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1.
Anesth Prog ; 68(1): 10-18, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33827126

RESUMO

The objectives of this research were to investigate (a) what was the most effective infusion rate of remifentanil and (b) the degree to which sympathomimetic effects were involved with cardiovascular stimulation by using a power spectral analysis of heart rate variability (HRV). A total of 63 healthy individuals scheduled for sagittal split ramus osteotomy were enrolled and randomly allocated to 1 of 3 groups: remifentanil infusion rate of 0.1, 0.2, or 0.4 µg/kg/min. Anesthesia was maintained with remifentanil and propofol. Before the surgical procedure, 2% lidocaine containing 12.5 µg/mL epinephrine was administered in the surgical field for local anesthesia. Systolic blood pressure (SBP), heart rate (HR), low-frequency (LF) and high-frequency (HF) components in HRV power spectral analysis, and the LF/HF ratio were analyzed. Increases in SBP and HR were observed after local anesthesia in all 3 groups, but no significant differences were observed between the groups. Remifentanil infusion at 0.1 µg/kg/min may be appropriate to minimize cardiovascular stimulation caused by exogenous epinephrine from local anesthesia. Although a rise in the LF/HF ratio was observed after local anesthesia in all groups, no relationship was observed between the cardiovascular changes and the increase in LF/HF ratio. This suggests that sympathomimetic effects are involved to a lesser extent with the cardiovascular stimulation caused by exogenous epinephrine.


Assuntos
Anestesia Local , Anestésicos Locais , Anestésicos Intravenosos/efeitos adversos , Anestésicos Locais/efeitos adversos , Pressão Sanguínea , Epinefrina/efeitos adversos , Frequência Cardíaca , Humanos , Piperidinas/efeitos adversos , Remifentanil/farmacologia
2.
Medicine (Baltimore) ; 100(14): e25324, 2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33832107

RESUMO

BACKGROUND: Awake fiberoptic endoscope intubation (AFOI) is the primary strategy for managing anticipated difficult airways. Adequate sedation, most commonly being achieved with remifentanil and dexmedetomidine, is integral to this procedure. This meta-analysis aimed to compare the safety and efficacy of these 2 sedatives. METHODS: We conducted electronic searches in Embase, Web of Science, PubMed, Google Scholar, Medline, Springer, and Web of Science with no language restrictions. Studies comparing safety and efficacy between the sole use of remifentanil and dexmedetomidine among patients who underwent AFOI were included. Eight randomized controlled trials, comprising 412 patients, met the inclusion criteria. The primary outcomes were first attempt intubation success rate and incidence of hypoxia. The secondary outcomes were the Ramsay Sedation Scale score at intubation, memory recall of endoscopy, and unstable hemodynamic parameters during intubation. RESULTS: Dexmedetomidine significantly reduced the incidence of hypoxemia during AFOI (risk ratio: 2.47; 95% confidence [CI]: 1.32-4.64]) compared with remifentanil; however, the first intubation success rates were equivalent (risk ratio: 1.12; 95% CI: 0.87-1.46]. No significant differences between the 2 sedatives were found for the Ramsay Sedation Scale score at intubation (mean difference: -0.14; 95% CI: -0.66-0.38) or unstable hemodynamic parameters during intubation (risk ratio: 0.83; 95% CI: 0.59-1.17). Dexmedetomidine reduced memory recall of endoscopy (risk ratio: 1.39; 95% CI: 1.13-1.72). CONCLUSIONS: While both remifentanil and dexmedetomidine are effective for AFOI and well-tolerated, dexmedetomidine may be more effective in reducing the incidence of hypoxemia and memory recall of endoscopy. PROSPERP REGISTRATION NUMBER: CRD42020169612.


Assuntos
Sedação Consciente/métodos , Dexmedetomidina/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação Intratraqueal/métodos , Remifentanil/uso terapêutico , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Endoscopia/instrumentação , Endoscopia/métodos , Tecnologia de Fibra Óptica , Hemodinâmica , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipóxia/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Remifentanil/administração & dosagem , Remifentanil/efeitos adversos
3.
Cochrane Database Syst Rev ; 3: CD013732, 2021 03 17.
Artigo em Inglês | MEDLINE | ID: mdl-33729556

RESUMO

BACKGROUND: Mechanical ventilation is a potentially painful and discomforting intervention that is widely used in neonatal intensive care. Newborn infants demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes. OBJECTIVES: To determine the benefits and harms of opioid analgesics for neonates (term or preterm) receiving mechanical ventilation compared to placebo or no drug, other opioids, or other analgesics or sedatives. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 9), in the Cochrane Library; MEDLINE via PubMed (1966 to 29 September 2020); Embase (1980 to 29 September 2020); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 29 September 2020). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing opioids to placebo or no drug, to other opioids, or to other analgesics or sedatives in newborn infants on mechanical ventilation. We excluded cross-over trials. We included term (≥ 37 weeks' gestational age) and preterm (< 37 weeks' gestational age) newborn infants on mechanical ventilation. We included any duration of drug treatment and any dosage given continuously or as bolus; we excluded studies that gave opioids to ventilated infants for procedures. DATA COLLECTION AND ANALYSIS: For each of the included trials, we independently extracted data (e.g. number of participants, birth weight, gestational age, types of opioids) using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included 23 studies (enrolling 2023 infants) published between 1992 and 2019. Fifteen studies (1632 infants) compared the use of morphine or fentanyl versus placebo or no intervention. Four studies included both term and preterm infants, and one study only term infants; all other studies included only preterm infants, with five studies including only very preterm infants. We are uncertain whether opioids have an effect on the Premature Infant Pain Profile (PIPP) Scale in the first 12 hours after infusion (MD -5.74, 95% confidence interval (CI) -6.88 to -4.59; 50 participants, 2 studies) and between 12 and 48 hours after infusion (MD -0.98, 95% CI -1.35 to -0.61; 963 participants, 3 studies) because of limitations in study design, high heterogeneity (inconsistency), and imprecision of estimates (very low-certainty evidence - GRADE). The use of morphine or fentanyl probably has little or no effect in reducing duration of mechanical ventilation (MD 0.23 days, 95% CI -0.38 to 0.83; 1259 participants, 7 studies; moderate-certainty evidence because of unclear risk of bias in most studies) and neonatal mortality (RR 1.12, 95% CI 0.80 to 1.55; 1189 participants, 5 studies; moderate-certainty evidence because of imprecision of estimates). We are uncertain whether opioids have an effect on neurodevelopmental outcomes at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 78 participants, 1 study; very low-certainty evidence because of serious imprecision of the estimates and indirectness). Limited data were available for the other comparisons (i.e. two studies (54 infants) on morphine versus midazolam, three (222 infants) on morphine versus fentanyl, and one each on morphine versus diamorphine (88 infants), morphine versus remifentanil (20 infants), fentanyl versus sufentanil (20 infants), and fentanyl versus remifentanil (24 infants)). For these comparisons, no meta-analysis was conducted because outcomes were reported by one study. AUTHORS' CONCLUSIONS: We are uncertain whether opioids have an effect on pain and neurodevelopmental outcomes at 18 to 24 months; the use of morphine or fentanyl probably has little or no effect in reducing the duration of mechanical ventilation and neonatal mortality. Data on the other comparisons planned in this review (opioids versus analgesics; opioids versus other opioids) are extremely limited and do not allow any conclusions. In the absence of firm evidence to support a routine policy, opioids should be used selectively - based on clinical judgement and evaluation of pain indicators - although pain measurement in newborns has limitations.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Processual/prevenção & controle , Respiração Artificial/efeitos adversos , Analgésicos Opioides/efeitos adversos , Viés , Desenvolvimento Infantil/efeitos dos fármacos , Fentanila/efeitos adversos , Fentanila/uso terapêutico , Heroína/efeitos adversos , Heroína/uso terapêutico , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Lactente , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Midazolam/efeitos adversos , Midazolam/uso terapêutico , Morfina/efeitos adversos , Morfina/uso terapêutico , Placebos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Remifentanil/efeitos adversos , Remifentanil/uso terapêutico , Respiração Artificial/estatística & dados numéricos , Sufentanil/efeitos adversos , Sufentanil/uso terapêutico
4.
Medicine (Baltimore) ; 100(13): e25288, 2021 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-33787614

RESUMO

ABSTRACT: Target-controlled infusion of remifentanil is known to reduce cough effectively during emergence from general anesthesia. The effect of smoking on emergence cough remains controversial. Therefore, we aimed to investigate the effect-site concentration (Ce) of remifentanil in the male patients undergoing laparoscopic or robotic cholecystectomy for suppressing emergence cough in smokers and non-smokers.Twenty smokers and 24 non-smokers (sex, male; age range, 20-65 years) were enrolled in this study. Anesthesia was maintained using sevoflurane and remifentanil. The Ce of remifentanil in 50% (EC50) and 95% (EC95) of the patients required for suppressing emergence cough were determined for each group (smokers and non-smokers) using Dixon up-and-down method and isotonic regression method with a bootstrapping approach.Dixon up-and-down method revealed that the EC50 value was significantly higher in smokers (3.51 ±â€Š0.60 ng/mL) than in non-smokers (2.71 ±â€Š0.30 ng/mL) (P < 0.001). In smokers and non-smokers, isotonic regression revealed EC50 to be 4.40 (83% CI, 4.17-4.58) ng/mL and 2.58 (83% CI, 2.31-2.87) ng/mL, respectively, and EC95 to be 4.76 (95% CI, 4.73-4.78) ng/mL and 3.15 (95% CI, 3.04-3.18) ng/mL, respectively.The Ces of remifentanil required to prevent cough during emergence were significantly higher in smokers than in non-smokers. Therefore, clinicians should pay attention to the smoking history of a patient to prevent cough during emergence.


Assuntos
Anestesia Geral/efeitos adversos , Antitussígenos/administração & dosagem , Colecistectomia , Tosse/prevenção & controle , Remifentanil/administração & dosagem , Fumar/efeitos adversos , Adulto , Idoso , Período de Recuperação da Anestesia , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Procedimentos Cirúrgicos Robóticos , Sevoflurano/administração & dosagem , Adulto Jovem
5.
J Opioid Manag ; 17(1): 69-78, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33735429

RESUMO

OBJECTIVE: Remifentanil, a rapid onset rapid offset synthetic opioid and potent analgesic, is often used for procedural conscious sedation in spontaneous ventilation, especially when delivered in target controlled infusion (TCI), which allows precise titration. We assessed efficacy, tolerance, and adverse events related with the use of remifentanil TCI during various procedures. DESIGN: Prospective, observational. SETTING: Two teaching hospitals. PATIENTS: We enrolled 434 patients undergoing procedures suitable for conscious sedation. INTERVENTIONS: The following procedures considered suitable were included: interventional radiology, gastrointestinal (GI) endoscopy, interventional cardiology, and peripheral dermatology. Sedation options were determined during the preoperative anesthesia assessment. MAIN OUTCOME MEASURES: Demographics were recorded as well as success rate, remifentanil dosage, pain scores, respiratory or cardiovascular events, and patient and operator satisfaction. RESULTS: The procedure was successful in 429 patients (99 percent), canceled in four patients because of agitation, apnea, desaturation, and converted to general anesthesia in two for major pain. The maximal remifentanil target was around 2-3 ng/ml for most procedures, but it was 3-5 ng/ml for GI endoscopy and urology. A total of 172 patients (40 percent) had bradypnea < 8 min-1, but only 26 (6 percent) had hypoxemia < 90 percent. Eighteen patients (4 percent) required mandibular luxation, and twelve needed face mask ventilation. There were no major cardiovascular adverse events. CONCLUSIONS: Remifentanil TCI is a suitable protocol for procedural sedation, but respiratory depression is a permanent concern. This risk requires equipped environment and competent medical personnel on hand to adjust the target before hypoxemia occurs. Respiratory rate monitoring, based on capnography or thoracic impedance is of a great help in anticipating this threat.


Assuntos
Analgesia , Antígeno Prostático Específico , Analgésicos Opioides/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Dor/tratamento farmacológico , Piperidinas/efeitos adversos , Estudos Prospectivos , Remifentanil
6.
Anesthesiology ; 134(4): 541-551, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33630043

RESUMO

BACKGROUND: It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. METHODS: Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. RESULTS: The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. CONCLUSIONS: This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia.


Assuntos
Analgésicos não Entorpecentes/uso terapêutico , Analgésicos Opioides/uso terapêutico , Anestesia Balanceada/métodos , Dexmedetomidina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Remifentanil/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego , Resultado do Tratamento
8.
Eur J Anaesthesiol ; 38(5): 512-523, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33399383

RESUMO

BACKGROUND: Nitrous oxide (N2O) has been used since the 19th century for its analgesic, antinociceptive and anxiolytic effects during surgical procedures in awake and anaesthetised patients. However, quantification of noxious stimuli that occur under general anaesthesia is a constant challenge for anaesthesiologists, and recently two new indices have been developed to assess intra-operative nociception. OBJECTIVE: The aim of this study was to quantify with new indices as well as with more classical clinical parameters the antinociceptive effect of N2O during general anaesthesia. DESIGN: Prospective, open label, patient-blinded, observational and descriptive trial. SETTING: Single-centre academic hospital. PARTICIPANTS: Forty American Society of Anesthesiologists' physical status 1 to 3 patients undergoing general anaesthesia for elective abdominal surgery via laparotomy were recruited. MAIN OUTCOMES MEASURES: Intra-operative pain was assessed using a standardised electrical stimulation of the forearm (tetanic stimulation at 70 mA, 100 Hz for 30 s), at 0, 25 and 50% inhaled N2O/O2. Heart rate (HR), mean arterial blood pressure, bispectral index, the analgesia nociception index and the nociception level (NOL) index were used to evaluate intra-operative nociception before and after each standardised tetanic stimulation. RESULTS: There was a 16% reduction of the analgesia nociception index reaction, a 31% reduction of the NOL reaction and a 51% reduction of the HR reaction to a standardised electrical tetanic nociceptive stimulation during administration of 50% N2O. Administration of 50 or 25% inhaled N2O produced the same quality of antinociception based on HR and NOL index analyses. HR and the NOL index were the best parameters to identify the antinociceptive effect of intra-operatively administered N2O. CONCLUSION: In anaesthetised patients, our study demonstrated clinically significant antinociceptive properties of N2O. Our results showed that low concentrations of N2O (25%) are as effective as higher concentrations (50%) to achieve a significant antinociceptive effect. These findings may help decrease negative effects of using higher concentrations of N2O, including its side effects and its environmental pollution. TRIAL REGISTRATION: ClinicalTrials.gov registration identifier: NCT02701478.


Assuntos
Óxido Nitroso , Nociceptividade , Humanos , Monitorização Intraoperatória , Estudos Prospectivos , Remifentanil
10.
Nan Fang Yi Ke Da Xue Xue Bao ; 41(1): 64-68, 2021 Jan 30.
Artigo em Chinês | MEDLINE | ID: mdl-33509754

RESUMO

OBJECTIVE: To investigate the maximum dose of continuous mivacurium infusion for intraoperative neuromonitoring (IONM) and observe the adverse reactions during thyroid surgery under total intravenous anesthesia (TIVA). METHODS: Thirty patients undergoing IONM during thyroid surgery received continuous infusion of mivacurium at the initial rate of 14.97 µg · kg-1 · min-1. The infusion rate was adjusted in the next patient based on the response of the previous patient in IONM. The depth of anesthesia was maintained with propofol and remifentanil during the surgery. The EC50 and 95%CI of mivacurium were calculated with Brownlee's up- and-down sequential method. During the operation, body movement and skin flushing of patient was monitored, and the mean arterial pressure (MAP) and heart rate (HP) were recorded immediately (T0) and at 5 min (T1) after injection of muscle relaxant for anesthesia induction, immediately (T2) and at 10 min (T3) and 20 min (T4) after initiation of intraoperative infusion of the muscle relaxant. RESULTS: The EC50 for continuous infusion of mivacurium without affecting IONM was 18.9 µg · kg-1 · min-1(95%CI: 17.3-20.5 µg · kg-1 · min-1) during thyroid surgery under TIVA. One patient (3.3%) developed transient facial skin redness after induction. Intubation difficulties or body motions occurred in none of the patients during the surgery. Pair-wise comparison showed no significant variations in MAP or HR of the patients at the 5 time points (P>0.05). CONCLUSIONS: In patients undergoing thyroid surgery under TIVA, the EC50 for continuous infusion of mivacurium is 18.9 µg · kg-1 · min-1 (95%CI: 17.3-20.5 µg · kg-1 · min-1), which does not affect IONM or causes serious adverse reactions during the operation.


Assuntos
Anestesia Intravenosa , Propofol , Humanos , Mivacúrio , Remifentanil , Glândula Tireoide
11.
13.
Anaesthesia ; 76(1): 45-53, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33253427

RESUMO

Sleep apnoea is associated with negative outcomes following general anaesthesia. Current recommendations suggest using short-acting anaesthetic agents in preference to standard agents to reduce this risk, but there is currently no evidence to support this. This randomised controlled triple-blind trial tested the hypothesis that a combination of short-acting agents (desflurane-remifentanil) would reduce the postoperative impact of general anaesthesia on sleep apnoea severity compared with standard agents (sevoflurane-fentanyl). Sixty patients undergoing hip arthroplasty under general anaesthesia were randomised to anaesthesia with desflurane-remifentanil or sevoflurane-fentanyl. Respiratory polygraphy was performed before surgery and on the first and third postoperative nights. The primary outcome was the supine apnoea-hypopnoea index on the first postoperative night. Secondary outcomes were the supine apnoea-hypopnoea index on the third postoperative night, and the oxygen desaturation index on the first and third postoperative nights. Additional outcomes included intravenous morphine equivalent consumption and pain scores on postoperative days 1, 2 and 3. Pre-operative sleep study data were similar between groups. Mean (95%CI) values for the supine apnoea-hypopnoea index on the first postoperative night were 18.9 (12.7-25.0) and 21.4 (14.2-28.7) events.h-1 , respectively, in the short-acting and standard anaesthesia groups (p = 0.64). Corresponding values on the third postoperative night were 28.1 (15.8-40.3) and 38.0 (18.3-57.6) events.h-1 (p = 0.34). Secondary sleep- and pain-related outcomes were generally similar in the two groups. In conclusion, short-acting anaesthetic agents did not reduce the impact of general anaesthesia on sleep apnoea severity compared with standard agents. These data should prompt an update of current recommendations.


Assuntos
Anestesia Geral/métodos , Apneia Obstrutiva do Sono/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Inalatórios , Anestésicos Intravenosos , Artroplastia de Quadril , Desflurano , Método Duplo-Cego , Feminino , Fentanila , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Dor Pós-Operatória/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Remifentanil , Sevoflurano , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/fisiopatologia , Decúbito Dorsal , Resultado do Tratamento
14.
Annu Int Conf IEEE Eng Med Biol Soc ; 2020: 5971-5975, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-33019332

RESUMO

The purpose of the present study was to investigate the ability of three different normalization methods, namely root mean square (RMS) value, mean value, and maximum which referred to pulse beat interval (PBI), based on photoplethysmographic diastolic interval (DI) in response to laryngeal mask airway (LMA) insertion under various remifentanil concentrations during general anesthesia. Sixty patients were randomly allocated to one of the four groups to receive a possible remifentanil effect-compartment target concentration (Ceremi) of 0, 1, 3, or 5 ng/ml, and an effect-compartment target controlled infusion of propofol to maintain the state entropy (SE) at 40~60. Three normalized measures DIRMS, DIMean, and DIPBI were compared with the DI values without normalization. Before LMA insertion, only DI showed a considerable correlation with remifentanil concentrations. DIRMS and DIMean performed better than DI in discriminating 'insufficient' concentrations (0 and 1 ng/ml) from 'sufficient' concentrations (3 and 5 ng/ml). DIRMS was superior to all other variables in grading analgesic depth after nociceptive event occurred with PK value of 0.836. These results demonstrate that the normalization using RMS value, compared to using mean value and maximum, seems to provide a more effective approach for signal pre-processing.


Assuntos
Analgésicos Opioides , Anestesia Geral , Máscaras Laríngeas , Fotopletismografia , Propofol , Remifentanil , Analgésicos , Analgésicos Opioides/administração & dosagem , Humanos , Piperidinas , Remifentanil/administração & dosagem
15.
Anesth Analg ; 131(5): 1589-1598, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079883

RESUMO

BACKGROUND: Intraoperative monitoring with pupillometry has shown promising results for nociception/antinociception balance monitoring. However, its benefits in clinical practice remain unproven. The aim of this study was to evaluate the efficacy of intraoperative pupillometry monitoring on intraoperative opioid consumption and postoperative pain compared to surgical pleth index (SPI), another widely investigated monitoring. METHODS: American Society of Anesthesiologists (ASA) I-II patients scheduled for elective laparoscopic cholecystectomy were included. This prospective, parallel-arm, single-center study was conducted in 2 steps. First, we evaluated the feasibility of using pupillometry and SPI monitoring compared with conventional hemodynamic monitoring. Next, a parallel-arm, double-blind randomized study compared the peak postoperative pain measured with numerical rating scale (NRS) from 0 (no pain) to 10 (extreme pain) as a primary outcome between pupillometry (pupillometry group, n = 43) and SPI monitoring (SPI group, n = 43) using Mann-Whitney U test. Secondary outcomes included intraoperative remifentanil consumption, postoperative opioid responsiveness (a decrease in NRS by ≥1 after fentanyl administrations), number of analgesic administrations, and opioid-related complications. RESULTS: In the preliminary study (n = 50), remifentanil consumption was less under pupillometry monitoring compared to SPI monitoring, and peak postoperative pain was lower under pupillometry compared to conventional monitoring. In the main study (n = 86), peak postoperative pain and intraoperative remifentanil consumption were lower in the pupillometry group (median [first to third quartile], 5 [4-6]; mean ± standard deviation [SD], 0.078 ± 0.019 µg·kg·minute) compared to the SPI group (7 [5-8] and 0.0130 ± 0.051 µg·kg·minute; P < .001), with the median difference in peak postoperative pain of -1 and its 95% confidence interval between -2 and -0.5. The pupillometry group had better responsiveness to fentanyl (84.6% vs 61.0%; P = .005) and lower number of analgesic administrations (2 [1-2] vs 2 [1-3]; P = .048) compared to the SPI group. CONCLUSIONS: Intraoperative pupillometry monitoring reduced intraoperative remifentanil consumption and postoperative pain. It may be an alternative option for intraoperative opioid control under general anesthesia in adult patients.


Assuntos
Analgésicos Opioides/uso terapêutico , Anestesia Intravenosa , Anestésicos Intravenosos , Monitorização Intraoperatória/métodos , Nociceptividade/efeitos dos fármacos , Propofol , Pupila/efeitos dos fármacos , Remifentanil , Adulto , Idoso , Colecistectomia Laparoscópica , Método Duplo-Cego , Estudos de Viabilidade , Feminino , Fentanila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Período Perioperatório , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento
16.
Medicine (Baltimore) ; 99(43): e22712, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120766

RESUMO

BACKGROUND: Although dexmedetomidine has been used as either the anesthetic agent for light sedation or as an adjunct to other sedatives, no study has investigated the usefulness of dexmedetomidine as the main sedative agent for invasive and painful procedures. The purpose of this study was to compare the safety of dexmedetomidine-remifentanil and propofol-remifentanil during monitored anesthesia care (MAC) for hysteroscopy. METHODS: Female patients undergoing hysteroscopy were randomly assigned to either the dexmedetomidine (group D) or the propofol group (group P). The study drug (0.6 ml/kg; dexmedetomidine 2 µg/ml or propofol 4 mg/ml) was loaded for 10 minutes followed by 0.1 to 0.5 ml/kg/hour to maintain a bispectral index of 60 to 80 during the procedure. In both groups, remifentanil was infused using a target-controlled-infusion system with a target concentration of 2 ng/ml and titrated during the procedure. The incidence rates of intraoperative respiratory depression in both groups were compared. Postoperative pain and patients satisfaction were also compared. RESULTS: A total of 69 female patients were included in this study. Dexmedetomidine significantly decrease the incidence of respiratory depression compared with propofol (15/34 [44.1%] vs 5/35 [14.3%], P = .006, group P and D, respectively). Postoperative pain and patients satisfaction score did not differ between the groups. CONCLUSION: The combination of dexmedetomidine-remifentanil can reduce the incidence of respiratory depression without increasing hemodynamic complications compared with propofol-remifentanil for MAC during hysteroscopy.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Histeroscopia , Monitorização Intraoperatória , Propofol/administração & dosagem , Remifentanil/administração & dosagem , Adulto , Combinação de Medicamentos , Feminino , Humanos , Pessoa de Meia-Idade , Método Simples-Cego
18.
Anesth Analg ; 131(4): 1173-1183, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925338

RESUMO

BACKGROUND: In the University Medical Center Groningen in Groningen, the Netherlands, moderate-to-deep sedation is provided by nursing staff trained and supervised by the anesthesia department using protocol-based target-controlled infusions (TCIs) of propofol and remifentanil. The aim of this retrospective cohort study was to investigate the incidence of events with potential adverse health consequences within this service model and the risk factors for the occurrence of these events. METHODS: We retrospectively interrogated a database containing the computerized anesthetic records of 2937 procedures where moderate-to-deep sedation was provided using TCI administration of propofol and remifentanil between May 2014 and October 2017. The primary outcome measures were the incidence of sedation-related events with potential adverse health consequences and risk factors for the occurrence of such events. The events under investigation were unplanned intensive care unit (ICU) admission, need for cardiopulmonary resuscitation (CPR), death on the day of the procedure due to sedation-related events, cardiovascular events (arrhythmias, hypertension, and hypotension), pulmonary events (aspiration, desaturation, unplanned tracheal intubation), anaphylactic or allergic reactions, and the termination of the procedure due to sedation-related events. Cardiovascular and pulmonary events were classified as severe, significant, or moderate. Events were identified by using computer algorithms to search the computerized records from all included procedures. RESULTS: Data from 2937 procedures were analyzed. No patients suffered catastrophic events (death, need for CPR, or unplanned ICU admission). Thirty-two severe sedation-related events occurred in 32 procedures. Severe desaturation (0.6%; 95% confidence interval [CI], 0.4-0.9) and severe hypertension (0.2%; 95% CI, 0.04-0.37) were the most common severe events. Significant hypotension (8.8%; 95% CI, 7.73-9.77) and significant desaturation (1.6%; 95% CI, 1.12-2.02) were found to be the most common events with potential adverse health consequences. No patient suffered lasting health consequences. Average mean and maximum targeted effect-site concentrations (Cet) for propofol were 2.6 ± 0.83 and 3.3 ± 1.09 µg·mL, respectively, and for remifentanil 0.84 ± 0.18 and 0.99 ± 0.22 ng·mL, respectively. Maximum Cets of propofol were lower among patients with higher body mass index (BMI) and were higher among patients of younger age. Higher BMI was a risk factor for desaturation. Increased age and lower BMI were risk factors for hypotension. Longer procedure time was a risk factor for both desaturation and hypotension. CONCLUSIONS: Moderate-to-deep sedation by propofol and remifentanil TCI has a low incidence of catastrophic and severe events.


Assuntos
Sedação Profunda/métodos , Hipnóticos e Sedativos , Propofol , Remifentanil , Idoso , Índice de Massa Corporal , Reanimação Cardiopulmonar , Estudos de Coortes , Cuidados Críticos , Sedação Profunda/efeitos adversos , Feminino , Cardiopatias/epidemiologia , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Infusões Intravenosas , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Propofol/administração & dosagem , Propofol/efeitos adversos , Remifentanil/administração & dosagem , Remifentanil/efeitos adversos , Fatores de Risco
19.
Anesth Analg ; 131(4): 1184-1192, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925339

RESUMO

BACKGROUND: Clinicians can optimize propofol titration by using 2 sources of pharmacodynamic (PD) information: the predicted effect-site concentration for propofol (Ceprop) and the electroencephalographically (EEG) measured drug effect. Relation between these sources should be time independent, that is, perfectly synchronized. In reality, various issues corrupt time independency, leading to asynchrony or, in other words, hysteresis. This asynchrony can lead to conflicting information, making effective drug dosing challenging. In this study, we tried to quantify and minimize the hysteresis between the Ceprop (calculated using the Schnider model for propofol) and EEG measured drug effect, using nonlinear mixed-effects modeling (NONMEM). Further, we measured the influence of EEG-based monitor choice, namely Bispectral index (BIS) versus qCON index (qCON) monitor, on propofol PD hysteresis. METHODS: We analyzed the PD data from 165 patients undergoing propofol-remifentanil anesthesia for outpatient surgery. Drugs were administered using target-controlled infusion (TCI) pumps. Pumps were programmed with Schnider model for propofol and Minto model for remifentanil. We constructed 2 PD models (direct models) relating the Schnider Ceprop to the measured BIS and qCON monitor values. We quantified the models' misspecification due to hysteresis, on an individual level, using the root mean squared errors (RMSEs). Subsequently, we optimized the PD models' predictions by adding a lag term to both models (lag-time PD models) and quantified the optimization using the RMSE. RESULTS: There is a counterclockwise hysteresis between Ceprop and BIS/qCON values. Not accounting for this hysteresis results in a direct PD model with an effect-site concentration which produces 50% of the maximal drug effect (Ce50) of 6.24 and 8.62 µg/mL and RMSE (median and interquartile range [IQR]) of 9.38 (7.92-11.23) and 8.41(7.04-10.2) for BIS and qCON, respectively. Adding a modeled lag factor of 49 seconds to the BIS model and 53 seconds to the qCON model improved both models' prediction, resulting in similar Ce50 (3.66 and 3.62 µg/mL for BIS and qCON) and lower RMSE (median (IQR) of 7.87 (6.49-9.90) and 6.56 (5.28-8.57) for BIS and qCON. CONCLUSIONS: There is a significant "Ceprop versus EEG measured drug effect" hysteresis. Not accounting for it leads to conflicting PD information and false high Ce50 for propofol in both monitors. Adding a lag term improved the PD model performance, improved the "pump-monitor" synchrony, and made the estimates of Ce50 for propofol more realistic and less monitor dependent.


Assuntos
Anestésicos Intravenosos , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória/métodos , Propofol , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Anestesia Intravenosa , Monitores de Consciência , Feminino , Humanos , Bombas de Infusão , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Valor Preditivo dos Testes , Estudos Prospectivos , Remifentanil , Adulto Jovem
20.
PLoS One ; 15(9): e0238661, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915840

RESUMO

We evaluated whether volatile anesthetics can improve the postoperative outcomes of non-cardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30-day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr).


Assuntos
Anestesia Intravenosa/efeitos adversos , Traumatismos Cardíacos/mortalidade , Remifentanil/efeitos adversos , Compostos Orgânicos Voláteis/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Feminino , Traumatismos Cardíacos/sangue , Traumatismos Cardíacos/induzido quimicamente , Traumatismos Cardíacos/fisiopatologia , Humanos , Rim/fisiopatologia , Rim/cirurgia , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Período Pré-Operatório , Propofol/administração & dosagem , Propofol/efeitos adversos , Remifentanil/administração & dosagem , Troponina I/sangue , Compostos Orgânicos Voláteis/administração & dosagem , Adulto Jovem
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