Remifentanil and propofol sedation for retrobulbar nerve block

We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I--remifentanil 1 microg/kg, Group II--remifentanil 0.5 microg/kg and propofol 0.5 mg/kg, Group III--remifentanil 1 microg/kg with propofol 0.5 mg/kg and Group IV--saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression. No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%). Hence, a combination of remifentanil 0.5 microg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.     

Remifentanil for analgesia during retrobulbar nerve block placement

BACKGROUND AND OBJECTIVES: Patients undergoing eye surgery under regional anaesthesia often require concomitant medication for analgesia and comfort. Remifentanil, with its ultra-short acting-profile, may be useful to reduce pain during retrobulbar nerve block for cataract surgery. METHODS: We performed a prospective, randomized, double-blind study to compare the efficacy of remifentanil for analgesia during retrobulbar nerve block placement. Ninety patients undergoing cataract surgery were randomly divided to receive either remifentanil 0.3 microg kg(-1) (n = 45) or an equivalent volume of saline (n = 45). The injection was administered within 30 s in both groups. Patients rated their amount of pain on a 10 cm visual analogue scale. Respiratory frequency, oxygen saturation, cardiac rhythm and postoperative nausea and vomiting (PONV) were recorded. RESULTS: The mean visual analogue score in the Remifentanil group was 2.56; it was 5.51 in the Saline group (P = 0.001, U-test). Three patients developed bradycardia and three had PONV in the Remifentanil group. Two patients developed tachycardia and one had PONV in the Saline group. No patient developed respiratory depression. CONCLUSION: In patients undergoing retrobulbar block placement for eye surgery, 0.3 microg kg(-1) remifentanil over 30 s significantly reduced their reported pain. In addition, remifentanil did not increase the risk of untoward side-effects.     

丙泊酚复合咪唑安定和/或芬太尼在胆道镜操作过程中的镇静作用

目的研究丙泊酚复合咪唑安定和/或芬太尼用于胆道镜操作过程中的镇静效果。方法选择18~65岁行胆道镜的患者90例,随机分为三组:PF组(n=31),首次静注芬太尼0.05 mg+丙泊酚1 mg/kg;PM组(n=29),首次静注咪唑安定2 mg+丙泊酚1 mg/kg;PMF组(n=30),首次静注芬太尼0.05 mg+咪唑安定2 mg+丙泊酚1 mg/kg。各组根据需要追加丙泊酚每次20~30 mg。记录心率、血压、脉搏血氧饱和度、镇静分级,观察患者症状及记忆缺失情况。结果用药后1 min三组患者都能达到满意的镇静效果(镇静分级2~3级);所有患者停药后17 min完全清醒,PF组恢复时间最短(P<0.01),但有21例(67.7%)对操作过程有记忆,只有15例(48.4%)患者对麻醉镇静的方法感到很满意。结论丙泊酚复合咪唑安定和/或芬太尼在胆道镜操作中镇静效果更好,无明显不良反应。     

丙泊酚复合咪唑安定和/或地佐辛在纤维支气管镜检查中的镇静作用

目的:研究丙泊酚复合咪唑安定和/或地佐辛用于纤维支气管镜检查中的镇静、镇痛效果.方法:选择18-65岁行纤维支气管镜的患者60例,随机分为三组:PD组(n=21),首次静注地佐辛5mg+丙泊酚1mg/kg; PM组(n=19),首次静注咪唑安定2mg+丙泊酚1mg/kg; PMD组(n=20),首次静注地佐辛5mg+咪唑安定2mg+丙泊酚1mg/kg.各组根据需要追加丙泊酚每次20-30mg.记录心率、血压、脉搏血氧饱和度、镇静分级,观察患者症状及记忆缺失情况.结果:用药后一分钟三组患者都能达到满意的镇静效果(镇静分级2-3级);所有患者停药后15分钟完全清醒,PD组恢复时间最短(P＜0.01),但有11例(52.4％)对操作过程有记忆,只有10例(47.6％)患者对麻醉镇静的方法很满意.结论:丙泊酚符合咪唑安定和/或地佐辛在纤维支气管镜检查中镇静效果更好,无明显不良反应.     

Target controlled infusion of ketamine as analgesia for TIVA with propofol

PURPOSE: To determine the accuracy of a target controlled infusion system for ketamine and to assess its suitability for the provision of analgesia when used in conjunction with a propofol infusion in spontaneously breathing patients. METHODS: Nineteen, adult, ASA I-III patients scheduled for elective surgery were studied. After premedication with 20 mg temazepam an appropriate plasma concentration of ketamine was selected and, when the target controlled infusion (TCI) system indicated that this had been achieved, anesthesia was induced and maintained using a propofol infusion. The plasma ketamine concentration was measured at predetermined intervals and cardiovascular and respiratory parameters recorded at 10 min intervals. Patients were reviewed in recovery and 24 hr postoperatively to assess the adequacy of their recovery and the presence of any undesirable side effects. RESULTS: The TCI system had a median performance error against predicted plasma concentrations of 18.9% (SE 2.5%) and a median absolute performance error of 23.3% (SE 2.3%). Divergence was 20.3% (SE 30.1%) and wobble was 12.9% (SE 2.1%). There was a mean decrease in arterial pressure of 6.4% (SD 19.7%) and a mean increase in heart rate of 4.3% (SD 17.4%). Little respiratory depression occurred and all patients made a rapid postoperative recovery with none describing unpleasant dreams or hallucinations. CONCLUSION: The TCI system provided a clinically acceptable degree of control of the plasma ketamine concentration although some further improvement should be possible by amending the pharmacokinetic model. Clinically the combination with a propofol infusion proved to be a satisfactory anesthetic technique.     

Sedation with ketamine and low-dose midazolam for short-term procedures requiring pharyngeal manipulation in young children

BACKGROUND: Pediatric intestinal biopsy procedures including considerable transpharyngeal manipulation of a wire-guided metal capsule require adequate sedation or anesthesia. This retrospective cohort study was designed to evaluate intravenous sedation with ketamine and low-dose midazolam in young children undergoing these procedures before and also after discharge from the hospital. METHODS: A total of 244 biopsy procedures in 217 children under the age of 16 years were evaluated. All anesthesia records were reviewed according to a defined study protocol and in 145 cases the parents were also interviewed by telephone to obtain further information on possible adverse effects before and after discharge. RESULTS: Ketamine and low-dose midazolam were carefully titrated by an experienced anesthesia team at an approximate dose ratio of 40 : 1 (total doses 2.3 and 0.05 mg.kg(-1)) in continuously monitored spontaneously breathing children. Possibly associated problems before discharge were salivation (5.7%), vomiting (4.9%), oxygen desaturation (3.3%), laryngospasm (2.5%) and rash (1.2%) according to the patient records and blurred vision (27%), nausea and vomiting (19%), vertigo (13%) and hallucinations or nightmares (3.5%) according to telephone interviews. Few, mild and transient problems remained after discharge from the hospital. CONCLUSIONS: Careful titration of ketamine and low-dose midazolam provides adequate sedation for nonsurgical pediatric short-term procedures also requiring considerable pharyngeal manipulation, particularly considering the low number of serious airway problems such as laryngospasm. The high incidence of late postoperative problems suggests that prospective studies should be designed for long-term follow-up of young children subjected to sedation or anesthesia.     

Sedation with continuously infused propofol in caudal block for elective pediatric surgery]

Twenty-nine patients aged between 2 months and 6 years, undergoing general surgery under regional analgesia (caudal block) combined with continuous infusion of propofol (3 mg/kg/h), were studied. During anesthesia the heart rate, the arterial pressure, the SaO2 and respiratory rate were recorded; the electrocardiogram was continuously displayed and all side-effects occurring during maintenance and recovery from anesthesia were noted. Satisfactory sedation without significant respiratory and cardiovascular depression and a rapid recovery, was observed. In conclusion, we feel that the use of combined caudal block and continuous infusion of propofol for paediatric surgery is rational.     

Effect of low-dose intravenous ketamine in postoperative analgesia for hysterectomy and adnexectomy

OBJECTIVE: To evaluate the efficacy of low dose ketamine (0.15 mg/Kg i.v.) as a pre-emptive pain relief after general anesthesia. METHOD: Sixty-nine gynecological surgery patients were enrolled in this prospective, double-blind study. All received total intravenous anesthesia and were randomized to group A (n = 23) to receive preoperative ketamine, to group B (n = 23) to receive postoperative ketamine or to group C (n = 23) to receive placebo. A patient-controlled anesthesia device with morphine and ketorolac was used to provide postoperative pain relief. We evaluated the time taken to resume spontaneous breathing and to administer the first analgesic dose; the pain score on a visual analogue scale at rest at 1, 6, 24, 48 h and on the fifth day, and upon movement on the first and fifth days; and morphine consumption at 6, 24 and 48 h. RESULTS: Recovery of spontaneous breathing occurred later in group B (10 +/- 5 min) than in group A (6.68 +/- 3.64 min; p < 0.05) or in group C (8 +/- 4 min). The first analgesic dose was infused later in group B (45.24 +/- 16.16 min; p < 0.001) than in group A (26.45 +/- 11.65 min) or in group C (25.47 +/- 9.19 min). The pain scores at rest were similar. On the fifth day, pain upon movement was less intense for patients treated with ketamine (group A 12 [10-21] and group B 13.5 [2-22]) than in patients treated with placebo (group C 23 [15.5-36.75]) (p < 0.05 group C vs. group A; and p < 0.01 group C vs. group B). Morphine consumption at 6 h was less in group B than group C (p < 0.01). CONCLUSIONS: A low dose of ketamine has no preemptive analgesic effect.     

丙泊酚复合氯胺酮静脉麻醉用于无痛肛肠外科手术的临床观察

目的:探讨丙泊酚复合氯胺酮用于肛肠外科手术的麻醉效果及安全性。方法:将96例ASAⅠ～Ⅱ级住院痔瘘手术患者随机分成两组(ASAⅠ-Ⅱ),F组53例,K组43例,F组为丙泊酚+舒芬太尼组,K组为丙泊酚+氯胺酮组。结果:F组血压在T2较T1明显下降,HRT2较T1明显下降,呼吸抑制程度明显重于K组,具有统计学意义;K组MAP在T2较T1稍有升高,无统计学意义,SpO2在T2较T1无明显变化,无统计学意义;苏醒时间F组稍短于K组。结论:在无痛肛肠外科手术麻醉中,丙泊酚复合氯胺酮对患者呼吸的抑制及生命体征的影响较丙泊酚复合舒芬太尼更低。     

Patient-controlled epidural analgesia with morphine or morphine plus ketamine for post-operative pain relief

Sixty patients were randomly assigned to two equal groups. Group I received epidural morphine 1 mg after surgery and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg h-1, 0.2 mg per bolus. Group II received an epidural loading dose of morphine 1 mg plus ketamine 5 mg and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg+ketamine 0.5 mg h-1, morphine 0.2 mg+ketamine 0.5 mg per bolus with a lockout time of 10 min. The mean morphine consumption was 8. 6+/-0.7 mg for group I and 6.2+/-0.2 mg for group II. Although group II utilized significantly less morphine (P < 0.05), pain relief was significantly better in group II than in group I (P < 0.05) in the first 3 h. Vomiting occurred more frequently in group I (26%) than in group II (13%). The frequency and severity of pruritus and level of sedation were similar in the two groups. These findings suggest that patient-controlled epidural analgesia with morphine plus ketamine may provide effective analgesia with a lesser dose of morphine and fewer subsequent side effects, compared with patient-controlled epidural analgesia with morphine alone after lower abdominal surgery.     

Comparison of caudal epidural bupivacaine with bupivacaine plus tramadol and bupivacaine plus ketamine for postoperative analgesia in children

This study compared the effect of single-dose caudal epidural bupivacaine, bupivacaine plus ketamine and bupivacaine plus tramadol for postoperative pain management in children having surgery for inguinal hernia. Following ethics committee approval and informed parental consent, 75 children ASA PS I and II, between three and nine years of age and scheduled for elective unilateral inguinal hernia repair with general anaesthesia were recruited. The patients were randomly divided into three groups to receive 0.5 ml/kg caudal bupivacaine 0.25% (group B), bupivacaine 0.25% plus tramadol 1 mg/kg (group BT) or bupivacaine 0.25% plus ketamine 0.5 mg/kg (group BK). The injections were performed under general anaesthesia. Mean arterial pressure, heart rate, pulse oximetry, respiratory rate and sedation and pain scores were recorded at defined intervals following recovery from anaesthesia. The groups were similar in age, weight and duration of operation (P >0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was (mean+/-SD) 6.5+/-4.1 h in group B, 9.2+/-3.9 h in group BK, and 8.5+/-3.1 h in group BT (P <0.05). More patients in group B required supplementary analgesics in the first 24 h (P <0.05). Sedation scores were comparable in all groups. Incidence of emesis and pruritus was similar in all the groups. Caudally administered 0.5 ml/kg bupivacaine 0.25% plus ketamine or bupivacaine 0.25% plus tramadol 1 mg/kg provided significantly longer duration of analgesia without an increase in the adverse effects when compared to bupivacaine alone.     

Sedation with intravenous benzodiazepine and ketamine for renal biopsies

“Lytic cocktail” is the customary sedation before percutaneous renal biopsy. Owing to deficient sedation and respiratory depression, this approach is no longer advised. The intravenous combination of a benzodiazepine plus ketamine, which has been found to be effective and safe in several conditions, was therefore used for 60 pediatric biopsies. In addition to pulse oximetry, a physician trained in airway management monitored the patient. The quality of sedation was acceptable (n = 7) or optimal (n = 53) in all cases. None of the patients required ventilation or intubation. A mild oxygen desaturation lasting 4 min or less was detected in 6 patients. None of the patients experienced major change in respiratory rate or blood pressure. The administration of ketamine and, in some cases, the biopsy puncture were associated with a mildly increased heart rate. In conclusion, a benzodiazepine plus ketamine provides effective deep sedation for renal biopsy in childhood. Received May 7, 1997; received in revised form September 3, 1997; accepted September 4, 1997     

阈下剂量氯胺酮与异丙酚并用的临床研究

选择２４例择期下肢手术患者，在硬膜外阻滞及血流动力学稳定的条件下，临床组静注氯胺酮０．５ｍｇ／ｋｇ和异丙酚２．５ｍｇ／ｋｇ，对照组单独静注异丙酚２．５ｍｇ／ｋｇ。做两组间血压、心率、经皮血氧饱和度（ＳｐＯ２）和麻醉苏醒时间的比较。结果表明，氯胺酮 ０．５ｍｇ／ｋｇ能防止由异丙酚引起的血压下降，同时两药的某些副作用明显减轻或消失，但异丙酚的呼吸抑制作用和苏醒时间明显延长。作者认为阈下剂量氯胺酮并用异丙酚用于麻醉诱导和维持，能产生较稳定的血流动力学效果，适宜门诊短小手术。     

Sedation for local analgesia

An approach to the patient is described that is of value when operations are performed under local analgesia during intravenous sedation with diazepam. The technique involves maintained distraction of the patient with some phantasy of his own choice. All mention of the different stages of the procedure is deliberately avoided.     

The comparison of caudal ketamine,alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children

BACKGROUND: Our aim was to compare the effect of single dose caudal ketamine, alfentanil or a mixture of both drugs in the treatment of pain after hypospadias repair surgery in children. METHODS: The group comprised 109 boys, ASA I-II, aged 1-9 years, who were undergoing hypospadias repair surgery as day cases. The children were randomly divided into three groups for postoperative analgesia: group 1, only alfentanil (20 microg x kg(-10) was given caudally; group 2, ketamine (0.5 mg x kg(-1)) alone; and group 3, alfentanil (20 microg x kg(-1))-ketamine (0.5 mg x kg(-1)) was given caudally. The analgesic effect of caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using a five-point sedation score. The first analgesic requirement time and the number of supplementary analgesics required by each child in a 24-h period were also recorded. RESULTS: No statistical differences were found in demographic characteristics, haemodynamic and respiratory parameters, objective pain scores, postoperative sedation scores and duration of surgery among the groups. The median time to first analgesia was significantly shorter in group 1 than in groups 2 and 3 (P=0.009, P=0.001). Significantly more patients in group 1 required additional postoperative analgesia (paracetamol 15 mg x kg(-1)) compared with groups 2 and 3 (P < 0.001). CONCLUSIONS: Caudal administration of ketamine 0.5 mg.kg-1 with or without alfentanil in children produced satisfactory postoperative analgesia without respiratory depression or other side-effects.     

小剂量氯胺酮复合丙泊酚-瑞芬太尼静脉麻醉在隆乳术中的应用

目的：观察小剂量氯胺酮复合丙泊酚-瑞芬太尼靶控输注用于隆乳术麻醉的效果和意义。方法：40例患者随机分为丙泊酚复合瑞芬太尼靶控输注组（PR组,n=20）和丙泊酚瑞芬太尼靶控输注联合氯胺酮组（PR-K组,n=20）。两组诱导起始效应室靶浓度相同,PR-K组于诱导时单次静注氯胺酮0.4mg/kg。观察并比较两组患者麻醉效果及血流动力学变化,记录丙泊酚和瑞芬太尼用量。结果：两种麻醉方法均取得较满意的麻醉效果;PR-K组较PR组诱导迅速,血流动力学波动小,且丙泊酚和瑞芬太尼诱导用量少。结论：单次静注小剂量氯胺酮诱导可安全用于隆乳术麻醉,兼具良好的麻醉效应和经济效益。