Cost-reduction analysis of propofol versus sevoflurane: maintenance of anaesthesia for gynaecological surgery using the bispectral index

BACKGROUND AND OBJECTIVE: The study was designed to compare the costs of propofol versus sevoflurane for the maintenance of the hypnotic component of anaesthesia during general anaesthesia, guided by the bispectral index, for gynaecological laparoscopic surgery. METHODS: Forty ASA Grade I-II female patients scheduled for gynaecological laparoscopy were randomly allocated to two groups. All patients received a continuous infusion of remifentanil (0.25 microg kg(-1) min(-1)) for 2 min. Then anaesthesia was induced with propofol 1% at 300 mL h(-1) until loss of consciousness. To guide the bispectral index between 40 and 60, Group 1 patients received propofol 10 mg kg(-1) h(-1) initially, which was increased or decreased by 2 mg kg(-1) h(-1) steps; Group 2 patients received sevoflurane, initially set at 2 vol.% and adjusted with steps of 0.2-0.4%. The time and quality of anaesthesia and recovery were assessed in two postoperative standardized interviews. RESULTS: Patient characteristics, the propofol induction dose, the bispectral index and the haemodynamic profiles during induction of anaesthesia, and its duration, were similar between the groups. In Group 1, 7.55 +/- 1.75 mg kg(-1) h(-1) propofol and in Group 2, 0.20 +/- 0.09 mL kg(-1) h(-1) liquid sevoflurane were used for maintenance. The cost for maintenance, including wasted drugs, was higher when using propofol (Euro 25.14 +/- 10.69) than sevoflurane (Euro 12.80 +/- 2.67). Postoperatively, recovery profiles tended to be better with propofol; however, the day after discharge no differences were found. CONCLUSIONS: When applying the bispectral index to guide the administration of hypnotic anaesthetic drugs, propofol-based maintenance of anaesthesia was associated with the highest cost. A trend towards a better recovery profile was obtained with propofol. However, on the day after discharge, no differences in quality were observed.     

TIVA mit Propofol/Remifentanil oder balancierte Anästhesie mit Sevofluran/Fentanyl bei laparoskopischen Operationen

OBJECTIVE: This study was designed to investigate the differences between TIVA with propofol/remifentanil (P/R) and balanced anaesthesia with sevoflurane/fentanyl (S/F) in gynaecological laparoscopic surgery. Emphasis was put on haemodynamic reaction, recovery profile, postoperative side effects and patient satisfaction. METHODS: Sixty patients were randomly assigned to receive either total intravenous anaesthesia with propofol/remifentanil or anaesthesia with sevoflurane/fentanyl. After premedication (midazolam) and induction of anesthesia (propofol, atracurium) in both groups, either 1 microgram/kg fentanyl (S/F) or 1 microgram/kg remifentanil (P/R) was injected. Anaesthesia was maintained with 0.5 microgram/kg/min remifentanil (reduced to 50% after 5 min) and 0.06 microgram/kg/min propofol (P/R) or 1.7 vol % sevoflurane (S/F). Both groups were mechanically ventilated with 30% oxygen in air. The administration of sevoflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. For postoperative analgesia 1 g paracetamol was administered rectally prior to surgery. After recovery 20 mg/kg metamizol was given intravenously. At the end of surgery the anaesthetics were discontinued and haemodynamics, early emergence from anaesthesia, pain level, frequency of analgesic demand, incidence of PONV, shivering and patient satisfaction were assessed. Parameters were recorded for 24 h postoperatively. RESULTS: Recovery time after propofol-remifentanil anaesthesia was significantly shorter than after administration of sevoflurane and fentanyl (spontaneous ventilation 4.1 vs. 6.3 min, extubation 4.3 vs. 9.3 min, eye opening 4.4 vs 8.2 min, stating name 5.3 vs. 13.2 min, stating date of birth 5.4 vs. 13.3 min). There were no significant differences between the groups in shivering, pain score, analgesic demand and PONV. The S/F group responded to tracheal intubation with significantly higher blood pressure than the P/R group. During maintenance of anaesthesia heart rate in patients with S/F was significantly higher (P/R:HR max +16/-10; S/F:HR max +24/-0.). Measured on a scale (S/F 62%). CONCLUSION: Compared with patients given balanced anaesthesia with sevoflurane and fentanyl, TIVA with propofol and remifentanil proved to be particularly suited for gynaecological laparoscopic surgery. Its major advantages are haemodynamic stability, significantly shorter times of emergence, and the exceptional acceptance by the patients.     

Rocuronium duration of action under sevoflurane, desflurane or propofol anaesthesia

BACKGROUND AND OBJECTIVE: We conducted a prospective randomized study to evaluate whether the duration of action of a single bolus dose of rocuronium is influenced by maintenance of anaesthesia with sevoflurane, desflurane or propofol infusion. METHODS: Fifty-seven ASA I-II patients undergoing elective abdominal surgery were enrolled in this study. Anaesthesia was induced with thiopental 3-5 mg kg(-1) or propofol 2.5 mg kg(-1) and fentanyl 5 microg kg(-1) and tracheal intubation was facilitated with rocuronium 0.9 mg kg(-1). Thereafter patients were randomly allocated to three different groups to receive sevoflurane, desflurane or propofol for maintenance of anaesthesia. Recovery of neuromuscular function was monitored by single twitch stimulation of the ulnar nerve and by recording the adductor pollicis response using accelerometry. Intergroup recovery times to 5% of control value of single twitch were analysed using analysis of variance with Bonferroni correction. RESULTS: The mean (95% confidence interval) recovery time to 5% of control value of single twitch during desflurane anaesthesia was 90.18 (86.11-94.25) min. Significantly shorter recovery times were observed during sevoflurane or propofol anaesthesia, 58.86 (54.73-62.99) min and 51.11 (45.47-56.74) min, respectively (P < 0.001). There were also significant differences in the recovery time between groups receiving desflurane vs. sevoflurane (P < 0.001) and desflurane vs. propofol (P < 0.001). CONCLUSIONS: Desflurane anaesthesia significantly prolongs the duration of action of rocuronium at 0.9 mg kg(-1) single bolus dose, compared to sevoflurane or propofol anaesthesia maintenance regimens.     

Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol

BACKGROUND: Emergence agitation in children is frequently associated with the use of the new highly insoluble volatile anaesthetics. Rapid emergence has been cited as one of the possible causes. Propofol also permits rapid emergence from general anaesthesia but is not associated with agitation. METHODS: The emergence characteristics of children receiving sevoflurane and propofol anaesthesia were examined. After induction with sevoflurane, 53 children, aged 2-36 months, who were undergoing ambulatory surgery, were randomized to receive maintenance anaesthesia with either sevoflurane or propofol. Introperative analgesia with either 2 micro g x kg-1 of intravenous fentanyl or a caudal block with 0.25% bupivacaine was supplied according to surgical procedure. An observer blinded to anaesthetic technique recorded the time to achieve extubation and recovery and assessed emergence behaviour. Data were analysed using Wilcoxon scores, Kruskal-Wallis test, chi-square and multiple regression analysis. RESULTS: The results showed that the time to extubation and recovery were similar between the two study groups, but that emergence agitation was significantly higher in the sevoflurane group compared with the propofol group. No relationship between analgesic technique and agitation scores was found. CONCLUSIONS: Although both sevoflurane and propofol allow for rapid emergence from general anaesthesia, only sevoflurane is associated with a high incidence of emergence agitation in infants and young children. Rapid emergence does not fully explain this phenomena.     

Sevoflurane versus propofol for induction and maintenance of anaesthesia with the laryngeal mask airway in children

We compared patient outcomes for propofol vs sevoflurane with the laryngeal mask airway (LMA) using either spontaneous breathing (SB) or pressure controlled ventilation (PCV). One hundred and twenty children undergoing minor surgery below the umbilicus were randomly assigned to receive either (1) propofol 3 mg.kg-1 followed by a maintenance infusion of 5 mg.kg-1.h-1, or (2) induction with sevoflurane 7% followed by maintenance with 1.7%. Following LMA insertion, patients were given atracurium and underwent PCV if surgery was expected to last > or = 30 min. The following assessments were made: time to LMA insertion/removal, airway problems, cardiorespiratory effects and recovery characteristics. The first time insertion success rates were similar, but insertion time was shorter with sevoflurane (115 +/- 67 s vs 252 +/- 107 s, P < 0.0001). One patient coughed during placement, but there were no other problems during any phase of anaesthesia in any group. Heart rate was higher in the sevoflurane group following insertion, during maintenance and emergence (all P < 0.03). There were no differences in blood pressure and oxygen saturation among groups PECO2 in the SB group was unaffected by the agent used. Emergence was more rapid (232 +/- 104 s vs 348 +/- 127 s, P < 0.0001) and postoperative agitation more common (15% vs 0%, P = 0.02) with sevoflurane. There were no differences in the Aldrete scores among groups. Patient outcome was similar for the SB and PCV groups. We concluded that the techniques described here using propofol and sevoflurane are equally suitable for induction and maintenance of anaesthesia with the LMA in children undergoing minor surgery below the umbilicus. Emergence is more rapid, but postoperative agitation more common with sevoflurane.     

Clinical and biochemical effects of propofol EDTA vs sevoflurane in healthy infants and young children

BACKGROUND: Propofol is frequently used for the induction and maintenance of anaesthesia in children aged 3 years and older. The present study compared the clinical and chemical effects of propofol containing disodium edetate (Diprivan) with that of sevoflurane in children younger than 3 years of age. METHODS: This was an open-label, comparative, parallel-group study. Fifty-six healthy children were randomly assigned to receive either propofol (n=28; mean age 14.7 months) or sevoflurane (n=28; mean age 13.2 months) for ambulatory surgical procedures. Anaesthesia was induced with nitrous oxide (60%), oxygen and sevoflurane (8%). In the propofol group, it was followed by an intravenous infusion of propofol at a rate of 200 microg.kg(-1).min(-1). For the sevoflurane group, anaesthesia was maintained with sevoflurane (1.5-2.5%). Haemodynamic measurements, recovery time and side-effects were recorded. Ionized calcium and magnesium concentrations in blood were measured. Statistical analysis was performed using ancova and the Fisher's exact test. RESULTS: The effects of propofol were similar to those of sevoflurane with respect to haemodynamic profile, recovery times (20 min vs 19.4 min) and side-effects (i.e. vomiting 10.7% vs 7.1%). Throughout the study, there were no significant differences between the mean ionized calcium and ionized magnesium concentrations in the two groups. CONCLUSIONS: In children younger than 3 years of age, propofol containing ethylenediaminetetraacetic acid has a similar profile to sevoflurane with respect to haemodynamic effects, recovery times, side-effects, ionized calcium and ionized magnesium levels.     

Effects of fentanyl on the incidence of emergence agitation in children receiving desflurane or sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE: In children, emergence agitation frequently complicates sevoflurane and desflurane anaesthesia. The effect of intravenous fentanyl 2.5 microg kg(-1) was examined on the incidence of emergence agitation in children who received desflurane or sevoflurane after midazolam premedication and intravenous thiopental induction. METHODS: One hundred and twenty children (2-7 yr) undergoing adenoidectomy or tonsillectomy, or both, were studied. All children were premedicated orally with midazolam 0.5 mg kg(-1). After intravenous induction with thiopental and atracurium to facilitate endotracheal intubation, patients were randomly assigned to one of four groups: Patients in Groups 1 and 3 received physiological saline solution, whereas patients in Groups 2 and 4 received intravenous fentanyl 2.5 microg kg(-1) during induction. Anaesthesia was maintained with sevoflurane in Groups 1 and 2 and with desflurane in Groups 3 and 4. After discontinuation of the volatile anaesthetic, the times to tracheal extubation and response to verbal stimuli (emergence time), and emergence behaviours were recorded. RESULTS: The time to tracheal extubation was significantly shorter in Groups 3 (5.2+/-1.7 min) and (6.4+/-2.1 min) than in Groups 1 (8.1+/-2.1 min) (P = 0.0001 and 0.006, respectively) and 2 (8.8+/-1.9 min) (P = 0.0001). The emergence time was significantly shorter in Group 3 (10.0+/-3.9 min) than in Groups 1 (13.8+/-4.9 min) (P = 0.017) and 2 (14.9+/-4.1 min) (P = 0.003). The incidence rate of severe agitation was 13% in Groups 1 and 3, and 7 and 10% in Groups 2 and 4, respectively (P > 0.05). CONCLUSIONS: After midazolam premedication and intravenous induction of anaesthesia with thiopental administration of intravenous fentanyl 2.5 microg kg(-1) did not provide any clinically significant benefit on emer gence agitation in children who receive sevoflurane or desflurane anaesthesia.     

Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia.

BACKGROUND: Office-based surgery is becoming increasingly popular because of its cost-saving potential Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and sevoflurane when used alone or in combination for office-based anesthesia. METHODS: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were randomly assigned to one of three general anesthetic groups. In groups I and II, propofol 2 mg/kg was administered for induction followed by propofol 75-150 microg x kg(-1) x min(-1) (group I) or sevoflurane 1-2% (group II) with N2O 67% in oxygen for maintenance of anesthesia In group m, anesthesia was induced and maintained with sevoflurane in combination with N2O 67% in oxygen. Local anesthetics were injected at the incision site before skin incision and during the surgical procedure. The recovery profiles, costs of drugs, and resources used, as well as patient satisfaction, were compared among the three treatment groups. RESULTS: Although early recovery variables (e.g., eye opening, response to commands, and sitting up) were similar in all three groups, the times to standing up and to be "home ready" were significantly prolonged when sevoflurane-N2O was used for both induction and maintenance of anesthesia. The time to tolerating fluids, recovery room stay, and discharge times were significantly decreased when propofol was used for both induction and maintenance of anesthesia. Similarly, the incidence of postoperative nausea and vomiting and the need for rescue antiemetics were also significantly reduced after propofol anesthesia. Finally, the total costs and patient satisfaction were more favorable when propofol was used for induction and maintenance of office-based anesthesia CONCLUSION: Compared with sevoflurane-N2O, use of propofol-N2O for office-based anesthesia was associated with an improved recovery profile, greater patient satisfaction, and lower costs. There were significantly more patients who were dissatisfied with the sevoflurane anesthetic technique.     

Remifentanil-sevoflurane anaesthesia for laparoscopic cholecystectomy: comparison of three dose regimens

The objective of this study was to determine a dosing regimen for remifentanil-sevoflurane anaesthesia that achieves an optimal balance between quality of anaesthesia and time to recovery. Patients undergoing elective laparoscopic cholecystectomy were randomly allocated to receive 0.4, 0.8 or 1.2 MAC (minimal alveolar concentration) of sevoflurane combined with remifentanil as required to maintain stable anaesthesia. For induction of anaesthesia, the remifentanil dose was 25 microg x kg(-1) x h(-1) and the mean propofol dose which was required to obtain loss of consciousness was 1.59 mg x kg(-1). During the maintenance phase, the mean remifentanil dose was 16.0, 14.1 and 13.0 microg x kg(-1) x h(-1) for the 0.4, 0.8 and 1.2 MAC groups, respectively. The mean sevoflurane maintenance dose was 0.91, 1.24 and 2.1% end-tidal for the 0.4, 0.8 and 1.2 MAC groups, respectively. The incidence of somatic responses was significantly higher in the 0.4 MAC sevoflurane group. Recovery times were significantly faster in the 0.4 compared to the 0.8 and 1.2 MAC groups and in the 0.8 compared to the 1.2 MAC group. The combination of 14 microg x kg(-1) x h(-1) remifentanil and 1.24% end-tidal sevoflurane achieved the optimal balance between the quality, and recovery from anaesthesia.     

Sevoflurane for interventional neuroradiology procedures is associated with more rapid early recovery than propofol

PURPOSE: Sevoflurane and propofol are both suitable for neuroanesthesia but have not previously been compared as maintenance agents for long duration (one to five hours) procedures. METHODS: Using a multicentre international study protocol, 103 patients were randomized to receive either sevoflurane or propofol for maintenance of anesthesia during interventional neuroradiology procedures. After a standardized induction of anesthesia with propofol, 53 patients received sevoflurane 1 to 3% with 60% nitrous oxide (N(2)O) in oxygen (O(2)), and 50 patients received propofol 4 to 10 mg x kg(-1) x hr(-1) with 60% N(2)O in O(2). Maintenance agents were titrated against systemic arterial blood pressure (baseline mean arterial pressure +/- 20%). Recovery times, changes in sedation, pain, nausea and vomiting and psychomotor function during recovery and use of rescue medication were recorded. RESULTS: The group receiving sevoflurane had a more rapid recovery to spontaneous ventilation, extubation, eye opening and orientation compared to the group receiving propofol (3 vs 4 min, P = 0.01; 5 vs 6 min, P = 0.015; 7 vs 10 min, P < 0.001; 13 vs 17 min, P = 0.028; respectively). Sedation, pain, nausea and vomiting, and psychomotor function scores were similar in the two groups. Use of opioid boluses and vasopressors were similar. CONCLUSION: The use of sevoflurane for maintenance of anesthesia for prolonged neuroradiological procedures is associated with more rapid early recovery than propofol and is associated with similar side effects. Sevoflurane and propofol can both be recommended for these procedures. The clinical benefit of the more rapid recovery with sevoflurane is unknown.     

A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia

BACKGROUND: Emergence agitation in children after sevoflurane is common. Different drugs have been used to decrease its occurrence with variable efficacy. The authors compared the incidence and severity of emergence agitation in children who received a single dose of propofol at the end of strabismus surgery versus children who received saline. METHODS: In this prospective, randomized, double-blind study, the authors enrolled 80 healthy children aged 2-6 yr. The children were randomly allocated to the propofol group (n = 41), which received 1 mg/kg propofol at the end of surgery, or to the saline group (n = 39), which received saline. RESULTS: The mean scores on the Pediatric Anesthesia Emergence Delirium scale were significantly lower in the propofol group compared with the saline group (8.6 +/- 3.9 vs. 11.5 +/- 4.5; P = 0.004). Also, the incidence of agitation was significantly lower in the propofol group compared with the saline group (19.5% vs. 47.2%; P = 0.01). A threshold score greater than 10 on the Pediatric Anesthesia Emergence Delirium scale was the best discriminator between presence and absence of emergence agitation. Times to removal of the laryngeal mask airway (10.6 +/- 1.5 vs. 9.4 +/- 1.9 min; P = 0.004) and emergence times (23.4 +/- 5.7 vs. 19.7 +/- 5 min; P = 0.004) were significantly longer in the propofol group. However, discharge times were similar between the two groups (propofol: 34.1 +/- 8.4 min; saline: 34.9 +/- 8.6 min). More parents in the propofol group were satisfied. CONCLUSIONS: In children undergoing strabismus surgery, 1 mg/kg propofol at the end of surgery after discontinuation of sevoflurane decreases the incidence of agitation and improves parents' satisfaction without delaying discharge from the postanesthesia care unit.     

A comparison of anaesthesia using remifentanil combined with either isoflurane, enflurane or propofol in patients undergoing gynaecological laparoscopy, varicose vein or arthroscopic surgery

BACKGROUND: Anaesthesia comprising remifentanil plus isoflurane, enflurane or propofol was randomly evaluated in 285, 285 and 284 patients, respectively, undergoing short-procedure surgery. METHODS: Anaesthesia was induced with propofol (0.5 mg x kg(-1) and 10 mg x 10 s(-1)), and a remifentanil bolus (1 microg x kg(-1)) and infusion at 0.5 microg x g(-1) x min(-1). Five minutes after intubation, remifentanil infusion was halved and 0.5 MAC of isoflurane or enflurane, or propofol at 100 microg x kg(-1) x min(-1) were started and titrated for maintenance. RESULTS: Patient demography and anaesthesia duration were similar between the groups. Surgery was performed as daycases (52%) or inpatients (48%). The median times (5-7 min) to extubation and postoperative recovery were similar between the groups. Responses to tracheal intubation (15% vs 8%) and skin incision (13% vs 7%) were significantly greater in the total intravenous anaesthesia (TIVA) group (P<0.05). Fewer patients given remifentanil and isoflurane (21%) or enflurane (19%) experienced > or =1 intraoperative stress response compared to the TIVA group (28%) (P<0.05). Median times to qualification for and actual recovery room discharge were 0.5-0.6 h and 1.1-1.2 h, respectively. The most common remifentanil-related symptoms were muscle rigidity (6-7%) at induction, hypotension (3-5%) and bradycardia (1-4%) intraoperatively and, shivering (6-7%), nausea and vomiting postoperatively. Nausea (7%) and vomiting (3%) were significantly lower with TIVA compared with inhaled anaesthetic groups (14-15% and 6-8%, respectively; P<0.05). CONCLUSION: Anaesthesia combining remifentanil with volatile hypnotics or TIVA with propofol was effective and well tolerated. Times of extubation, postanaesthesia recovery and recovery room discharge were rapid, consistent and similar for all three regimens.     

Maintenance and recovery characteristics after sevoflurane or propofol during ambulatory surgery in children with epidural blockade

PURPOSE: To compare the maintenance and recovery characteristics after sevoflurane with those after propofol in children with epidural blockade. METHODS: Fifty unpremedicated, children ASA I-II, 2-8 yr of age, scheduled for elective urological surgery as outpatients, were randomly allocated to receive either: 1) sevoflurane for induction and maintenance of anaesthesia or 2) propofol for induction (2-3 mg.kg-1 i.v.) and for maintenance (5-10 mg.kg-1.hr-1 i.v.). All children received N2O 70% in oxygen before induction and throughout the anaesthetic, rocuronium for neuromuscular blockade and a lumbar or caudal epidural block before incision. Heart rate (HR), systolic blood pressure (SBP), recovery times and all side effects during maintenance and recovery were recorded by a blinded observer. Adverse events during the first 24 hr were also recorded. RESULTS: Mean HR increased 5-10% after induction in both groups reaching a maximum by five minutes. Heart rate returned to baseline by skin incision in the sevoflurane group and by 10 min after induction in the propofol group. During maintenance, HR decreased by 10-20% below baseline values by 20 min in the propofol group only, where it remained for the remainder of the anaesthetic. Similarly, SBP increased by 10% after induction of anaesthesia in both groups, but returned to baseline by 10 min. Light anaesthesia occurred in four (16%) children, all in the propofol group. Emergence and recovery indices were similar in the two groups. DISCUSSION: Sevoflurane and propofol exhibit similar maintenance and recovery profiles when combined with epidural analgesia in children undergoing ambulatory surgery.     

Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia

BACKGROUND: Our aim was to study the feasibility of total intravenous anaesthesia with propofol in spontaneously breathing children undergoing ophthalmic procedures. METHODS: Fifty-five children (aged 6 months to 5 years) were randomly allocated to receive either propofol bolus (until loss of eyelash reflex) followed by infusion [group P (n=29)] or halothane 3-4% for induction, followed by 1-2% in 70% nitrous oxide and oxygen via face mask [group H (n=28)]. Dose for induction and maintenance, intraoperative adverse events, time to recovery (on an Observer's Assessment of Alertness/Sedation Scale, 5 at each level) and duration of procedure were recorded. All children in both groups, were anaesthetized successfully. RESULTS: 4.0 +/- 0.7 mg x kg(-1) and 5.1 +/- 1.0 mg x kg(-1) of propofol were required for loss of eyelash reflex and tolerance of the ophthalmic speculum, respectively. An infusion rate of 8.3 +/- 1.7 mg x kg(-1) x h(-1) was needed for maintenance of anaesthesia; 3.4 +/- 0.5%, 3.6 +/- 0.4% and 1.4 +/- 0.4% halothane was needed for induction, tolerance of the eye speculum and maintenance of anaesthesia, respectively. Induction and recovery were significantly faster with halothane compared with propofol [induction - 38.3 +/- 6.6 s (group H)/60.9 +/- 15.2 s (group P) (P < 0.001); recovery 12.8 +/- 4.6 min (group H)/27.0 +/- 23.3 min (group P) (P < 0.001)]. Apnoea, coughing and breath-holding were seen only in group H. Group P had significantly higher incidence of involuntary movements (minor degree) (n=6) (P < 0.01). CONCLUSIONS: Propofol is a feasible option for paediatric diagnostic ophthalmic procedures with the advantage over halothane of providing complete access to the eye.     

Emergence agitation after sevoflurane versus propofol in pediatric patients

Sevoflurane may be associated with a high incidence of emergence agitation in preschool children. We tested the hypothesis that maintenance of anesthesia with propofol after sevoflurane induction would reduce the incidence of this excitatory behavior compared with continuing sevoflurane for maintenance. We conducted a randomized, single-blinded, two-period, cross-over study in 16 preschool age children undergoing repeated brief general anesthetics for eye examination. After sevoflurane induction, patients were randomly assigned to receive either sevoflurane or propofol anesthesia for maintenance. The alternative anesthetic was used for the maintenance of anesthesia on the second occasion. We compared the speed and quality of recovery characteristics of these anesthetics, as well as, overall parent satisfaction with anesthesia. Eight patients first received sevoflurane and the remaining eight patients first received propofol. Of the patients who received sevoflurane for the maintenance of anesthesia, 38% developed emergence agitation. In contrast, none developed emergence agitation when propofol was administered for maintenance of anesthesia. Despite emergence agitation, sevoflurane provided a shorter postanesthesia care unit stay than propofol. Parent satisfaction with anesthesia was greater with propofol than with sevoflurane. IMPLICATIONS: In this cross-over study, we observed the incidence of emergence agitation with sevoflurane (38%) was significantly greater than with propofol (0%) in premedicated, preschool-aged children undergoing minor noninvasive surgery.     

Post-induction alfentanil reduces sevoflurane-associated emergence agitation in children undergoing an adenotonsillectomy

Background: Emergence agitation is a common problem in paediatric anaesthesia, especially after volatile induction and maintenance anaesthesia (VIMA) with sevoflurane. The purpose of this study was to investigate the effect of alfentanil to prevent emergence agitation without delayed recovery after VIMA with sevoflurane in children undergoing an adenotonsillectomy.
Methods: One hundred and five children, aged 3–10 years, were randomly allocated to receive normal saline (control group), alfentanil 10 μg/kg (A10) or 20 μg/kg (A20) 1 min after loss of the eyelash reflex. Anaesthesia was induced and maintained with sevoflurane. Time to tracheal extubation, recovery time, Paediatric Anaesthesia Emergence Delirium (PAED) scale and emergence behaviour were assessed.
Results: The incidence of severe agitation was significantly lower in the A10 and A20 groups compared with those in the control group (11/32 and 12/34 vs. 24/34, respectively) ( P =0.007, 0.006, respectively). PAED scales were significantly different between the three groups ( P =0.008), and lower in the A10 and A20 groups than that in the control group ( P =0.044, 0.013, respectively). However, the incidence of severe agitation and PAED scale was not different between the A10 and the A20 groups. Time to tracheal extubation and recovery time were similar in all three groups.
Conclusion: The administration of alfentanil 10 μg/kg after induction of anaesthesia for children undergoing an adenotonsillectomy under VIMA reduced the incidence of emergence agitation without delaying the recovery time or causing significant hypotension.     

Midazolam premedication delays recovery from propofol-induced sevoflurane anesthesia in children 1–3 yr

PURPOSE: To study the effect of midazolam premedication on the recovery characteristics of sevoflurane anesthesia induced with propofol in pediatric outpatients. METHODS: Sixty children, one to three years, presenting for ambulatory adenoidectomy were randomly assigned , in a double-blind fashion, to receive either 0.5 mg x kg(-1) midazolam (Group M) or placebo (Group P) p.o. 30 min before anesthesia. Anesthesia was induced with 10 microg x kg(-1) atropine, 10 microg x kg(-1) alfentanil, and 3-4 mg x kg(-1) propofol i.v.. Tracheal intubation was facilitated with 0.2 mg x kg(-1) mivacurium. Anesthesia was maintained with nitrous oxide/oxygen (FiO2 0.3) and sevoflurane with controlled ventilation. Recovery characteristics were compared using the modified Aldrete scoring system, the Pain/Discomfort scale and measuring specific recovery end-points (emergence, full Aldrete score, discharge). A postoperative questionnaire was used to evaluate the children's well-being at home until 24 hr after discharge. RESULTS: Emergence from anesthesia (22 +/- 9 vs 16 +/- 6 min (mean +/- SD), P = 0.005) and achieving full Aldrete scores (30 +/- 11 vs 24 +/- 16 min, P = 0.006) were delayed in patients receiving midazolam. Children in the placebo group were given postoperative analgesia sooner than those in the midazolam group (18 +/- 11 vs 23 +/- 8 min, P = 0.009). More children premedicated with midazolam suffered from arousal distress (20% vs 3%, P = 0.04) and scored higher on the Pain/Discomfort scale (P = 0.004) at 20 min after arrival in the recovery room. Discharge was not affected by premedication and well-being at home was similar in the groups. CONCLUSIONS: Oral premedication with midazolam delays early recovery but not discharge after ambulatory sevoflurane anesthesia induced with propofol in children one to three years. Midazolam did not improve the quality of recovery.     

Vomiting and Recovery after Outpatient Tonsillectomy and Adenoidectomy in Children: Comparison of Four Anesthetic Techniques Using Nitrous Oxide with Halothane or Propofol

Background: The authors' purpose in this study was to compare prospectively four different anesthetic induction and maintenance techniques using nitrous oxide with halothane and/or propofol for vomiting and recovery after outpatient tonsillectomy and adenoidectomy procedures in children.

Methods: Eighty unpremedicated children, aged 3-10 yr, were assigned randomly to four groups: group H/H, 0.5-2% halothane induction/halothane maintenance; group P/P, 3-5 mg *symbol* kg sup -1 propofol induction and 0.1-0.3 mg *symbol* kg sup -1 *symbol* min sup -1 propofol maintenance; group H/P, 0.1-0.3 mg *symbol* kg sup -1 *symbol* min sup -1 halothane induction/propofol maintenance; and group P/H, 3-5 mg *symbol* kg sup -1 propofol induction and 0.5-2% halothane maintenance. Nitrous oxide (67%) and oxygen (33%) were administered in all the groups. Other treatments and procedures were standardized intra- and postoperatively. Results of postoperative vomiting and recovery were analyzed in the first 6 h and beyond 6 h.

Results: Logistic regression showed that vomiting occurred 3.5 times as often when halothane was used for maintenance of anesthesia (groups H/H and P/H) compared with the use of propofol (groups P/P and H/P; Odds Ratio 3.5; 95% confidence interval 1.3 and 9.4, respectively; P = 0.012). A significant association between vomiting (< 6 h: yes/no) and discharge times (> 6 h: yes/no) (Odd's Ratio = 3.6; 95% confidence interval: 1.02, 12.4, respectively) (P = 0.046) was shown. However, no significant differences among the groups in the incidence of vomiting beyond 6 h, recurrent vomiting, or hospital discharge times were shown.     

Recovery characteristics of sevoflurane- or propofol-based anaesthesia for day-care surgery

Background: Sevoflurane has a low blood-gas partition coefficient resulting in a rapid recovery. Few studies have examined the maintenance and recovery characteristics of sevoflurane compared with propofol in a standardized outpatient population. Methods: The study was a multicentre study performed in 10 centres. One hundred and sixty-nine elective outpatients due for knee-arthroscopy received 100 mg diclofenac rectally as pain prophylaxis prior to induction of general anaesthesia with fentanyl 1.0–1.5 μg/kg+propofol 2.0–2.5 mg/kg iv. Anaesthesia was maintained with 60% nitrous oxide in oxygen through a laryngeal mask and continuous administration of either: sevoflurane (group S) or propofol infusion (group P) in order to maintain stable haemodynamics. Data of postoperative function and side-effects were collected in a double-blind design, including a patient interview after 24 h. Results: The sevoflurane patients had a significantly faster emergence from anaesthesia, with response to commands at 6.9±0.4 min versus 8.2±0.4 min in the propofol group (P < 0.05, mean±SD). At 15 min after surgery, group S had a better score in the digit symbol substitution test and felt less confused in a visual analogue scale test compared with group P (P<0.05). Peroperative bradycardia, nausea and vomiting and late postoperative dizziness were more common in group S. In the sevoflurane group, 32% had nausea or vomiting in the 24 h observation period compared with 18% for propofol (P < 0.05). There was no difference between group S and group P in postoperative pain, eligibility for recovery room discharge (75±12 versus 70±11 min) or home-readiness (155±12 versus 143±11 min). Conclusion: Maintenance of anaesthesia with sevoflurane results in a more rapid emergence, but a higher incidence of nausea and vomiting compared with propofol. The side-effects were minor in our study, and did not result in any difference in time to discharge from the recovery ward or the hospital.     

Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia for immediate postoperative ophthalmic evaluation following strabismus surgery

BACKGROUND AND OBJECTIVE: Following strabismus surgery, immediate postoperative ophthalmic evaluation may be desired. Thus, an anaesthetic technique allowing rapid recovery of ocular motility is required. Saccadic eye movements is a biophysical monitor of ocular motility and may be used to assess recovery from anaesthesia. The aim of this study is to compare the time to the recovery of saccadic eye movements in patients, following one of two anaesthetic techniques: Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia. METHODS: Fifty adult patients undergoing strabismus surgery were randomly assigned to one of two groups: patients in Group R received induction and maintenance of anaesthesia with propofol and remifentanil, while patients in Group S received induction of anaesthesia with propofol and fentanyl and maintenance of anaesthesia with sevoflurane. Recovery from anaesthesia was measured from the time all anaesthetics were turned off and was assessed every 2 min. Recovery time was attained when patients were able to generate brisk saccadic eye movements. At recovery time, the ophthalmic evaluation was started. RESULTS: The mean recovery time of saccadic eye movements was significantly shorter in the Group R when compared to the Group S (12.1 +/- 4.3 min vs. 21.5 +/- 4.7 min, respectively, P < 0.0001). More patients in Group S experienced nausea and vomiting postoperatively as compared to Group R (9/25 vs. 2/25, respectively, P = 0.037). CONCLUSIONS: Propofol-remifentanil-based anaesthesia may be a useful technique in strabismus surgery when immediate postoperative ophthalmic evaluation is desired. When compared to sevoflurane maintenance of anaesthesia, it allows for a more rapid recovery from anaesthesia as judged by recovery of saccadic eye movements and a decreased incidence of postoperative nausea and vomiting.