Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr. 22, D-81675 Munich, Germany
Corresponding author. E-mail: o.detsch@lrz.tum.de Presented in part at the annual meeting of the American Society of Anesthesiologists, Orlando, USA, October 2002.
Accepted for publication: June 2, 2003
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Abstract |
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Methods. Adult patients having panendoscopy, microlaryngoscopy, or tonsillectomy were randomly assigned to receive either propofol-pronounced (propofol 100 µg kg1 min1; remifentanil 0.15 µg kg1 min1) or remifentanil-pronounced (propofol 50 µg kg1 min1; remifentanil 0.45 µg kg1 min1) anaesthesia. In both groups, the procedure was started with remifentanil 0.4 µg kg1, propofol 2 mg kg1, and mivacurium 0.2 mg kg1. Cardiovascular measurements and EEG bispectral index (BIS) were recorded. To maintain comparable anaesthetic depth, additional propofol (0.5 mg kg1) was given if BIS values were greater than 55 and remifentanil (0.4 µg kg1) if heart rate or arterial pressure was greater than 110% of pre-anaesthetic values.
Results. Patient and surgical characteristics, cardiovascular measurements, and BIS values were similar in both groups. There were no differences in recovery times between the groups (time to extubation: 12.7 (4.5) vs 12.0 (3.6) min, readiness for transfer to the recovery ward: 14.4 (4.4) vs. 13.7 (3.6) min, mean (SD)).
Conclusions. In patients having short painful surgery, less propofol does not give faster recovery as long as the same anaesthetic level (as indicated by BIS and clinical signs) is maintained by more remifentanil. However, recovery times were less variable following remifentanil-pronounced anaesthesia suggesting a more predictable recovery.
Br J Anaesth 2003; 91: 5802
Keywords: anaesthetic techniques, i.v.; anaesthetics i.v., propofol; analgesics opioid, remifentanil; brain, electroencephalography; recovery
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Introduction |
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Methods and results |
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Values of MAP, HR, SpO2, and BIS were recorded at 1-min intervals during induction and emergence, and at 5-min intervals during maintenance. The times from stopping the infusions to eye opening (verbal command repeated every 15 s), to spontaneous respiration, to extubation, and to readiness for transfer to the recovery ward (based on adequate respiration, stable arterial pressure, HR, and response to command) were recorded. Data are given as mean (SD) or number of patients. For statistical analysis, t-tests for paired and unpaired data, and 2-tests were used, as appropriate. A Bonferroni-adjusted P<0.05 was considered significant. A sample size calculation before the study (
=0.05, ß=0.8) based on the results of a pilot study suggesting a sample size of 21 patients in each group should detect a 3-min reduction in readiness for discharge to the recovery unit.
Forty-four patients were enrolled. One patient was excluded because of changes in the surgical procedure. The groups did not differ with respect to patient characteristics, type and duration of surgery, and duration of infusion of propofol/remifentanil (Table 1). The number of patients given additional doses of propofol and remifentanil and the number of doses did not differ between groups. There were no significant differences between groups for MAP, HR, and BIS values at any time in the study. Mean recovery times (resumption of spontaneous ventilation, eye opening, extubation, or readiness for transfer to the recovery ward) did not show significant differences between groups. However, the ranges of all recovery variables were less in the remifentanil-pronounced group; for example, the range for the time to extubation and readiness for transfer to the recovery ward were 21 and 20 min in the propofol-pronounced group compared with 11 and 12 min in the remifentanil-pronounced group. There were no differences between groups in drug usage (analgesics, antiemetics) and nausea/vomiting in the recovery ward. No intra-operative awareness with recall was reported.
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Comment |
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In the study, additional anaesthetic doses were given when anaesthesia was deemed inadequate. This may be a weakness of the study design, because it could increase the infusion rate of the low dose drug, which may end up being a high dose rate; however, this did not take place in our patients. For remifentanil, additional doses were small and similar between groups and infusion rates remained nearly unchanged. For propofol, dose adjustment increased the total propofol dose by approximately 50 µg kg1 min1 in both groups; that is propofol doses in both groups were increased as compared with the intended drug regimen, but the difference between high and low propofol dose was maintained.
A fast and predictable emergence from anaesthesia can improve efficiency of operating theatre use, especially in surgery with a rapid turn-over. In the present study, panendoscopies, microlaryngoscopies, and tonsillectomies were chosen. These include laryngoscopy during surgery, which is an intensely painful stimulus.10 Deep analgesia and hypnosis are required until the end of surgery, which can prolong emergence. We found no decrease in mean recovery times. However, for efficient operating theatre scheduling, not only the average recovery times but also the variation of these times are important. Our data show a smaller variability (i.e. smaller range) of recovery times following remifentanil-pronounced anaesthesia. This suggests predictable emergence and may help in scheduling operating theatre allocations. A shortcoming of our study is that we did not measure intermediate recovery such as discharge from the recovery ward. However, an effect on intermediate recovery was not expected, as previous studies have shown that the use of remifentanil only affects early recovery.3 4 In addition, the actual discharge from the recovery ward may be highly influenced by logistic factors or a preconception of a minimal period of stay in the recovery ward.4
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Acknowledgement |
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References |
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2 Monk TG, Yifeng D, White PF. Total intravenous anesthesia: effects of opioid versus hypnotic supplementation on autonomic responses and recovery. Anesth Analg 1992; 75: 798804[Abstract]
3 Loop T, Priebe HJ. Recovery after anesthesia with remifentanil combined with propofol, desflurane, or sevoflurane for otorhinolaryngeal surgery. Anesth Analg 2000; 91: 1239
4 OHare RA, Mirakhur RK, Reid JE, Breslin DS, Hayes A. Recovery from propofol anaesthesia supplemented with remifentanil. Br J Anaesth 2001; 86: 3615
5 Wuesten R, Van Aken H, Glass PSA, Buerkle H. Assessment of depth of anesthesia and postoperative respiratory recovery after remifentanil- versus alfentanil-based total intravenous anesthesia in patients undergoing ear-nose-throat surgery. Anesthesiology 2001; 94: 2117[ISI][Medline]
6 Lang E, Kapila A, Shlugman D, Hoke JF, Sebel PS, Glass PSA. Reduction of isoflurane minimal alveolar concentration by remifentanil. Anesthesiology 1996; 85: 7218[ISI][Medline]
7 Fragen RJ, Randel GI, Librojo ES, et al. The interaction of remifentanil and propofol to prevent response to tracheal intubation and the start of surgery for outpatient knee arthroscopy. Anesthesiology 1994; 81: A376
8 Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology 2000; 93: 133644[ISI][Medline]
9 Koitabashi T, Johansen JW, Sebel PS. Remifentanil dose/electroencephalogram bispectral response during combined propofol/regional anesthesia. Anesth Analg 2002; 94: 15303
10 Zbinden AM, Petersen-Felix S, Thomson DA. Anesthetic depth defined using multiple noxious stimuli during isoflurane/oxygen anesthesia. II. Hemodynamic responses. Anesthesiology 1994; 80: 2617[ISI][Medline]