Effect of a balanced anaesthetic technique using desflurane and remifentanil on surgical conditions during microscopic and endoscopic sinus surgery.

OBJECTIVES: Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. Several drug combinations are suitable to provide deep and predictable level of anaesthesia combined with an exact control of intraoperative blood pressure. However, only little is known about the relative importance of the level of hypnosis on the one hand and analgesia on the other hand. STUDY DESIGN: Prospective, randomized, patient and observer-blinded study. METHODS: All 100 consecutive patients received a balanced anaesthesia technique using desflurane and remifentanil. Anaesthesia was desflurane-accentuated with remifentanil-supplementation (DARS-group: 1 MAC desflurane; remifentanil: 0.2 microg x kg(-1) x min(-1)) or remifentanil-accentuated with desflurane-supplementation (RADS-group: desflurane: 0.5 MAC; remifentanil: 0.4 microg x kg(-1) x min(-1)). Administration of anaesthetics performed to maintain a sufficient level of anaesthesia and to keep mean arterial pressure between 60 and 70 mmHg (8-9.3 hPa). The attending ENT-surgeons were unaware of the type of anaesthesia and rated general surgical conditions and the dryness of the operating site on a visual analogue scale (0-10 cm) and on a verbal rating scale immediately after surgery. RESULTS: Blood pressure and heart rate was not different between the two groups. Dryness of the operating site was rated significantly better (p < 0.0001) in the DARS-group (median; 25th/75th-percentile: 2.0; 1.5-3.5 vs. RADS-group: 2.6; 2.0-4.0) but the overall rating of the surgical conditions did not differ between the groups (DARS-group: 2.0; 1.0-2.4 vs. RADS-group: 2.2; 1.5-3.2). Immediate postoperative recovery times were increased in the RADS-group, but there was no difference with respect to fit-for-discharge criteria one hour after surgery. CONCLUSION: Balanced anaesthesia using high dose of desflurane offers small but statistically significant advantages with respect to dryness of the operating site compared to an opioid-accentuated anaesthesia technique. However, since the opioid-accentuated anaesthetic group had a faster immediate recovery both techniques are equally effective for microscopic and endoscopic sinus surgery.

[Does fentanyl or midazolam improve patient's comfort and cooperation when given for regional catheter placement? A randomized, controlled and double-blind trial]. / Verbessern intravenöses Fentanyl oder Midazolam vor Durchführung einer peripheren Regionalanästhesie Patientenakzeptanz und Kooperativität bei der Katheteranlage? Eine randomisierte, placebokontrollierte und doppelblinde Untersuchung.

BACKGROUND: The procedure of placing a catheter for continuous regional anaesthesia is often associated with fear and pain in the patient. Thus, we evaluated the use of midazolam and fentanyl to improve patient's comfort and cooperation. METHODS: After an oral dose of 20 mg clorazepate, 174 patients receiving peripheral nerve catheters for regional anaesthesia where randomized into 3 groups to receive either intravenous placebo, 3 mg midazolam or 0.1 mg fentanyl immediately before catheter placement in a double-blind manner. Stepwise regression analysis was used to identify factors associated with patient's assessment of subjective discomfort (measured using a VAS 0-10) during the procedure. Amnesia was evaluated 24 h later. The anaesthetist rated patient's cooperation during catheter placement. RESULTS: Female sex and longer duration of catheter placement had significant negative impact on patient's comfort, whereas fentanyl showed an improvement. Age, body mass index, midazolam and the type of catheter had no influence. The following day 27% of the midazolam group, 6% of the placebo group and 9% of the fentanyl patients did not remember catheter placement. Patient's cooperation was poor in 26% of the midazolam patients but only in 9% of the placebo and 3% of the patients receiving fentanyl. Of the placebo patients 18.4% had to be supplemented with fentanyl because they found the procedure of catheter placement unbearable. No side effects occurred in either group. CONCLUSION: As patient's comfort and cooperation were significantly improved by fentanyl, we recommend fentanyl to facilitate catheter placement for regional anaesthesia.