Remifentanil sedation compared with propofol during regional anaesthesia

BACKGROUND: The short onset and offset of remifentanil may allow for accurate dosing of sedative effect with few side-effects and rapid recovery. In this study remifentanil is compared with propofol for sedation during successful regional anaesthetic blocks. METHODS: After informed consent was given, 125 patients undergoing surgery under spinal or brachial plexus anaesthesia were randomized to receive, either propofol: bolus 500 microg/kg plus initial infusion 50 microgkg/min or remifentanil: bolus 0.5 microg/kg plus initial infusion 0.1 microgkg/min. Study drug infusion rate was titrated throughout the procedure according to level of sedation and side-effects. Pain, discomfort, sedation level and side-effects were recorded at regular intervals until discharge from the post operative care unit (PACU). RESULTS: Two patients in the remifentanil group versus ten in the propofol group were treated for discomfort or pain during surgery (P<0.02). Due to a significantly higher rate of respiratory depression (46% vs. 19% with propofol, P<0.01) the mean remifentanil infusion rate was decreased to 0.078 +/- 0.028 microgkg/min, whereas it was kept stable with propofol. Propofol patients had significantly higher (P<0.05) sedation levels and experienced more frequent amnesia of the procedure. Eleven propofol patients experienced pain at injection site, versus two remifentanil patients (P<0.02). Nausea and vomiting were more frequent in the remifentanil patients during infusion (27% vs. 2% in the propofol group, P<0.001) but similar postoperatively. Time to discharge from PACU was similar in the two groups. CONCLUSION: Propofol results in less respiratory depression and nausea when sedation is needed during a case with a successful regional block. Remifentanil may be considered as an alternative if pain during the procedure is a major concern or if amnesia is contraindicated.     

Remifentanil-Propofol- Anästhesie bei Bandscheibenoperationen: ein Vergleich mit einer Desfluran-N2O- Inhalationsanästhesie Effekte auf Hämodynamik und Aufwachverhalten

Zusammenfassung Fragestellung: Unterscheidet sich eine totale intraven?se An?sthesie mit Propofol (P) und Remifentanil (R) von einer Inhalationsan?sthesie mit Desfluran (D) und Lachgas (L) bei lumbalen Bandscheibenoperationen hinsichtlich der Steuerbarkeit der Narkose, der Beeinflussung h?modynamischer Parameter, des Aufwachverhaltens und des postoperativen Analgetikabedarfs der Patienten? Methodik: 50 Patienten (ASA I–II, 18–65 Jahre) wurden randomisiert entweder einer P/R- oder D/L-Gruppe zugeteilt. Nach standardisierter Narkoseeinleitung (1 μg/kg Remifentanil, 1,5 mg/kg Propofol, 0,1 mg/kg Cisatracurium) wurde die An?sthesie in der D/L-Gruppe bedarfsadaptiert mit Desfluran in 50% N₂O und in der P/R-Gruppe mit 2 mg/kg/h Propofol und 0,5 μg/kg/min Remifentanil aufrechterhalten, wobei die Remifentanildosis nach 15 min halbiert wurde. Am Operationsende unmittelbar vor der Umlagerung in die horizontale Rückenlage wurde die Zufuhr der An?sthetika abrupt unterbrochen und folgende Aufwachzeiten erfa?t: Eintritt Spontanatmung (V_T>4 ml/kg), Extubation, Augen?ffnen, richtiges Benennen von Namen und Geburtsdatum und der Analgetikabedarf der ersten 2 postoperativen Stunden im Aufwachraum. Ergebnisse: Die Patienten der D/L-Gruppe reagierten auf den Intubationsreiz und die Hautinzision mit signifikanten Blutdruckanstiegen und zeigten signifikant h?here Herzfrequenzwerte, w?hrend ansonsten die h?modynamischen Parameter w?hrend des Narkoseverlaufs vergleichbar waren. Die Patienten der P/R-Gruppe erreichten signifikant früher eine stabile Spontanatmung (3,2 vs. 6,4 min), konnten früher extubiert werden (3,8 vs. 9,5 min), ?ffneten früher die Augen (3,0 vs. 11,5 min) und waren eher in der Lage, ihren Namen und Geburtsdatum zu benennen (4,8 vs. 14,3 min), wiesen aber auch signifikant h?ufiger Muskelzittern auf. Keine signifikanten Unterschiede fanden sich im Analgetikabedarf sowie in der Inzidenz von übelkeit und Erbrechen. Schlu?folgerung: Die Patienten erwachen aus der TIVA mit Propofol/Remifentanil schneller als aus der Desfluran/N₂O-Narkose und erreichen schneller ein h?heres Vigilanzniveau, wobei die geringe Intensit?t postoperativer Wundschmerzen nach Bandscheibenoperationen kein aufwendiges Konzept zur postoperativen Analgesie erfordert.      

Remifentanil-clonidine-propofol versus sufentanil-propofol anesthesia for coronary artery bypass surgery

OBJECTIVE: To compare a remifentanil-clonidine-propofol regimen with conventional sufentanil-propofol anesthesia. DESIGN: Randomized, nonblinded trial. SETTING: A single university hospital. PARTICIPANTS: Male patients scheduled for coronary artery bypass graft (CABG) surgery. INTERVENTIONS: In the control group, anesthesia was induced with 0.5 microg/kg of sufentanil and 0.2 to 0.3 mg/kg of etomidate after preoxygenation. Propofol (50 to 100 microg/kg/min) and sufentanil (0.5 to 1.0 microg/kg/h) were started after endotracheal intubation. Sufentanil was stopped after aortic decannulation. In the remifentanil-clonidine group, anesthesia was started with remifentanil (0.15 to 0.3 microg/kg/min), followed by etomidate (0.2 to 0.3 mg/kg). Propofol was started at 50 to 100 microg/kg/min, and after endotracheal intubation, clonidine infusion was started (6 to 20 microg/h). Patients received piritramide (0.15 mg/kg) and metamizole (20 mg/kg) for transitional analgesia. In both groups, propofol infusion was reduced to 30 to 60 microg/kg/min at skin closure and stopped when assisted spontaneous breathing led to adequate gas exchange. MEASUREMENTS AND MAIN RESULTS: The main outcomes were recovery times; somatic variables; plasma catecholamine levels; and self-recorded pain, nausea, and vomiting. Patients in the remifentanil-clonidine group were extubated earlier and had lower plasma epinephrine and norepinephrine levels. After transitional analgesia, the remifentanil-clonidine patients had similar postoperative analgesic use and self-reported pain and side-effect scores. CONCLUSION: Compared with a sufentanil-propofol regimen, an anesthetic regimen for CABG surgery that combines remifentanil, clonidine, and propofol provides similar hemodynamics. The remifentanil-clonidine regimen reduces catecholamine levels and hastens recovery from anesthesia.     

Less postoperative nausea and vomiting after propofol + remifentanil versus propofol + fentanyl anaesthesia during plastic surgery

BACKGROUND: The effect of different opioids on postoperative nausea and vomiting (PONV) has not been conclusively determined yet, thus the aim of this study was to compare the incidence of PONV in propofol-anaesthetized patients receiving either fentanyl or remifentanil as opioid supplement. METHODS: Sixty ASA physical status I and II patients scheduled for plastic surgery gave their written informed consent for this prospective, randomized, double-blind study. Anaesthesia was induced with propofol, rocuronium and fentanyl (n = 30; 2 microg kg(-1)) or remifentanil (n = 30; 1 microg kg(-1)). After tracheal intubation, anaesthesia was maintained with propofol, oxygen in air and an infusion of the opioid studied, which was modified according to clinical criteria. Baseline postoperative analgesia was achieved with intravenous propacetamol + metamizol. Intravenous morphine was given if visual analogic scale (VAS) for pain was > or = 4 (scale 0-10) and metoclopramide was administered if a patient presented > or = 2 PONV episodes (nausea or vomiting) in less than 30 min. Postoperatively (2, 12 and 24 h), we registered VAS, rescue morphine consumption, number of patients with episodes of PONV and number of patients requiring metoclopramide. P < 0.05 was considered significant. RESULTS: There were no significant differences between groups in the demographic parameters, ASA physical status, propofol dose, VAS, and rescue morphine requirements. Fourteen patients in the fentanyl group and four in the remifentanil group presented PONV episodes 2-12 h postoperative hours' interval; (P < 0.05). Ten patients in the fentanyl group and four in the remifentanil group presented vomiting episodes in the same period (P < 0.05); and eight patients in the fentanyl group and one in the remifentanil group required metoclopramide; (P < 0.05). The number of postoperative PONV episodes were low, both in the 0-2-h period (n = 2 vs. n = 1, fentanyl and remifentanil, respectively) and in the 12-24-h period (n = 3 vs. n = 1). CONCLUSION: Propofol + fentanyl anaesthesia resulted in a higher incidence of PONV and requirements of antiemetic drugs in the period between 2 and 12 postoperative hours compared with propofol + remifentanil, in patients undergoing plastic surgery.     

Analgesic transition after remifentanil-based anesthesia in neurosurgery. A comparison of sufentanil and tramadol

AIM: Transition from the end of remifentanil infusion and postoperative analgesia must be planned carefully owing to remifentanil's (R) rapid offset. Intraoperative morphine has been used for the transition to postoperative analgesia following remifentanil-based anesthesia. Sufentanil (S) is a very potent opioid with high micro-receptor affinity, a much wider therapeutic index and a lower fractional receptor occupancy. These pharmacological and dynamics features make sufentanil an interesting alternative to morphine for immediate postoperative analgesia. METHODS: Experimental design: perspective, randomized, single blinded and comparative study. Institution: neurosurgical operating theatre at University. Patients: 96 patients, aging from 25 to 67 years, ASA class I-III, undergoing neurosurgical operations, were studied. Interventions and Measurements: the anesthetic management was: premedication: atropine 0.01 microg kg(-1) + remifentanil 0.20 microg kg(-1) min(-1); induction: propofol 2.0 microg kg(-1) + cisatracurium 0.15 microg kg(-1); maintenance: sevoflurane 0.8% + remifentanil (titrated infusion) cisatracurium. All patients received ketorolac 30 mg i.v. 1 hour before the end of surgery and ketorolac (60-90 mg) + tramadol (200-300 mg) by elastomeric pump; patients were divided into 2 groups: group T receiving tramadol 100 mg and group S receiving a bolus dose of sufentanil 0.10 microg kg(-1), 30 and 15 minutes before the end of surgery respectively. Recovery time, postoperative analgesia evaluated by VAS, cardiocirculatory parameters and side effects like nausea, vomiting, shivering, muscle rigidity, sedation and respiratory depression were recorded. RESULTS: VAS was significantly lower in Group S. Recovery time was shorter in Group T than in Group S (8.8 +/- 3.6 vs 11.6 +/- 4.6 min), no statistically significant differences between groups as regards nausea, vomiting and shivering. Short-lasting respiratory depression was detected in 3 cases in Group S. CONCLUSION: At the emergence much better control of the transition phase in patients treated with sufentanil: smooth recovery with better tolerability of the endotracheal tube; efficacious analgesia along with cardiocirculatory stability.     

Bispectral index-guided administration of anaesthesia: comparison between remifentanil/propofol and remifentanil/isoflurane

BACKGROUND AND OBJECTIVE: The bispectral index of the electroencephalogram is a measure of the hypnotic component of anaesthesia and can be used to guide the administration of anaesthesia. This study compares bispectral index-guided anaesthesia with remifentanil and either propofol or isoflurane. METHODS: Eighty consenting patients were randomly assigned to two groups. Following induction with propofol and remifentanil, anaesthesia was maintained with remifentanil/propofol or remifentanil/isoflurane. Remifentanil infusion rates were guided by haemodynamic responses--maintaining mean arterial pressure and heart rate within 20% of baseline. Propofol and isoflurane administration was guided using the bispectral index (45-60). Thirty minutes before the end of surgery, morphine was administered (0.15 mg kg(-1) intravenously). Fifteen minutes before end of surgery, propofol and isoflurane were reduced (bispectral index 60-75). At the end of surgery, the anaesthetic agents were discontinued. Groups were compared for recovery, remifentanil doses and signs of inadequate anaesthesia using the chi2-test and ANOVA (P < 0.05). RESULTS: The duration of surgery was longer in the propofol/remifentanil group (121 +/- 53 versus 94 +/- 40 min). Recovery data were not different between groups. The remifentanil infusion rate was significantly lower with additional isoflurane (0.18 +/- 0.06 microg kg(-1) min(-1)) than with additional propofol (0.31 +/- 0.20 microg kg(-1) min(-1)). The propofol infusion rate was 123 +/- 48 microg kg(-1) min(-1); isoflurane concentration was 0.66 +/- 0.13%. CONCLUSIONS: Bispectral index-guided anaesthesia with remifentanil plus propofol or isoflurane results in the absence of postoperative recall and a fast recovery with both drug combinations. In our patients, at comparable bispectral index-levels, haemodynamic control requires higher doses of remifentanil with propofol than with isoflurane.     

Magnesium as part of balanced general anaesthesia with propofol, remifentanil and mivacurium: a double-blind, randomized prospective study in 50 patients

BACKGROUND AND OBJECTIVE: To test the hypothesis that magnesium sulphate reduces the amount of remifentanil needed for general anaesthesia in combination with propofol and mivacurium, we studied 50 patients undergoing elective pars plana vitrectomy in a double-blind, randomized prospective fashion. METHODS: Magnesium sulphate (50 mg kg(-1) body weight) or placebo (equal volume of NaCl) was given slowly intravenously after induction of anaesthesia with propofol 1-2 mg kg(-1). Anaesthesia was maintained with propofol (using electroencephalographic control), mivacurium (according to train-of-four monitoring of neuromuscular blockade) and remifentanil (according to heart rate and arterial pressure). RESULTS: We observed a significant reduction in remifentanil consumption from 0.14 to 0.09 microg kg(-1) min(-1) (P < 0.01). Mivacurium consumption was also markedly reduced from 0.01 to 0.008 mg kg(-1) min(-1) (P < 0.01), whereas propofol consumption remained unchanged. There was a trend towards lower postoperative pain scores, less pain medication requirements in 24 h after surgery and less postoperative nausea and vomiting in the magnesium group but not statistically significant. No side-effects were observed. CONCLUSION: We can recommend the use of magnesium sulphate as a safe and cost-effective supplement to a general anaesthetic regimen with propofol, remifentanil and mivacurium, although we cannot clearly distinguish between a mechanism as a (co)analgesic agent at the NMDA-receptor site or its properties as a sympatholytic. The effect of a single bolus dose of 50 mg kg(-1) on induction lasts for about 2 h. For longer cases, either a continuous infusion or repeated bolus doses might be necessary.     

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.     

Intraoperative wake-up test and postoperative emergence in patients undergoing spinal surgery: a comparison of intravenous and inhaled anesthetic techniques using short-acting anesthetics

Surgical procedures on the vertebral column may result in spinal cord damage, leading to neurological deficits that demand immediate therapeutical intervention. We designed this study to determine which anesthetic regimen allows a rapid wake-up test during and after surgery to detect neurological deficits. Fifty-four patients were randomly allocated to the following groups: group PR (propofol/remifentanil): target-controlled infusion with propofol (plasma concentration, 2-4 microg/mL) and remifentanil 0.2-0.5 microg . kg(-1) . min(-1); group PS (propofol/sufentanil): propofol (2-4 microg/mL) and repetitive boluses of 0.1-0.2 microg/kg of sufentanil adjusted to patients requirements; and group DR (desflurane/remifentanil): desflurane/air 3.0-4.0 vol% combined with remifentanil 0.2-0.5 microg . kg(-1) . min(-1). Group PS required significantly longer times for the onset of breathing (8.9 +/- 1.6 min), elevation of the head (17.0 +/- 3.8 min), and motion of the feet (17.0 +/- 7.4 min) than group PR (6.9 +/- 2.6 min, 9.3 +/- 2.2 min, and 9.4 +/- 2.4 min, respectively) or group DR (5.4 +/- 0.8 min, 6.1 +/- 1.0 min, and 6.2 +/- 1.0 min, respectively). The anesthetic regimen with desflurane and remifentanil allowed faster awakening during and after surgery that permitted immediate neurological examination after spinal surgery compared with propofol/remifentanil.     

Mood change after anaesthesia with remifentanil or alfentanil

BACKGROUND AND OBJECTIVE: There are anecdotal reports of dysphoria occurring in patients on the first day after anaesthesia with remifentanil. This study was performed to investigate this allegation and to find a possible relationship to postoperative shivering or to nausea and vomiting. METHODS: Patients undergoing otorhinolaryngeal surgery took part in a prospective, randomized, double-blind study comparing total intravenous anaesthesia with propofol (2 mg kg(-1) bolus injection then 100 microg kg(-1) min(-1)) and remifentanil (1 microg kg(-1) bolus then 0.1-0.5 microg kg(-1) min-1) or alfentanil (30 microg kg(-1) bolus then 0.16-0.83 microg kg((-1) min(-1)). The patients were carefully insulated and actively warmed by convective heating and rectal temperature was monitored continuously. Postoperative shivering was graded on a three-point scale, and the cumulative incidence of nausea and vomiting were registered at 24 h after surgery. Pre- and postoperative mood was measured with the von Zerssen mood scale (Befindlichkeits-Skala) and changes tested for significance. High scores reflect discontent and dysphoria. RESULTS: The data of 98 patients (49 in each group, ASA I-II, age 42 +/- 13 yr, anaesthesia time 141 +/- 60 min; mean +/- SD; intergroup P values > 0.1) were evaluated. Core temperature did not change perioperatively (before 36.6 +/- 0.2 degrees C; after 36.8 +/- 0.3 degrees C, inter- and intragroup P > 0.1). The incidence of nausea was the same in each group; vomiting occurred with equal frequency (6/49 vs. 7/49). Shivering was significantly more frequent after remifentanil (41% vs. 10%, P < 0.001). The patients' mood remained stable after remifentanil but worsened after alfentanil (von Zerssen score from 9.3 +/- 2.5 to 13.9 +/- 3.6; mean +/- 95% confidence intervals; P < 0.01). DISCUSSION: Postoperative shivering was more frequent after remifentanil but was unrelated to intraoperative heat loss. Contrary to preliminary informal observations, there was no evidence that remifentanil caused postanaesthetic dysphoria on the day one after surgery.     

Remifentanil or sufentanil for coronary surgery: comparison of postoperative respiratory impairment

BACKGROUND AND OBJECTIVE: High-dose opioid anaesthesia contributes to decreasing metabolic and hormonal stress responses in patients undergoing cardiac surgery. However, the increase in context-sensitive half-life of opioids given as a high-dose regimen can affect postoperative respiratory recovery. In contrast, remifentanil can be given in high doses without prolonging context-sensitive half-life due to its rapid metabolism. Therefore, we performed a prospective, randomized trial to compare anaesthesia consisting of propofol/remifentanil or propofol/sufentanil with regard to postoperative respiratory function and outcome. METHODS: Patients undergoing coronary artery bypass grafting were randomized to a propofol/remifentanil (0.5-1.0 microg kg(-1) min(-1)) or propofol/sufentanil (30-40 ng kg(-1) min(-1)) based anaesthetic. Carbon dioxide response, forced expiratory volume in one second, vital capacity, and functional residual capacity were measured 1 day prior to the operation, 1 h before extubation, 1, 24 and 72 h after extubation. In addition, the incidence of atelectasis, pulmonary infiltrates, intensive care unit and postoperative length of stay were compared. Patients and physicians were blinded to the treatment group. RESULTS: Twenty-five patients in each treatment group completed the study. There was no difference between patients of the treatment groups regarding demographics, risk- or pain scores. In all patients, carbon dioxide response, forced expiratory volume in one second, vital capacity and functional residual capacity were decreased postoperatively compared to baseline. Patients randomized to remifentanil had less depression of carbon dioxide response, less atelectasis and shorter postoperative length of stay (12 d vs. 10 d) than after sufentanil (P < 0.05). CONCLUSIONS: Intraoperative use of high-dose remifentanil for coronary artery bypass grafting may be associated with improved recovery of pulmonary function and shorter postoperative hospital length of stay than sufentanil.     

Can remifentanil be a better choice than propofol for colonoscopy during monitored anesthesia care?

BACKGROUND AND OBJECTIVE: This prospective, randomized trial was designed to test the hypothesis that continuous infusion of low-dose remifentanil can provide effective analgesia, sedation, amnesia, patient comfort and stable recovery profile without respiratory depression when compared with propofol infusion during colonoscopy. METHODS: One hundred patients were randomly assigned to receive either remifentanil (group R, 0.5 microg/kg followed by 0.05 microg/kg/min, n = 50) or propofol (group P, 0.5 mg/kg followed by 50 microg/kg/min, n = 50). Supplemental doses of remifentanil 12.5 microg in group R and propofol 10 mg in group P were given to treat complaints of moderate to severe pain and discomfort. Hemodynamic and respiratory data, pain, discomfort and sedation scores, patient and gastroenterologist satisfaction and recovery profiles were recorded. RESULTS: The duration of colonoscopy was longer in group P. The mean arterial pressure, heart rate and end-tidal CO2 remained stable during the procedure and were comparable between the groups. After bolus injection of the study drugs, the respiratory rate and oxygen saturation values were lower in group R than in group P. Only one patient in group R required airway support. Pain and discomfort scores were better in group R than in group P. Sedation levels were higher in group P than in group R. Group P needed more supplemental doses than group R. The time to reach an Aldrete score of nine or more was shorter in group R, but discharge times were similar in the two groups. Amnesia was better in group P. Nausea and vomiting were more frequent in group R during the recovery phase. CONCLUSION: Low-dose remifentanil infusion with intermittent bolus injections can provide adequate sedation, amnesia and better analgesia than propofol infusion during colonoscopy. However, remifentanil-induced nausea and vomiting may be a problem during the recovery phase.     

Postoperative analgesia after preincisional administration of remifentanil

AIM: The aim of this study was to assess postoperative analgesia after preincisional and postincisional administration of remifentanil. METHODS: Randomized trial, 24 hours. Setting: University hospital, hospitalized care. Patients: 48 adult patients scheduled for lumbar vertebral surgery. Interventions: in group R5, patients received an infusion of 0.2 microg kg(-1) min(-1) remifentanil over 5 minutes, followed by a break of 15 minutes before anesthesia was started. Anesthesia was induced by infusion of 0.25 microg kg(-1) min(-1) remifentanil and a bolus of 1.5 microg kg(-1) propofol, followed by a continuous infusion of 2 to 3 microg kg(-1) h-1 propofol and 0.25 microg kg(-1) min(-1) remifentanil until end of anesthesia. In group R20, patients received 0.05 microg kg(-1) min(-1) remifentanil over 20 minutes before the induction of anesthesia. In group RL, anesthesia was induced and maintained with propofol. After surgery began, a remifentanil infusion of 0.5 microg kg(-1) min(-1) was given for 50 minutes, then reduced to 0.25 microg kg(-1) min(-1). The total remifentanil doses were similar in the 3 groups. Measures: patients used patient-controlled analgesia (piritramide) for postoperative pain management. They recorded pain on a numeric rating scale every half hour. Statistics: Kruskal-Wallis test, pairwise Mann-Withney U-test, orthogonal polynomials (pain scores). RESULTS: Patients given postincisional remifentanil (RL) had the slowest decrease in postoperative pain scores (p<0.01) and the highest cumulative piritramide consumption (p<0.08). CONCLUSION: The preincisional administration of remifentanil followed by a continuous infusion of 0.25 microg kg(-1) min(-1) appears to reduce pain scores and piritramid consumption when compared with a postincisional regimen.     

Propofol versus remifentanil for monitored anaesthesia care during colonoscopy

BACKGROUND AND OBJECTIVE: We conducted an open, prospective, randomized study to compare the efficacy, safety and recovery characteristics of remifentanil or propofol during monitored anaesthesia care in patients undergoing colonoscopy. METHODS: Forty patients were randomly assigned to receive either propofol (1 mg kg(-1) followed by 10 mg kg (-1) h(-1), n = 20) or remifentanil (0.5 microg kg(-1) followed by 0.2 microg kg(-1) min(-1), n = 20). The infusion rate was subsequently adapted to clinical needs. RESULTS: In the propofol group, arterial pressure and heart rate decreased significantly from the baseline. These variables remained unchanged in the remifentanil group, but hypoventilation occurred in 55% of patients. Early recovery was delayed in the propofol group (P < 0.002). Recovery of cognitive and psychomotor functions was faster in the remifentanil group. Fifteen minutes after anaesthesia, the Digit Symbol Substitution Test score was 28.6 +/- 12.8 versus 36.2 +/- 9.4 and the Trieger Dot Test score was 25.6 +/- 8.1 versus 18.7 +/- 4.1 in the propofol and remifentanil groups, respectively (both P < 0.05). Patient satisfaction, using a visual analogue scale, was higher in the propofol group (96 +/- 7 versus 77 +/- 21, P < 0.001). CONCLUSIONS: Remifentanil proved efficient in reducing pain during colonoscopy. Emergence times were shorter and the recovery of cognitive function was faster with remifentanil compared with propofol. Remifentanil provided a smoother haemodynamic profile than propofol; however, the frequent occurrence of remifentanil-induced hypoventilation requires the cautious administration of this agent.     

Anaesthesia with remifentanil infusion in diabetic versus non-diabetic patients undergoing vitrectomy. A Holter-controlled study

Diabetic patients are known to have additional risks in surgery. We evaluated haemodynamic profiles, incidence of arrhythmias and post-operative recovery when remifentanil infusion was used for vitrectomies. We compared 22 diabetics with 22 age-matched controls undergoing vitrectomy. ECG Holter monitoring was continued throughout the operation and until 20 hours postoperatively. Autonomic tests including breathing and stand up were performed in the beginning of Holter-monitoring. Anaesthesia was induced with a bolus of remifentanil (1 microg/kg) and continued with 0.4 microg/kg/ h. Thereafter, propofol, 0.5 mg/kg, was given with additional doses of 0.25 mg/kg if needed. Anaesthesia was maintained with 40% oxygen in air and 0.5% isoflurane. After the operation time to obey commands, pain scores, nausea and vomiting, and haemodynamic parameters were registered. Both breathing and stand up tests differed statistically between the groups (p = 0.001 and p = 0.000, respectively). Diabetic patients needed less remifentanil (p = 0.039) than controls. Hypotensive periods were more frequent in diabetic patients (p = 0.013) and they needed more etilefrine than controls (p = 0.014). Holter recordings revealed no ischaemic episodes in either group. Periods of short ventricular and supraventricular extra beats occurred without any clinical relevance in both groups. Time to obey commands or need for pain medicine postoperatively did not differ between the groups. Diabetic patients were haemodynamically more instable with more frequent hypotensive periods during anaesthesia despite of less amount of remifentanil compared to controls. On the other hand, during remifentanil infusion no ischaemic or clinically significant arrhythmic episodes occurred in either group.     

Comparison of hemodynamics,recovery profile,and early postoperative pain control and costs of remifentanil versus alfentanil-based total intravenous anesthesia (TIVA)

STUDY OBJECTIVE: To compare hemodynamics, recovery profiles, early postoperative pain control and costs of total intravenous anesthesia (TIVA) with propofol and remifentanil and propofol and alfentanil. DESIGN: Randomized, double-blind study. SETTING: University hospital. PATIENTS: 40 ASA physical status I and II adult patients scheduled for lumbar discectomy. INTERVENTIONS: Patients were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 1 microg kg(-1) or alfentanil 20 microg kg(-1) with propofol 2 mg kg(-1), and maintained with infusions of propofol 150 to 100 microg kg(-1)min(-1) and either remifentanil 0.1 microg kg(-1) min(-1) or alfentanil 0.5 microg kg(-1) min(-1). MEASUREMENTS: Hemodynamic parameters (heart rate and mean arterial pressure), times to awakening, and tracheal extubation were recorded. In the postanesthesia care unit, pain level, frequency of analgesic demand, frequency of postoperative nausea and vomiting (PONV), partial oxygen saturation (SpO2), and respiratory rates were noted. Drug dosages and costs of each technique were determined. MAIN RESULTS: The mean arterial pressure significantly decreased compared to baseline values 1 minute after induction (p < 0.05) in both groups, and it significantly decreased at 5, 15, and 30 minutes perioperatively in the remifentanil group compared to the alfentanil group (p < 0.05). Time of extubation, spontaneous eye opening, and response to verbal command were similar in both groups. Visual analog scale pain scores at 30 minutes and 60 minutes were significantly lower in the alfentanil group than remifentanil group (p < 0.05). At 15, 30, and 60 minutes after terminating the operation oxygen saturation and respiratory rate were significantly higher (p < 0.05) and analgesics were required sooner in the remifentanil group than the alfentanil group (p < 0.05). The frequency of PONV was similar in both groups. The remifentanil-propofol anesthesia was found to be slightly more expensive as compared to the alfentanil based TIVA (33.41 +/- 4.53 vs. 29.97 +/- 4.1 USD) (p < 0.05). CONCLUSIONS: Both remifentanil and alfentanil provided a reasonably rapid and reliable recovery. The remifentanil-based TIVA was associated with high intraoperative cost and early postoperative pain, but it allowed a more rapid respiratory recovery.     

Facilitation of laryngeal mask airway insertion: effects of remifentanil administered before induction with target-controlled propofol infusion

Eighty-six adult day-case patients were recruited into a prospective, randomised study and allocated to one of two groups. Patients received either intravenous remifentanil 0.3 microg.kg(-1) or an equivalent volume of sodium chloride 0.9% followed by induction of anaesthesia with propofol target-controlled infusion until the effect (brain) site calculated concentration was 2 microg.ml(-1). Jaw opening and ease of laryngeal mask insertion were assessed immediately after mask insertion. A higher incidence of failure of induction of anaesthesia was observed in the control group compared with the remifentanil group [15 (35%) vs. 3 (7%); p < 0.01] and addition of remifentanil significantly increased the ease and success of laryngeal mask insertion, with grade 1 (no coughing/gagging) conditions observed in 29 (68%) of the remifentanil group and 21 (49%) of the control group (p < 0.01).The doses of remifentanil and propofol used were not associated with any significant cardiorespiratory instability. In conclusion, when combined with propofol target-controlled infusion, remifentanil 0.3 microg.kg(-1) facilitates laryngeal mask insertion with minimal adverse haemodynamic changes.     

Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm

OBJECTIVE: To compare the effectiveness of propofol versus sevoflurane associated with remifentanil on the maintenance of anesthesia and on recovery in patients undergoing elective supratentorial craniotomy. PATIENTS AND METHODS: Prospective randomized trial enrolling 90 patients scheduled for excision of a brain neoplasm. All received an infusion of remifentanil at a dose of 0.5 microg x Kg(-1) x min(-1) until tracheal intubation and then 0.25 microg x Kg(-1) x min(-1) during surgery. Induction was achieved with propofol and anesthesia was maintained with either sevoflurane at a maximum alveolar concentration of 0.4 (45 patients) or propofol by target controlled infusion at a concentration of 2.5 microg x mL(-1) (45 patients, group P). Variables assessed were hemodynamic stability during anesthesia and times and quality of recovery from anesthesia (eye opening, initiation of spontaneous ventilation, extubation, cough reflex, and temporal and spacial orientation 3 minutes after extubation. During the first 24 hours after surgery, pain intensity was evaluated on a verbal visual analog scale (VAS) and the incidence of nausea and vomiting was recorded. RESULTS: Times until eye opening upon request and until extubation were significantly shorter in the sevoflurane group than in the propofol group: 3.7 (SD, 1.2) minutes vs 5 (3.1) minutes, respectively, for eye opening and 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation (P<0.01). The incidence of nausea and vomiting was significantly higher in the sevoflurane group (40% vs 13%, respectively, P<0.01). CONCLUSIONS: Combining remifentanil with propofol or with sevoflurane provides satisfactory anesthesia during elective supratentorial craniotomy to remove a brain neoplasm. Hemodynamic stability is appropriate and recovery from anesthesia is rapid.     

The effect of propofol vs desflurane on recovery from anesthesia with remifentanil in outpatient surgery]

OBJECTIVES: To compare the effect on parameters of postanesthetic recovery of propofol and desflurane administered with high doses of remifentanil for major outpatient surgery. PATIENTS AND METHODS: Seventy patients were randomly assigned to receive propofol (target concentration 1.5-2 microg/ml) or desflurane in perfusion (end expiratory concentration 0.5 MAC) during maintenance of anesthesia with remifentanil (0.25-1 microg/kg/min). The anesthetic agents were withdrawn after surgery. We recorded the times until eye opening, respiration, tracheal extubation, ability to cough, response to verbal orders and orientation. We also recorded the time until a score of 10 on the Aldrete recovery scale was attained, pain on a visual analog scale, sedation on the Ramsay scale, and instances of nausea or vomiting during the first 24 h after surgery. RESULTS: No statistically significant differences in patient characteristics, type of surgery or anesthesia were found. Times until early signs of postanesthetic recovery (eye opening, spontaneous breathing, tracheal extubation) were significantly less (p < 0.05) in the desflurane group. The groups were similar for all other parameters compared (times until ability to cough, respond to verbal orders, orientation and a score of 10 on the Aldrete scale). Duration of stay in the postanesthetic recovery unit, time in the day surgery ward and intensity of postoperative pain were also similar. The rate of postoperative nausea or vomiting was significantly lower in the propofol group. CONCLUSION: During anesthesia with remifentanil, the administration of desflurane is associated with better psychomotor recovery parameters than is propofol, but the rate of nausea and vomiting is higher with desflurane.     

Comparison of continuous sufentanil and fentanyl infusions for outpatient anaesthesia

Fifty ASA physical status class I or II patients undergoing outpatient D&C (dilatation and curettage of the uterus) were studied. Patients were divided into two groups in a random double-blind manner and given either a fentanyl bolus 0.7 μg kg^-1 followed by continuous fentanyl infusion of 0–50 μg·min^-1 or sufentanil bolus 0.1 μg·kg^-1 followed by continuous sufentanil infusion 0–7 μg·min^-1 as an adjuvant to thiopentone, nitrous oxide:oxygen anaesthesia. Patients were followed throughout the recovery process with respect to level of consciousness, nausea, vomiting, pain, and discharge time. Groups were equal with respect to awakening and discharge time. The incidence of nausea (p < 0.05) and pain requiring analgesics (p < 0.05) were less in the sufentanil group. It is concluded that the technique of continuous sufentanil infusion was superior to fentanyl in healthy outpatients undergoing D&C.