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.     

Epidural analgesia during labor: intermittent bolus or patient controlled administration?

BACKGROUND: The aim of the study was to compare efficacy and side effects produced by two techniques of epidural analgesia during labor: intermittent bolus and patient-controlled epidural analgesia. METHODS: Eighty parturients were enrolled in this study: forty received intermittent bolus analgesia (first bolus: 20 mg of ropivacaine 0.1% + 10 gamma of sufentanil, next bolus: 10 mg of ropivacaine 0.1% during the first 4 hours, and then 10 mg of ropivacaine 0.1% + 2.5 gamma of sufentanil each time they complained of pain), and forty parturients received PCEA (starting with a bolus of 20 mg ropivacaine 0.1% + 10 gamma sufentanil, followed by administration with a pump programmed to deliver a continuous background infusion of ropivacaine 0,1% + 0.25 gamma/ml of sufentanil at 5 ml/h and 5 ml patient-triggered boluses with a 15 min lock-out interval; insufficient analgesia was treated by extra boluses of the same ropivacaine solution). In each group the efficacy of the analgesia (verbal numerical pain scores, amount of local anesthetics consumption), labor duration, side effects and patient satisfaction have been studied. RESULTS: There were no differences between the two different epidural techniques. CONCLUSIONS: This regimen of PCEA proves a viable and safe alternative for epidural analgesia during labor.     

Anaphylaxis: What is monitored to make a diagnosis? How is therapy monitored?

Anaphylaxis is one of the most life-threatening emergencies that can occur in the perioperative period. Multiple agents can be responsible, and nonallergic reactions can mimic anaphylaxis. Developing a therapeutic plan for the acute therapy of anaphylaxis is important. Prompt recognition with appropriate and aggressive therapy can help avoid a disastrous outcome.     

Bisulfite-containing propofol: is it a cost-effective alternative to Diprivan for induction of anesthesia?

Propofol (Diprivan(TM); AstraZeneca, Wilmington, DE) is a commonly used drug for the induction of general anesthesia in the ambulatory setting. With the availability of a new bisulfite-containing generic formulation of propofol, questions have arisen regarding its cost effectiveness and safety compared with Diprivan(TM). Two hundred healthy outpatients were randomly assigned, according to a double-blinded protocol, to receive either Diprivan(TM) or bisulfite-containing propofol 1.5 mg/kg IV as part of a standardized induction sequence. Maintenance of anesthesia consisted of either desflurane (4%-8% end-tidal) or sevoflurane (1%-2% end-tidal) in combination with a remifentanil infusion (0.125 microg x kg(-1) x min(-1) IV). Patient assessments included pain on injection, induction time, hemodynamic and bispectral electroencephalographic changes during induction, emergence time, and incidence of postoperative nausea and vomiting. The two propofol groups were comparable demographically, and the induction times and bispectral index values during the induction were also similar. However, the bisulfite-containing formulation was associated with less severe pain on injection (5% vs 11%), with fewer patients recalling pain on injection after surgery (38% vs. 51%, P<0.05). None of the patients manifested allergic-type reactions after the induction of anesthesia. The acquisition cost (average wholesale price in US dollars) of a 20-mL ampoule of Diprivan(TM) was $15 compared with $13 for the bisulfite-containing propofol formulation. Therefore, we concluded that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM) for the induction of outpatient anesthesia. Implications: Bisulfite-containing propofol and Diprivan(TM) (AstraZeneca, Wilmington, DE) were similar with respect to their induction characteristics; however, the generic formulation was associated with a smaller incidence of injection pain. Assuming that the drug costs are similar, these data suggest that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM).     

Are bronchoscopic approaches to post-pneumonectomy bronchopleural fistula an effective alternative to repeat thoracotomy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether bronchoscopic or other minimal access approaches to the closure of bronchopleural fistulae (BPFs) were effective compared to a conventional re-thoracotomy. Our search identified 1052 abstracts, from which we identified six case series of greater than two post-pneumonectomy bronchopleural fistula patients. These series included reports of bronchial stenting, glue occlusion and scar obliteration of fistulae. No thoracoscopic techniques were reported except in case report form. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We identified 85 post-pneumonectomy bronchopleural fistulae reported in the literature who underwent bronchoscopic procedures to attempt repair. There was a 30% cure rate using a range of bronchoscopic techniques in these series. Bronchoscopic techniques included cyanoacrylate or fibrin glue application, YAG laser therapy, injection of the vein sclerosant polidocanol and tracheo-bronchial stenting. The mortality was 40% in these patients reflecting the very high mortality with this complication. Many patients required multiple bronchoscopic procedures and also further drainage procedures of their empyemas. Bronchoscopic treatment has so far only been reported in small case series but may offer further treatment options in patients too unwell to undergo re-thoracotomy.     

Nitrous oxide analgesia for minor pediatric surgical procedures: an effective alternative to conscious sedation?

Background/purpose

Minor surgical procedures in children, while usually not requiring general anesthesia, need effective control of pain, anxiety, and motion. Certain techniques of conscious sedation may result in loss of protective airway reflexes. Nitrous oxide, however, when inhaled at levels below 50% maintains protective reflexes and does not require fasting or postprocedure monitoring. This study prospectively examines the efficacy of nitrous oxide analgesia in children undergoing outpatient surgical procedures.

Methods

Over a 2-year period (2000 to 2002), 150 consecutive children were given nitrous oxide analgesia as an alternative to a general anesthetic, sedation, or local anesthetic alone. Nitrous oxide (<50%) was administered by our practice’s sedation-certified nurse practitioner without an anesthesiologist present. The children used the Wong-Baker Faces Scale (0-5) to score pain at different intervals (preprocedure, at injection, during procedure, and postprocedure) and event memories were tabulated.

Results

Of 150 children, 5 were uncooperative and could not participate. One hundred forty-five children, ages 1 to 20 years (Mean, 9.83 ± 4.92 years) successfully underwent procedures (58 cyst/nevus excisions, 49 abscess drainages, 38 other) using nitrous. Two patients were too young to score pain. Pre- and postprocedure pain scores were significantly higher in the abscess group (P < .0001); during the procedures, however, all groups reported pain scores less than 1, with parents citing 100% satisfaction with the technique. Of 128 children receiving local anesthesia, 107 (84%) had no recall of the injection. Complications were limited to 4 patients; 2 experienced nausea, and 2 vomited. All resolved without interrupting the procedure.

Conclusions

Nitrous oxide analgesia is a cost-effective and efficacious alternative to conscious sedation or general anesthesia for minor pediatric surgical procedures. In the office or outpatient setting, the technique provides for almost pain/anxiety-free surgery, no postoperative monitoring, and a high degree of satisfaction for patients, parents, and staff.     

Baclofen neurotoxicity in uremic patients: is continuous ambulatory peritoneal dialysis less effective than intermittent hemodialysis?

OBJECTIVES: To compare the efficacy between continuous ambulatory peritoneal dialysis (CAPD) and intermittent hemodialysis in the treatment of baclofen-associated neurotoxicity. METHODS: Three uremic patients suffering baclofen-associated neurotoxicity were treated by CAPD at our hospital. We obtain 12 cases with detailed clinical course of baclofen-associated neurotoxicity treated by hemodialysis from a literature review using the Medline and Science Citation Index, six of these patients were treated by early hemodialysis which was defined as hemodialysis intervention within 48 h of the onset of clinical toxicity. RESULTS: Our cases regain full consciousness within 2-3 days after the onset of neurotoxicity. Clinical characteristics of our cases including age, dialysis time, preexisting central nervous system (CNS) lesion, concomitant use of CNS depressant, total baclofen dose, onset of neurotoxicity, and duration of neurotoxicity are not significantly different from reported cases that treated by either early or routine hemodialysis. CONCLUSIONS: Baclofen should be avoided in uremic patients. When consciousness disturbance occurs in uremic patients, baclofen-associated neurotoxicity should be included in the list of differential diagnosis. According to experiences of our patients, we conclude that neither early nor routine hemodialysis is more effective than CAPD in shortening the recovery time of baclofen-associated neurotoxicity.