Sedoanalgesia en neonato a base de remifentanyl. En relación con un caso para epiglotopexia / Sedoanalgesia in neonate based on remifentanyl. In relation to a case for epiglottopexy

Resumen: La etapa neonatal comprende del primer día hasta el día 28 de vida. Se caracteriza por ser una etapa de inmadurez anatómica, fisiológica y metabólica. Por estas características del neonato, los fármacos anestésicos impactan de manera importante en su fisiología respiratoria y cardiovascular; además la farmacocinética se ve modificada por esta inmadurez. La laringomalacia es una de las principales causas de estridor en esta etapa, misma que, dependiendo de la severidad puede requerir manejo quirúrgico, siendo una opción la epiglotopexia. Dicho procedimiento requiere analgesia potente y a su vez la posibilidad de mantener la ventilación espontánea para su adecuada evaluación, mismas que pueden ser alcanzadas con el uso de remifentanyl. Presentamos el caso clínico de un neonato de término de 22 días de vida a quien se le administró remifentanyl como base de la sedoanalgesia para realización de epiglotopexia de manera exitosa. Su potencia analgésica, capacidad de mantener el automatismo ventilatorio y la farmacocinética predecible en el neonato, convierten al remifentanyl en un agente ideal para proporcionar adecuada sedoanalgesia para diferentes procedimientos con un perfil de fácil titulación y de recuperación rápida en el neonato.

Abstract. The neonatal stage comprises from the first day of birth until day 28 of life. It is characterized by being a stage of anatomical, physiological and metabolic immaturity. Due to these characteristics of neonates, anesthetic drugs have an important impact on their respiratory and cardiovascular physiology, and their immaturity on pharmacokinetics. Laryngomalacia is one of the main causes of stridor in this stage, which depending on its severity could require surgical treatment, such as an epiglotopexy. This procedure requires potent analgesia and at the same time the possibility of maintaining spontaneous ventilation for its appropriate evaluation. This can be achieved with the use of remifentanyl. We present the clinical case of a term neonate of 22 days of age who we administered Remifentanyl as the basis of sedoanalgesia for the successful completion of an epiglotopexy. Its analgesic potency, ability to maintain ventilatory automatism and predictable pharmacokinetics in the neonate, makes it an ideal agent to provide adecuate sedoanalgesia for different procedures with an easy titration profile and rapid recovery in the neonate.

The anesthesia and hemodynamic effect of etomidate compound remifentanyl in laparoscopic surgery / 中国基层医药

Objective@#To observe the anesthesia and hemodynamic effect of etomidate compound remifentanyl in laparoscopic surgery.@*Methods@#From January 2016 to May 2016, 160 patients with gynecologic laparoscopic surgery in the Second Hospital of Shanxi Medical University were selected and randomly divided into observation group and control group according to the digital table, with 80 cases in each group.The observation group received the etomidate compound remifentanyl anesthesia, while the control group received the propofol compound remifentanyl anesthesia.the The anesthesia effect, awakening time, extubation time, pain relief time and systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) before and after extubation of the two groups were observed and recorded.@*Results@#The excellent and good rate in the observation group was 98.0%, which was significantly higher than 86.0% in the control group (χ2=4.444, P<0.05). The waking time, extubation time, analgesic time in the observation group were shorter than those in the control group, the differences were no statistically significant(t=1.875, 1.631, 1.761, all P>0.05). At tracheal intubation, the SBP, DBP, HR and other indicators between the two groups had no statistically significant differences(t=1.301, 1.093, 1.097, all P>0.05). After induction of anesthesia, the SBP, DBP in the observation group were higher than those in the control group, the differences were statistically significant(t=6.182, 7.388, all P<0.05), but HR between the two groups had no statistically significant difference(t=1.428, P>0.05). After laparoscopic placement and tracheal extubation, the SBP and DBP in the observation group were significantly higher than those in the control group, the differences were statistically significant (t=5.781, 5.028, all P<0.05), and the SBP in the observation group was higher than that in the control group after tracheal extubation(t=1.203, 1.039, all P<0.05).@*Conclusion@#The anesthesia effect of etomidate compound remifentanyl is superior to propofol compound remifentanyl, the hemodynamic parameters of SBP, DBP, HR are more stable during the period of anesthesia, the curative effect is clear.

The anesthesia and hemodynamic effect of etomidate compound remifentanyl in laparoscopic surgery / 中国基层医药

Objective To observe the anesthesia and hemodynamic effect of etomidate compound remifentanyl in laparoscopic surgery.Methods From January 2016 to May 2016,160 patients with gynecologic laparoscopic surgery in the Second Hospital of Shanxi Medical University were selected and randomly divided into observation group and controlgroup according to the digital table,with 80 cases in each group.The observation group received the etomidate compound remifentanyl anesthesia,while the control group received the propofol compound remifentanyl anesthesia .the The anesthesia effect,awakening time,extubation time,pain relief time and systolic blood pressure (SBP),diastolic blood pressure (DBP),heart rate (HR) before and after extubation of the two groups were observed and recorded .Results The excellent and good rate in the observation group was 98.0％,which was significantly higher than 86.0％in the control group (χ2 =4.444,P<0.05).The waking time,extubation time,analgesic time in the observation group were shorter than those in the control group,the differences were no statistically significant (t =1.875,1.631,1.761,all P>0.05).At tracheal intubation,the SBP,DBP,HR and other indicators between the two groups had no statistically significant differences(t=1.301,1.093,1.097,all P>0.05).After induction of anesthesia,the SBP,DBP in the observation group were higher than those in the control group ,the differences were statistically significant (t=6.182,7.388,all P<0.05),but HR between the two groups had no statistically significant difference(t=1.428,P>0.05).After laparoscopic placement and tracheal extubation,the SBP and DBP in the observation group were significantly higher than those in the control group,the differences were statistically significant (t=5.781,5.028,all P<0.05),and the SBP in the observation group was higher than that in the control group after tracheal extubation (t=1.203,1.039,all P<0.05).Conclusion The anesthesia effect of etomidate compound remifentanyl is superior to propofol compound remifentanyl ,the hemodynamic parameters of SBP ,DBP,HR are more stable during the period of anesthesia ,the curative effect is clear .

Pregnancy and delivery in women with esophageal varices due to hepatic vein thrombosis.

AIM: Retrospective analysis of the course of pregnancy, labor and mode of anesthesia in women with portal hypertension and esophageal varices induced by portal vein thrombosis. MATERIAL: From 2000 to 2012 seven pregnant were admitted. None had liver transplantation (Ltx), the varicose have been in the 1st stage. Each of them has been consulted by the obstetrician, transplant surgeon and anesthetist. The patient condition during pregnancy, labor and postpartum period was analyzed. RESULTS: Pregnancy in five cases proceeded physiologically. In one threatening miscarriage was diagnosed and treated with gestagens, two patients had tocolytic. One required variceal banding twice. In three thrombocytopenia worsened, with platelet count <70 g/L (up to 59 g/L). They received platelet transfusion before delivery. In one case, significant hipoproteinemia (4.7 g/L) occurred. In a case, GDM G1 and oligohydramnios were found. All women delivered at term (37-40 Hbd). In all general anesthesia with the use of remifentanil was done. There were no fluctuations in MAP and HR. Incision to delivery time was 2.5 min. Time from opioid administration to birth was <4 min. All children were born in good condition, weight 10-90 percentile. Regional anesthesia is contraindicated in patients with thrombocytopenia. In patients with esophageal varices sudden increase in heart rate and blood pressure can cause hemorrhage. CONCLUSION: Patients with portal hypertension can deliver at term. It is a high-risk pregnancy. In this group it is desirable to shorten the second stage of labor or complete it by c-section under general anesthesia with remifentanyl which allows getting desired analgesia without complications in the newborn. Surveillance of pregnant with portal hypertension must include monitoring of liver function and coagulation disorders.

Retrospective Analysis on Effects of Propofol Isoflurane Composite Anesthesia on Stress Hormones and He-modynamic Changes in Patients with Gynecological Laparoscopic Surgery / 中国药师

Objective:To compare the effects of different anesthesia methods on stress hormones and hemodynamic changes in the patients with gynecological laparoscopic surgery. Methods:Retrospective analysis was carried out. Totally 145 patients with gynecolog-ical laparoscopic surgery were divided into two groups according to the anesthesia method, the control group with 72 cases was given routine remifentanyl propofol intravenous anesthesia, and the observation group with 73 cases was given routine propofol isoflurane com-posite anesthesia. Such hemodynamic indices as SBP, DBP and HR, and plasma NE, E, cort and AT II levels at different time points in the two groups were studied and compared, and adverse drug reactions were also observed in the two groups. Results:The BP and HR at T2 and T3 time point in the two groups were significantly lower than those at T0 time point (P<0. 05), and those in the obser-vation group were lower than those in the control group at the same time point(P<0. 05). The levels of NE, E, cort and ATⅡat T2 and T3 time point in the two groups were significantly higher than those at T0 time point (P<0. 05), while the increase in the observa-tion group was lower than that in the control group (P<0. 05). The incidence of adverse drug reactions (ADR), such as respiratory depression, hypertension, bradycardia and so on, and the total incidence of ADR in the observation group were both lower than those in the control group (P<0. 05). Conclusion:Compared with remifentanyl propofol intravenous anesthesia, propofol isoflurane composite anesthesia can keep the hemodynamic stability more effectively and reduce the stress reaction with fewer ADR and promising safety, which is worthy of wider application in clinics.

Median effective plasma target concentration of propofol administered for lumbar surgery during inhala-tion-intravenous balanced anesthesia when BIS is 50 / 临床麻醉学杂志

Objective To investigate the median effective plasma target concentration of propo-fol (Cp50 )needed for lumbar surgery during inhalation-intravenous balanced anesthesia when BIS is 50.Methods Patients aged 40-56 years,scheduled for vertebral pulp ectomy were included.Anesthe-sia were maintained by TCI of propofol,sevoflurane 0.5 MAC,remifentanyl 0.2 μg·kg-1 ·min-1 , and vecuronium 0.08 mg·kg-1 ·h-1 .The target plasma concentration of propofol was initially set at 1.8 μg/ml,and adjusted by the sequential up-and-down methods,based on BIS index.The Cp50 of propofol and its 95% confidence interval (CI)were calculated.Results Twenty-six patients were en-rolled in this study.The median effective plasma target concentration of propofol was 1.61 μg/ml (95%CI 1.52-1.70)μg/ml.Conclusion The Cp50 of propofol needed for maintaining the BIS index of 50 is 1.61 μg/ml during the anesthesia with 0.5 MAC of sevoflurane combined with remifentanyl in lumbar surgery.

A retrospective study of anesthesia during rigid bronchoscopy for airway foreign body removal in children: propofol and sevoflurane with spontaneous ventilation.

BACKGROUND: Tracheobronchial foreign body aspiration is a significant cause of childhood morbidity and mortality. We analyzed our experience in management of aspirated foreign bodies, including methods of anesthesia used, over a 4-year period. METHODS: We retrospectively reviewed the records of tracheobronchial foreign body removal by rigid bronchoscopy with spontaneous ventilation in 435 children. All patients had received initial anesthesia with inhaled sevoflurane. One hundred and ninety-seven patients (Group PropRemi) then received intravenous propofol and remifentanyl for maintenance of anesthesia; the remaining 238 patients (Group PropSevo) received propofol and sevoflurane. RESULTS: Tracheobronchial foreign body was found in 405 children (93.1%) and successfully removed from 402 (99.3%) children. Among three patients who failed bronchoscopy, one child suffered cardiac arrest and died during the bronchoscopy, and two required subsequent tracheotomy for foreign body removal. Adverse effects (intraoperative coughing, breath holding, body movement, bronchospasm, and laryngospasm) were significantly more frequent in Group PropRemi than in Group PropSevo. No complications such as bleeding, pneumothorax, pneumomediastinum, or the need for thoracotomy were encountered. CONCLUSION: Sevoflurane induction followed by a combination of sevoflurane and continuous infusion of propofol resulted in fewer adverse events than sevoflurane induction followed by TIVA with propofol and remifentanyl during rigid bronchoscopy for airway foreign body removal in children with spontaneous ventilation.

Issues of critical airway management (Which anesthesia; which surgical airway?).

Which anesthesia for patients with critical airway? Safe and effective analgesia and anesthesia in critical airway is a skilled task especially after severe maxillofacial injury combined with head injury and hemorrhagic shock. If on one side sedation is wanted, on the other hand it may worsen the airway and hemodynamic situation to a point where hypoventilation and decrease of blood pressure, common side-effect of many opioids, may prejudice the patient's level of consciousness and hemodynamic compensation, compounding an already critical situation. What to do when endotracheal intubation fails and blood is trickling down the airways in an unconscious patient or when a conscious patient has to sit up to breathe? Which surgical airway in critical airway? Comparative studies among the various methods of emergency surgical airway would be unethical; furthermore, operator's training and experience is relevant for indications and performance.

Anestesia con Dexmedetomidina y Remifentanyl versus anestesia balanceada en craniectomía, Perfil hemodinámico, sedación y analgesia / Anesthesia with Dexmedetomidine and Remyphentanyl versus balanced anesthesia in craniotomy, hemodinamic profi le, sedation and analgesia

El advenimiento de nuevas drogas es un reto para el anestesiólogo, muchas de éstas resultan ser efectivas, otras quedan sin poder demostrar los beneficios para el paciente. Por esta razón, se hace necesario a través de la investigación clínica darle evidencia a cada una de ellas. La Dexmedetomidina y el Remifentanyl son dos fármacos de reciente introducción en anestesia y sus efectos en el paciente neuroquirúgico no han sido totalmente descritos. Objetivos: evaluar los cambios hemodinámicos durante las tres fases de la anestesia utilizando Fentanyl y Sevoflurane comparado con dexmedetomidina, remifentanyl y sevoflurane a dosis menores de 1 Concentración Alveolar Mínima adicionalmente se evaluaron tiempos de extubación, sedación y analgesia postoperatoria. Adicionalmente se evaluó el costo indirecto de las dos técnicas. Materiales y métodos: se realizo un ensayo clínico no aleatorizado en 50 pacientes, con riesgo anestésico entre I y III entre 18 y 80 años, sometidos a craniectomía. Se evaluó el riesgo relativo de presentar hipo o hipertensión, taquicardia o bradicardia, sedación y analgesia postoperatoria. Resultados: El análisis estadístico no mostro diferencias respecto a las características basales de los pacientes como género, edad, peso o clasificación ASA. Durante la intubación se presentaron cambios hemodinámicos en el 56% de los pacientes de cada grupo, pero sin diferencias entre ellos. Durante el mantenimiento y extubación, el riesgo relativo de presentar taquicardia e hipertensión fue menor y significativo en el grupo intervenido (RR de 0,625 y 0,357 p=0,041 y 0,009). El tiempo a la extubación fue menor en el grupo intervenido (6,8 vs 13,6min. p=0,000), con un nivel Ramsey 3 en el 96% (n=24) versus 12% (n=3) en el grupo control (p=0,000). El dolor postoperatorio se dio en el 54% del grupo control y solo en el 4% del intervenido (p=0,000). Conclusiones: La dexmedetomidina y el Remifentanyl son dos drogas promisorias que nos dan la oportunidad de cumplir mejor los objetivos de la anestesia neuroquirurgica y deben ser evaluadas en futuros estudios clínicos controlados...

The coming of new drugs is a challenge for the anesthesiologist, many of these they turn out to be effective, others are without being able to demonstrate the benefits for the patient. It becomes necessary through the clinical investigation to give him evidences to each one of them. The Dexmedetomidine and the Remifentanyl they are two drugs of recent introduction in anesthesia and their effects in the patient neurosurgical they have not been completely described. Objectives: The major goal of this study was to evaluate the hemodynamic changes during the three phases of the anesthesia using fentanyl and sevoflurane compared with dexmedetomidine, remifentanyl and sevoflurane (DRS) to dose smaller than 1 CAM. A secondary goal was to compare times of extubación, sedation, postoperative analgesia and costs. Patient and Methods: Prospective study not randomized in 50 patients ASA I, II, III between 18 and 80 years, subjected to craniectomía. Patients were divided into one of two groups: Group FS (n=25) and DRS (n=25). The relative risk was evaluated (RR) of presenting hypertension, hypotension, taquicardia, bradicardia, sedation and postoperative analgesia. Results: The statistical analysis did not show differences regarding sex, age or ASA classifi cation between two groups. Group DRS Patients presenting taquicardia and hypertension was smaller and more significant in the intervened group (RR 0.625 and 0.357 p=0.041 and 0.009). The time to the extubación was smaller in the intervened group (6.8 vs 13.6min. p=0.000), with a level Ramsey 3 in 96% (n=24) versus 12% (n=3) in the group control (p=0.000). The postoperative pain was given in 54% of the group control and alone in 4% of the one intervened (p=0.000). Conclusion: The dexmedetomidina and the Remifentanyl are two promissory drugs that give us the opportunity to complete the objectives of the anesthesia neurosurgical better and they should be evaluated in future controlled clinical studies disease and in people older than 60 years, the underlying neoplasm and cases of unknown etiology prevail. The anticoagulant treatment is effective and safe. The prognosis was excellent in the most of the cases...

Anestesia total intravenosa: de la farmacéutica a la farmacocinética / Total intravenous anesthesia: from pharmaceutics to pharmacokinetics

Introducción. En la actualidad, la disponibilidad de medicamentos como el remifentanilo y el propofol, ha creado la necesidad en los anestesiólogos de tener conceptos básicos sobre la anestesia total intravenosa. Más allá de conocer cómo se construye un modelo farmacocinético, es fundamental entender la diferencia entre administrar un medicamento de forma farmacéutica, farmacocinética o farmacodinámica. Objetivo. Reflexionar sobre los conceptos básicos que le permitan al anestesiólogo moderno la administración de los medicamentos utilizados en la anestesia intravenosa de una forma farmacocinética. Metodología. Se realizó una búsqueda en la literatura indexada para obtener artículos didácticos e ilustrativos en los conceptos de anestesia total intravenosa y farmacocinética. Se seleccionaron aquellos que se consideraron más relevantes y se complementaron con textos guía en anestesia en lo concerniente a farmacocinética y anestesia total intravenosa. Resultados. Se obtuvieron 51 artículos y 5 capítulos de texto guía en anestesia. Independientemente de cuál de estos instrumentos utilicemos o qué tan exactos sean, lo realmente importante es saber que contamos con herramientas que nos permiten adecuar, con base en la estimación de los niveles plasmáticos, la anestesia en los diferentes momentos de la cirugía y, en el caso del remifentanilo, a condiciones particulares como la edad. Se trata de la evolución del anestesiólogo a la par con la de los fármacos cada vez más predecibles con los que contamos en la actualidad y de la posibilidad de obtener una anestesia más segura, más predecible, más costo-eficiente y con mayor control por parte del profesional.

Introduction. The availability of medications such as remifentanyl and propofol has made anesthesiologists feel the need to understand the basics of total intravenous anesthesia (TIVA). In fact. beyond knowing how to develop a pharmacokinetic model, it is essential to differentiate among the pharmaceutical, pharmacokinetic and pharmacodynamic approach for administering a particular drug. Objective. To review the basic concepts the modern anesthesiologist needs for the pharmacokinetic administration of the drugs used for intravenous anesthesia. Methodology. A search of the indexed literature was done to identify educational and illustrative articles about total intravenous anesthesia concepts and pharmacokinetics. The most relevant articles were selected for this review and it was supplemented with anesthesia textbooks in the gueareaof pharmacokinetics and total intravenous anesthesia. Results. 51 articles and 5 chapters from textbooks on anesthesia were selected. Regardless of the instruments used or how accurate they may be, what is really important is knowing that we have the tools available and based on the estimated plasma levels, we can adjust the anesthesia to the different stages of the surgical procedure; in the case of remifentanyl, it can be adjusted to the specific conditions such as the age of the patient. The point is that the anesthesiologist has to evolve keeping pace with the increasingly more predictable drugs now available and with the possibility of achieving a safer, more predictable and cost-effective anesthesia with greater control both by the experienced professional and the trainee.

Validación de nomogramas de remifentanil y propofol para la administración de anestesia total endovenosa / Remifentanyl and propofol nomograph validation for the administration of total intravenous anesthesia

Objetivo: Establecer la concordancia en cuanto al cálculo de la concentración plasmática, entre los nomogramas (Remifentanil-Propofol) y los sistemas computarizados. Métodos: Se diseñaron nomogramas de remifentanil y propofol basados en los modelos farmacocinéticos de Marsh y Minto respectivamente. Se realizó un estudio analítico de corte transversal de la siguiente forma: Se tomaron 66 muestras en 11 pacientes a quienes se les administró TIVA. A las muestras se les cálculo la concentración plasmática (CP) por medio del simulador Rugloop®. Luego, un observador ciego con la tasa de infusión, los nomogramas y las variables de peso y talla, calculó la CP. Posteriormente se evaluó la concordancia entre los dos métodos. Métodos estadísticos: Análisis de correlación y regresión lineal. Análisis de varianza para probar la bondad de ajuste del modelo de regresión. Nivel de significación estadística α=0.01. Resultados: El coeficiente de correlación de Pearson entre los sistemas computarizados (SC) y los nomogramas es de 0.96 [IC 95% (0.87-1) y 0,87 [IC 95% (0,75-1)] para el remifentanil y el propofol respectivamente, valor_p<0.001. Conclusiones: La correlación entre los nomogramas y los sistemas computarizados es significantemente alta. Los nomogramas que hemos diseñado son una herramienta adecuada para estimar la concentración plasmática de remifentanil y propofol de una manera precisa, fácil y económica.

Objective: To stablish the concordance of the Plasma Concentration obtained using nomograms for Remifentanil and Propofol vs. Computerized systems.Methods: Using the pharmacokinetic models of Marsh and Minto, we designed nomograms for remifentanil and porpofol respectively. We conducted a cross sectional analytic study as follows: we obtained Sixty-six samples from eleven patients who underwent procedures under total intravenous anesthesia (TIVA). Using the Rugloop software we calculated the plasma concentration from the samples. A blind observer also calculated the plasma concentrations using the data from the infusion rate, the nomograms and the height and weight of each patient. Later the concordance between the two methods was evaluated. Statistical Methods: Linear regression – correlation analysis. We used analysis of variance in order to test the goodness of adjustment of the regression model. Level of statistical significance α = 0.01.Results. Pearson’s correlation coefficient between the computerized systems and nomograms is 0.96 [CI 95% (0.87-1)] y 0.87 [CI 95% (0.75-1)] for remifentanil and propofol respectively (p value < 0.001). Conclusions. There’s a significantly high correlation between the nomograms and the computerized systems.