Sedation in patients above 60 years of age undergoing urological surgery under spinal anesthesia: comparison of propofol and midazolam infusions.

CONTEXT: Propofol and midazolam are commonly used sedatives during regional anesthesia in adults. Smaller doses of these drugs are required in older age due to altered pharmacokinetics and pharmacodynamics. AIMS: To study the sedation, side-effects and the costs involved with smaller doses of propofol and midazolam in patients aged above 60 years during spinal anesthesia. SETTINGS AND DESIGN: A randomized single-blind study was conducted in 60 ASA I-II patients aged > or = 60 years undergoing urological surgery under spinal anesthesia. MATERIALS AND METHODS: Sedation was administered after spinal anesthesia using propofol (bolus 0.4 mg.kg -1; infusion 3 mg/kg/hr) or midazolam (bolus 0.02 mg/kg; infusion 0.06 mg.kg -1.h -1) and titrated to achieve a sedation score of 3 on the modified Observer's Assessment of Alertness/Sedation Scale. Perioperative sedation, hemodynamics and respiratory events were monitored. STATISTICAL ANALYSIS: The analysis for parametric data was done using Student's unpaired t test and the incidence data using Chi-square test. RESULTS: The onset (13.0+/-4.2 vs. 18.8+/-4.2 min, P < 0.001) and offset (8.9+/-2.8 vs. 12.5+/-3.5 min, P < 0.001) of sedation were faster and the duration of adequate sedation longer (44.7+/-12.5 vs. 29.8+/-12.9% of total infusion time, P < 0.001) with propofol than midazolam. More patients receiving propofol compared to midazolam had hypotension (16 [50%] vs.4 [14.3%], P= 0.003). Airway obstruction occurred frequently in both the groups. Sedation was significantly more expensive with propofol than midazolam (US$ 9.83 +/- 2.80 vs. US$ 0.33 +/- 0.06, P 0.001). CONCLUSIONS: Propofol provided better titration and adequacy of sedation than midazolam in patients above 60 years of age, but caused hypotension. Lighter sedation is recommended in this age group.

Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant.

BACKGROUND: Tracheal intubation in children can be achieved by deep inhalational anaesthesia or an intravenous anaesthetic and a muscle relaxant, suxamethonium being widely used despite several side-effects. Studies have shown that oral intubation can be facilitated safely and effectively in children after induction of anaesthesia with propofol and alfentanil without a muscle relaxant. Remifentanil is a new, ultra-short acting, selective mu-receptor agonist that is 20-30 times more potent than alfentanil. This clinical study was designed to assess whether combination of propofol and remifentanil could be used without a muscle relaxant to facilitate tracheal intubation in children. METHODS: Forty children (5-10 years) admitted for adenotonsillectomy were randomly allocated to one of two groups to receive remifentanil 2 microg.kg(-1) (Gp I) or remifentanil 3 microg.kg(-1) (Gp II) before the induction of anaesthesia with i.v. propofol 3 mg.kg(-1). No neuromuscular blocking agent was administered. Intubating conditions were assessed using a four-point scoring system based on ease of laryngoscopy, jaw relaxation, position of vocal cords, degree of coughing and limb movement. Mean arterial pressure (MAP) and heart rate (HR) measured noninvasively before induction of anaesthesia to 5 min after intubation (seven time points). RESULTS: Tracheal intubation was successful in all patients without requiring neuromuscular blocking agent. Intubating conditions were clinically acceptable in 10 of 20 patients (50%) in Gp I compared with 18 of 20 patients (90%) in Gp II (P < 0.05). MAP and HR decreased in both groups after induction of anaesthesia (P < 0.01). Both HR and MAP were significantly lower in Gp II compared with Gp I after tracheal intubation (P < 0.01). No patient in the present study developed bradycardia or hypotension. CONCLUSIONS: We conclude that remifentanil (3 microg.kg(-1)), administered before propofol (3 mg.kg(-1)) provides acceptable tracheal intubating conditions in children, and completely inhibited the increase in HR and MAP associated with intubation.

Fibreoptic assessment of post intubation laryngotracheal injuries.

The use of endotracheal intubation for respiratory support of critically ill patients has become a standard life saving form of therapy. Most complications of intubation become apparent only after extubation which may manifest in the early or late post extubation period. This study was undertaken to demonstrate the occurrence and extent of laryngotracheal injuries in intubated patients by performing flexible fibreoptic bronchoscopy at varying intervals following extubation. It was found that initial laryngoscopy findings were more pronounced in patients intubated for upto twelve days. Furthermore, it was also observed that the initial laryngeal pathology seen on fibreoptic laryngoscopy was not an accurate predictor for the development of adverse post extubation sequelae. Maxillary sinusitis developed significantly in patients intubated nasally. Routine flexible fibreoptic examination of the larynx following extubation is recommended for early detection of granulomas, synechia of vocal cords and vocal cord immobility to prevent troublesome sequelae.