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Anaesthesia May 2023Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in... (Review)
Review
Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol-based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α-2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target-control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic-opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non-opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose.
Topics: Humans; Remifentanil; Propofol; Anesthesia, Intravenous; Piperidines; Analgesics, Opioid; Anesthesia, General; Hypnotics and Sedatives; Anesthetics, Intravenous
PubMed: 36562193
DOI: 10.1111/anae.15952 -
Aesthetic Plastic Surgery Jun 2023Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery...
BACKGROUND
Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.
METHODS
This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.
RESULTS
Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.
CONCLUSIONS
Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.
LEVEL OF EVIDENCE IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Topics: Humans; Adult; Female; Prospective Studies; Analgesics, Opioid; Anesthesia, Local; Esthetics; Breast Neoplasms
PubMed: 36544050
DOI: 10.1007/s00266-022-03214-w -
Drug Design, Development and Therapy 2022Propofol is widely used for sedation of hysteroscopy. It can cause injection pain, respiratory depression, and hypotension. Remimazolam is a novel ultra-short-acting... (Randomized Controlled Trial)
Randomized Controlled Trial Clinical Trial
BACKGROUND
Propofol is widely used for sedation of hysteroscopy. It can cause injection pain, respiratory depression, and hypotension. Remimazolam is a novel ultra-short-acting benzodiazepine. Clinical practice has found that the use of remimazolam alone often leads to body movement during hysteroscopy, which decreases the safety and comfort. Here this study is to investigate whether remimazolam combined with low-dose propofol can improve the sedation effect and safety of hysteroscopy.
PATIENTS AND METHODS
In this prospective, randomized, parallel-controlled trial, women (18 to 60 years) undergoing hysteroscopy were randomly assigned to receive propofol (Group P), remimazolam tosylate (Group R), or remimazolam tosylate plus propofol (Group RP). Intraoperative sedation depth was kept at the bispectral index (BIS) value of 40-60. 6 μg/kg alfentanil was used for analgesic before sedation. Intraoperative low pulse oxygen saturation (SpO), body movement, injection pain, mean arterial pressure (MAP), heart rate (HR), and postoperative recovery time, dizziness, nausea and vomiting were recorded and compared.
RESULTS
From February to July 2022, 193 patients were recruited and randomly assigned to group P (n=64), group R (n=64), or group RP (n=65). There was no significant inter-group difference of the intraoperative BIS values. The incidence of low SpO, injection pain, hypotension, and postoperative dizziness in group RP were less than that in group P, and had no significant difference from group R. The incidence of body movement in group RP was less than that in group R, and had no significant difference from group P. Postoperative recovery time of group RP was shorter than that of the other two groups. No significant inter-group difference in bradycardia, nausea and vomiting was observed.
CONCLUSION
Remimazolam tosylate combined with low dose of propofol improved sedation and safety in hysteroscopy, and may be a more ideal sedative method for hysteroscopy.
Topics: Humans; Female; Pregnancy; Propofol; Hysteroscopy; Prospective Studies; Dizziness; Benzodiazepines; Hypnotics and Sedatives; Hypotension; Pain; Vomiting; Nausea
PubMed: 36471692
DOI: 10.2147/DDDT.S390403 -
BMC Anesthesiology Nov 2022Opioid-reduced anesthesia may accelerate postoperative rehabilitation by reducing opioid-related side effects. The objective was to investigate the feasibility of... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Opioid-reduced anesthesia may accelerate postoperative rehabilitation by reducing opioid-related side effects. The objective was to investigate the feasibility of opioid-reduced general anesthesia based on esketamine and to observe postoperative nausea and vomiting (PONV), postoperative pain, hemodynamics and other adverse reactions in gynecological day surgery compared with the traditional opioid-based anesthesia program.
METHOD
This study was conducted as a prospective parallel-group randomized controlled trial. A total of 141 adult women undergoing gynecological day surgery were included. Patients were randomly assigned to receive traditional opioid-based anesthesia (Group C) with alfentanil, or opioid-reduced anesthesia (a moderate-opioid group (Group MO) and low-opioid group (Group LO) with esketamine and alfentanil). For anesthesia induction, the three groups received 20, 20, 10 μg/kg alfentanil respectively and Group LO received an additional 0.2 mg/kg esketamine. For maintenance of anesthesia, the patients in Group C received 40 μg/kg/h alfentanil, and those in Group MO and Group LO received 0.5 mg/kg/h esketamine.
RESULTS
Patients in the three groups had comparable clinical and surgical data. A total of 33.3% of patients in Group C, 18.4% of patients in Group MO and 43.2% of patients in Group LO met the primary endpoint (p = 0.033), and the incidence of nausea within 24 hours after surgery in Group MO was lower than in Group LO (p < 0.05). The extubation time, median length of stay in the hospital after surgery and visual analog scale (VAS) of postoperative pain were equivalent in the three groups. The frequencies of adverse hemodynamic events in the MO 1(0, 2) and LO 0(0, 1) groups were significantly decreased (p < 0.05). Compared with Group C, the median length of stay in the postanesthesia care unit (PACU) in Group LO was increased, 60.0 (36.25, 88.75) vs. 42.5 (25, 73.75) minutes (p < 0.05).
CONCLUSIONS
Opioid-reduced anesthesia based on esketamine is feasible and provides effective analgesia for patients. Esketamine provided a positive analgesic effect and the opioid-reduced groups showed more stable hemodynamics. However, less or no use of opioids did not result in a more comfortable prognosis.
TRIAL REGISTRATION
This study was registered at Chictr.org.cn (NO. ChiCTR2100053153 ); November 13, 2021.
Topics: Adult; Humans; Female; Analgesics, Opioid; Ambulatory Surgical Procedures; Alfentanil; Prospective Studies; Pain, Postoperative; Anesthesia, General
PubMed: 36384481
DOI: 10.1186/s12871-022-01889-x -
Frontiers in Pharmacology 2022Sedation is recommended by most guidelines to be offered to all patients undergoing diagnostic flexible bronchoscopy (DFB) without contraindications, and the most...
Sedation is recommended by most guidelines to be offered to all patients undergoing diagnostic flexible bronchoscopy (DFB) without contraindications, and the most commonly reported regimen is midazolam in combination with a short-acting opioid (fentanyl or alfentanil) to provide both sedative and antitussive effects. However, the optimal dose or ideal regimen of the combination therapy with midazolam and opioids has not yet been found. So this randomized, double-blinded clinical trial was designed and registered (ChiCTR2100049052) to assess the safety and efficacy of midazolam combined with different doses of alfentanil in DFB sedation. Our study showed that relative high doses of alfentanil (10-25 μg/kg) combined with a fixed low dose of midazolam can markedly reduce hemodynamic fluctuations, cough reactions, patients' discomforts, and improve their satisfaction in a dose-dependent manner during DFB, with no significant increase in the desaturation risks.
PubMed: 36339547
DOI: 10.3389/fphar.2022.1036840 -
Contrast Media & Molecular Imaging 2022The efficacy and adverse reactions of remimazolam besylate (RB) in combination with alfentanil in patients with painless gastroscopy remain unclear. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The efficacy and adverse reactions of remimazolam besylate (RB) in combination with alfentanil in patients with painless gastroscopy remain unclear.
OBJECTIVE
The aim of the study is to observe the efficacy and adverse reactions of RB in combination with alfentanil in patients with painless gastroscopy RB.
METHODS
All patients were randomly divided into two groups: RB combined with the alfentanil group (research group) and propofol combined with the alfentanil group (control group). After full oxygen inhalation and electrocardiographic monitoring, the research group was given 10 g/Kg alfentanil + RB 0.2 mg/kg intravenously, and the control group was given 10 g/Kg alfentanil + propofol 1.5 mg/kg. If there is a clinical need, the research group was given 2.5 mg/additional RB, whereas the control group was treated with an additional 0.5 mg/kg propofol. Main outcome measures were as follows: The vital endpoints including diachronic changes in heart rate (HR), blood pressure (BP), respiratory rate (RR), blood oxygen saturation (SPO), end-expiratory carbon dioxide (etCO), IPI, modified observer's assessment of alert/sedation (MOAA/S), time-related endpoints, perioperative adverse events, endoscopy, and anesthesiologist satisfaction, and 24-hour follow-up of adverse reactions, IPI scores, and satisfaction were recorded.
RESULTS
The HR and BP of the patients in the research group and the control group decreased, with a greater decrease in the control group, and the difference was statistically significant ( < 0.05). The values of RR, PETCO, and IPI in the research group and the control group decreased to the lowest at 2-3 min but the decrease in the control group was more significant. Furthermore, there was no significant difference in the time from the completion of administration to 4 minutes of IPI and the total examination time, but the awakening time in the research group was slightly longer than that in the control group, and the difference was statistically significant ( < 0.05). The incidences of respiratory depression and hypotension during the operation were shown to be markedly smaller in the investigation relative to the control team, and the difference was statistically significant ( < 0.05), whereas the occurrence of cough, movements, and singultus was more common in the investigations, and the difference was statistically significant ( < 0.05). The results of the 24-hour follow-up showed that the adverse reactions such as nausea, dizziness, fatigue, abdominal pain, and abdominal distension were much less frequent in the study team, and the difference was statistically significant ( < 0.05), and the patient satisfaction was higher than in the control group, and the difference was statistically significant ( < 0.05). The regression results showed that age, sedative, and total dose of analgesia had significant effects on the results, and the covariance coefficient of sedative was 1.57 of IPI score in the research group higher than that of the control group.
CONCLUSIONS
RB combined with alfentanil can provide safe and effective sedation for patients undergoing painless gastroscopy. Compared with propofol, RB and alfentanil for injection can avoid large hemodynamic fluctuations and deep sedation, and have fewer adverse reactions. However, the cases involved in this study are all from a single-center data, which requires further multicenter research and conformation.
Topics: Humans; Alfentanil; Propofol; Single-Blind Method; Gastroscopy; Carbon Dioxide; Conscious Sedation; Hypnotics and Sedatives; Oxygen
PubMed: 36263002
DOI: 10.1155/2022/7102293 -
Frontiers in Medicine 2022Oral dental treatment cause anxiety, fear, and physical stress. This study aimed to investigate the efficacy and safety of moderate sedation by remimazolam with...
BACKGROUND
Oral dental treatment cause anxiety, fear, and physical stress. This study aimed to investigate the efficacy and safety of moderate sedation by remimazolam with alfentanil vs. propofol with alfentanil in third molar extraction.
METHODS
This single-center, randomized, single-blind clinical trial included 100 adults who underwent third molar ambulatory extraction. All patients had continuous infusion of Alfentanil 0.2 μg/kg/min. Group remimazolam with alfentanil (group RA) had an induction dose of 80 μg/kg and maintenance dosage of 5 μg/kg/min. In group propofol with alfentanil (PA group), propofol was infused at an initial concentration of 1.8 μg/mL under target controlled infusion (TCI) mode and a maintenance concentration of 1.5 μg/mL. The incidence rates of adverse effects were recorded and compared. Depth of sedation was assessed using the modified observer alertness/sedation assessment (MOAA/S) and entropy index. Recovery characteristics were recorded and complications observed for next 24 h.
RESULTS
The incident of adverse events 6 (12%) in the group RA was lower than the group PA 25 (50%) [Mean difference 0.136 (95%CI, 0.049-0.377); < 0.05], with no serious adverse events during the sedation procedure. The incidence of injection pain in group RA was significantly lower than that in group PA [4 vs. 26%, mean difference 0.119 (95%CI, 0.025-0.558); = 0.004]. Before starting local anesthesia, the mean arterial pressure, heart rate, and respiratory rate of the PA group were lower than those of the RA group. None of the patients required further treatments for a decreased heart rate, blood pressure, or low SpO. The rate of moderate sedation success was 100% in both groups. The MOAA/S score was similar between the groups indicating that the depth of sedation was effective. Group RA had significantly shorter recovery and discharge times than those of group PA.
CONCLUSIONS
Remimazolam with alfentanil is a safer and more effective alternative for ambulatory sedation and can reduce recovery and discharge time and the incidence of perioperative adverse events compare with propofol.
CLINICAL TRIAL REGISTRATION
http://www.chictr.org.cn/index.aspx, identifier: ChiCTR2200058106.
PubMed: 36117971
DOI: 10.3389/fmed.2022.950564 -
BMC Anesthesiology Sep 2022To observe the effect of different antiemetic drugs for the prevention of postoperative nausea and vomiting (PONV) after gynaecological day surgery under remimazolam... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
To observe the effect of different antiemetic drugs for the prevention of postoperative nausea and vomiting (PONV) after gynaecological day surgery under remimazolam general anesthesia.
METHODS
One hundred ninety-two patients were selected for gynaecological day surgery and randomly divided into three groups: droperidol group (DD group), tropisetron group (DT group) and control group (DC group). Flurbiprofen axetil 50 mg and dexamethasone 5 mg were given intravenously before induction of anesthesia, and 2 min later droperidol 1 mg was given intravenously to the DD group, tropisetron 5 mg to the DT group and saline (5 ml) to the DC group. Induction of anesthesia: remimazolam 6 mg/kg/h was continuously infused until sleep, mivacurium 0.2 mg/kg and alfentanil 20ug/kg were slowly pushed, 3 min later intubation was performed to control breathing. Maintenance of anesthesia: 40ug/kg/h of alfentanil, 1 mg/kg/h of remimazolam continuous infusion. After awakening and extubation, the patient was transferred to the PACU. PONV were recorded in the PACU and an electronic questionnaire was pushed 24 h after surgery.
RESULTS
The incidence of PONV within the PACU was significantly lower in the DD (14.5%)and DT(26.7%) groups than in the DC(50%) group (p < 0.01), there was no significantly difference between the DT and DD groups. There were no significant difference in the incidence of PONV in 24 h after surgery between the three groups(DD:DT:DC = 44.5%:45.1%:63.8%,p > 0.05).
CONCLUSIONS
Droperidol or tropisetron combined with dexamethasone is superior to dexamethasone alone for the prevention of PONV in the PACU after remimazolam combined with alfentanil anesthesia, with no significant difference in the incidence of PONV in 24 h after surgery.
Topics: Alfentanil; Ambulatory Surgical Procedures; Anesthesia, General; Antiemetics; Benzodiazepines; Dexamethasone; Droperidol; Female; Humans; Mivacurium; Postoperative Nausea and Vomiting; Tropisetron
PubMed: 36109691
DOI: 10.1186/s12871-022-01835-x -
Translational Cancer Research Aug 2022There is a high risk of hypoxia or apnea for patients with huge tracheal tumor during general anesthesia. Here we reported two cases of extremely huge endotracheal...
BACKGROUND
There is a high risk of hypoxia or apnea for patients with huge tracheal tumor during general anesthesia. Here we reported two cases of extremely huge endotracheal tumors undergoing fiberoptic bronchoscopic interventional therapy under general anesthesia. We hope the experience will be of reference value for formulating reasonable anesthesia scheme for such critically ill patients.
CASE DESCRIPTION
The two patients were accompanied with severe respiratory distress. And fiberoptic bronchoscopy revealed that the trachea cavity was blocked nearly completely by extremely huge tracheal tumor. Tracheal tumors were scheduled to be removed with fiberoptic bronchoscopic interventional therapy. General anesthesia was inducted with alfentanil and propofol. Then a laryngeal mask was inserted and spontaneous breath was preserved. During the operation, complete airway obstruction occurred, but it was effectively handled by using the fiberoptic bronchoscope to push the tumor and reopen the gap between the mass and the tracheal wall. After the therapy, the patients' symptom of respiratory distress was relieved significantly.
CONCLUSIONS
For patients with huge tracheal tumor that to be handled with fiberoptic bronchoscopic interventional therapy, general anesthesia with spontaneous breath induced by alfentanil and propofol is preferable. The most important, when complete airway blockade occurs during the process, pushing the tumor and reopening the respiratory tract with fiberoptic bronchoscope is a fairly effective solution to enable patients to be reoxygenated.
PubMed: 36093539
DOI: 10.21037/tcr-22-199 -
British Journal of Anaesthesia Nov 2022Rapid elimination of remifentanil facilitates application of intense opioid effect during general anaesthesia whilst maintaining prompt emergence. Interruptions in...
Rapid elimination of remifentanil facilitates application of intense opioid effect during general anaesthesia whilst maintaining prompt emergence. Interruptions in remifentanil supply mean clinicians must relearn titration of pharmacokinetically longer-acting opioids to achieve appropriate levels of opioid effect whilst maintaining acceptable recovery times. Opioid-free anaesthesia is achievable for many minor and intermediate surgical procedures for which remifentanil might have been used previously.
Topics: Humans; Remifentanil; Anesthetics, Intravenous; Alfentanil; Propofol; Piperidines; Analgesics, Opioid; Anesthesia, General
PubMed: 36057481
DOI: 10.1016/j.bja.2022.08.001