describes the conceptual basis for MAC and reviews the current MAC practices.

Neurobehavioral development of rats exposed to toluene through maternal milk.

Organic solvents have been detected in the milk of workers in the rubber industry exposed during gestation to a mixture of solvents at average concentrations lower than the currently accepted occupational limit of exposure (100 ppm). The objective of the present study was to determine if exposure of rat offspring to toluene during lactation, through maternal milk, would affect the developing brain. Three month old, lactating Wistar rats were injected with toluene (1.2 g/kg, sc, N = 10) daily from lactation day 2 (day of delivery = day 1) to day 21. Controls (N = 9) were injected with the vehicle (corn oil). Offspring (7 pups per liter) were evaluated for neurosomatic development and exploratory behavior before weaning and behavior in the open field. A second group of toluene-treated rats (N = 6) and controls (N = 6) was used to evaluate behavior of the offspring in the open-field on day 35 and performance in a shuttle box in adulthood. Toluene levels in blood and milk after a single 1.2 g/kg sc injection were studied in a third group of rats on lactation day 10. Toluene levels in milk 4 h after a single injection (10.3 +/- 6.2) were 5 times higher than in blood (2.1 +/- 0.8). No effects of treatment on offspring development or on any of the behavioral tests were observed. Sex differences were observed in open-field behavior and performance in the shuttle box. The present results suggest that exposure of pups to high concentrations of toluene through maternal milk does not result in blood levels high enough to affect growth or development.

Neurobehavioral development of rats exposed to toluene through maternal milk

Organic solvents have been detected in the milk of workers in the rubber industry exposed during gestation to a mixture of solvents at average concentrations lower than the currently accepted occupational limit of exposure (100ppm). The objective of the present study was to determine if exposure of rat offspring to toluene during laction, through maternal milk, would affect the developing brain. There month old, lactating Wistar rats were injedted with toluene (1.2 g/Kg, sc, N = 10) daily from laction day 2(day of delivery - day 1) to day 21. Controls (N=9) were injected with the vehicle (c0rn oil). Offspring (7 pups per litter) were evaluated form neurosomatic development and exploratory behavior before weaning and behavior in the open field. A second group of toluene treated ratas (N=6) and controls (N=6) was used to evaluate behavior of the offspring in the open-field on day 35 and performance in a shuttle box in adulthood. Toluene levels in blood and milk after a single 1.2 g/Kg sc injection were studied in a third group of rats on laction day 10. Toluene levels in milk 4 h after a single injection (10.3ñ6.2) were 5 times higher than in blood (2.1ñ0.8). No effects of treatment on offspring development or on any of the behavioral tests were observed. Sex differences were observed in open-field behavior and performance in the shuttle box. The present results suggest that exposure of pups to high concentrations of toluene through maternal milk does not result in blood levels high enough to affect growth or development