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.     

Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro‐con discussion

Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short‐acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile‐based anesthesia versus TIVA. This pro‐con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.     

七氟烷、七氟烷复合笑气和TIVA全麻苏醒过程的比较

目的:比较吸入七氟烷(Sevo)、吸入Sevo复合笑气(N2O)以及全凭静脉麻醉(TIVA)行腹腔镜胆囊切除术后患者苏醒的过程。方法:择期腹腔镜胆囊切除手术患者45例随机分为3组(每组15例),Sevo组:以单纯吸入Sevo维持麻醉;(Sevo N2O)组:以吸入Sevo复合N2O(60%)维持麻醉,TIVA组:以血浆靶控丙泊酚3μg.mL-1 瑞芬太尼2~4 ng.mL-1维持麻醉。麻醉过程中记录最高和最低吸气,呼气末Sevo的浓度,MAC值,脑电双频指数值(B IS),手术结束后记录患者苏醒时间,拔除气管导管时间,出恢复室时间,唤醒即刻的B IS值,术后2 h内疼痛的视觉模拟评分(VAS)。同时记录不良反应。结果:清醒时间和拔管时间:Sevo组分别为(10.4±2.6)和(11.5±3.2)m in,(Sevo N2O)组分别为(8.1±1.7)和(9.1±1.7)m in,TIVA组分别为(7.1±1.7)和(8.3±1.7)m in。Sevo组和(Sevo N2O)组相比有显著性差异(P<0.05),Sevo组和TIVA组相比有显著性差异(P<0.01),(Sevo N2O)组和TIVA组相比无显著性差异(P>0.05)。出恢复室时间:Sevo组,(Sevo N2O)组和TIVA组分别为(19.3±4.8),(16.6±3.0)和(13.9±2.8)m in。Sevo组和TIVA组相比有显著差异(P<0.001)。清醒即刻的B IS值:Sevo组,(Sevo N2O)组和TIVA组分别为(80.4±4.8),(80.8±3.3)和(75.7±2.2)。Sevo组和TIVA组,(Sevo N2O)组和TIVA组之间相比均有显著性差异(P<0.01),Sevo组和(Sevo N2O)组相比无显著性差异(P>0.05)。术毕VAS评分:Sevo组,(Sevo N2O)组和TIVA组分别为(2.9±1.2),(2.8±0.7)和(5.0±1.5)。Sevo组和TIVA组,(Sevo N2O)组和TIVA组之间相比均有显著性差异(P<0.001),Sevo组和(Sevo N2O)组相比无显著性差异(P>0.05)。恶心、呕吐、嗜睡等不良反应各组间无显著性差异。结论:七氟烷复合N2O(60%)可以提供较满意的麻醉效果,术后苏醒快,离开恢复室早而且恢复质量高。     

Narcotrend联合肌松闭环注射系统在全身麻醉中的应用

目的研究Narcotrend(NT)麻醉深度监测仪与闭环肌松注射系统(Close-Loop Muscle Relaxant Injection System,CLMRIS)联合应用于全身麻醉的临床效果及安全性。方法随机选择352例择期全身麻醉患者,ASAⅠ～Ⅱ级,随机分为4组:经验组(E组即对照组),NT组(N组),CLMRIS组(C组),NT与CLMRIS联合组(NC组),每组88例。E组依据麻醉医师临床经验判断实施麻醉;N组依据NT监测指导实施麻醉;C组依据CLMRIS指导肌松药使用;NC组联合使用NT及CLMRIS指导实施麻醉及肌松药使用。以入室(T0)、诱导即刻(T1)、插管(T2)、切皮(T3)、进腹(T4)、探查(T5)、关腹(T6)、缝皮(T7)、意识恢复(T8)、气管拨管(T9)、出室(T10)等11个时间点,观察记录平均动脉压(MAP)、心率(HR)、呼吸频率(RR)、脉搏氧饱和度(SpO2)、NT分级(NTS)、NT指数(NTI)、肌松计数、TOF值、麻醉用药总量、插管时间(T2～T1)、苏醒时间、拔管时间、插管评级、出室时镇静评分,记录不良反应。结果 4组患者术中生命体征均较平稳;NC组MAP、HR变化更为平稳(P<0.05);E组T8～T10各时点RR、SpO2较低(P>0.05)。NC组NTS、NTI处于麻醉目标者较多(P<0.05);C、NC组肌松计数、TOF值于T3～T8时较低(P<0.05),T9～T11时较高(P>0.05)。诱导期药量比较无统计学意义,差异主要产生于维持阶段。维持期NC组麻醉用药最小,E组最大(P<0.05);C组肌松及N组镇静镇痛药与NC组比较无统计学意义(P>0.05)。NC组插管时间最长,苏醒时间、拔管时间最短、Copper评级、Ramsay评分最适宜(P<0.05)。4组术中知晓无差异(P>0.05),NC组无不良反应。结论 NT麻醉深度监测仪与闭环肌松注射系统联合应用于全身麻醉,提高了全身麻醉的安全性。麻醉可控性强,诱导维持平稳,苏醒彻底及时,使用较少的麻醉药物达到最佳的麻醉效果,并可降低全身麻醉的不良反应。     

不同麻醉方法对活体供肾肾移植患者围术期肾功能的影响

目的 探讨选择全静脉全身麻醉(total intravenous anesthesia,TIVA)和腰-硬联合麻醉(combinedspinal-epidural anesthesia,CSEA)不同的麻醉方法对接受亲属活体供肾移植手术患者围术期肾功能的影响是否存在差异.方法 选择择期行亲属活体供肾移植手术的患者60例,均为首次接受肾移植术患者.供受者均为血缘亲属关系,供肾者全部选择在全静脉全身麻醉下经开放术式取肾,供肾热缺血时间50秒～90秒,冷缺血时间60 min～120 min.随机将60例患者分为2组(TIVA组和CSEA组),每组30例,TIVA组术后给予经静脉术后镇痛(patient-controlled intravenous analgesia,PCIA)2d;CSEA组术后给予经硬膜外术后镇痛(patient-controlled epidural analgesia,PCEA)2d.分别记录肾移植手术时间;移植肾开放时平均动脉压(MAP)和心率(HR);移植肾开放后第1、2、3、5、7天的尿量;血肌酐(Cr);血尿素氮(BUN)以及内生肌酐清除率(Ccr)的变化;术后随访患者镇痛满意度.结果 TIVA组手术时间为(171±29)min,CSEA组手术时间为(173±29)min,两组比较无统计学差异(P＞0.05);移植肾血管吻合口开放时TIVA组MAP为(149±10)mm Hg,CSEA组MAP为(139±12)mm Hg,两组比较为差异有统计学意义(P＜0.05);两组移植肾血管吻合口开放时HR组间比较差异无统计学意义(P＞0.05);两组移植肾开放后第1、2、3、5、7天尿量、Cr、BUN和Ccr组间比较差异均无统计学意义(P＞0.05).结论 全静脉全身麻醉与腰-硬联合麻醉对接受亲属活体供肾移植手术患者围术期肾功能的影响无统计学差异,两种麻醉方法都可以安全用于肾移植手术患者.     

老年肺癌患者行肺叶切除术采用不同浓度舒芬尼、丙泊酚靶控输注麻醉与传统静脉麻醉比较

目的：比较不同浓度舒芬尼和丙泊酚联合靶控输注麻醉（TCI）与传统全凭静脉麻醉（TIVA）对老年患者行开胸肺叶切除时血流动力学、意识和苏醒的影响。方法：60例全身麻醉下行肺叶切除术的病人,随机分为3组（n=20）,舒芬尼初始靶浓度为0．2ng／ml TCI（Ⅰ组）、舒芬尼初始靶浓度为0．3ng／ml TCI（Ⅱ组）、舒芬尼＋丙泊酚单次输注、连续输注（Ⅲ组）。在麻醉的不同阶段分别设定不同的舒芬尼靶浓度,同时根据病人意识情况和脑电双频谱指数（BIS）的变化调整丙泊酚靶浓度,记录入室时（基础值base）、气管插管前即刻（T1）、双腔管调整到位时（T2）、气管插管后3min时（T3）、手术切皮时（T4）、手术后15min（T5）和拔管即刻（T6）,记录MAP、HR、BIS、丙泊酚、舒芬尼用量及术毕睁眼时间和拔管时间。结果：3组间脑电双频谱指数（BIS）比较差异无统计学意义（P〉0．05）。舒芬尼用量Ⅰ组与Ⅱ组和Ⅲ组比较差异有统计学意义（P〈0．05）,Ⅱ组和Ⅲ组比较差异无统计学意义（P〉0．05）。丙泊酚用量Ⅰ组与Ⅱ组和Ⅲ组比较有统计学意义（P〈0．05）,Ⅱ组和Ⅲ组比较差异有统计学意义（P〈0．05）。结论：舒芬尼0．2～0．6ng／ml靶控输注既能保证充分的镇痛和足够意识水平深度,有利于术中控制性降压,又不影响中等长度手术患者的术后苏醒和拔管;而单次和持续输注30～40ml／h,亦能达到同样的效果,且舒芬尼和丙泊酚用量明显小于靶控输注组。     

Leptin and perioperative neuroendocrine stress response with two different anaesthetic techniques

Background: Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy).
Methods: We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A =9) or sevoflurane anaesthesia (group B =9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4).
Results: The comparative analysis between the groups shows significantly higher values of NE ( P <0.001 at time 1 and P <0.01 at time 3), E ( P <0.001 at times 1 and 2; P <0.01 at time 3 and P <0.05 at time 4), ACTH ( P <0.001 at times 1and 2; P <0.05 at time 3) and cortisol ( P <0.001 at times 1and 2; P <0.01 at time 3; P <0.05 at time 4) in group B .
The serum values of leptin were not significantly different between the two groups.
Conclusion: The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E.     

Relationship between age and spontaneous ventilation during intravenous anesthesia in children

BACKGROUND: Maintaining spontaneous ventilation in children, using total intravenous anesthesia (TIVA), is often desirable, particularly for airway endoscopy. The aim of this study was to evaluate the effect of age on the dose of remifentanil tolerated during spontaneous ventilation under anesthesia maintained with infusions of propofol and remifentanil and to provide guidelines for the administration of remifentanil and propofol to maintain spontaneous ventilation in children. METHODS: Forty-five children scheduled for strabismus surgery were divided by age into three groups (group I: 6 months-3 years, group II: 3 years-6 years, and group III: 6 years-9 years). The propofol infusion was titrated using State Entropy as a pharmacodynamic endpoint and remifentanil infused, using a modified up-and-down method, with respiratory rate depression as a pharmacodynamic endpoint. A respiratory rate of just greater than 10, stable for 10 min, determined the final remifentanil infusion rate. The group mean was estimated from the final remifentanil infusion rate tolerated (RD(50)). RESULTS: The RD(50) of groups I, II, and III were 0.192 (0.08), 0.095 (0.04), and 0.075 (0.03) microg x kg(-1) x min(-1) respectively. Pair-wise comparisons between the groups for the rate of remifentanil tolerated revealed a statistically significant increase in the RD(50) in children less than 3 years of age compared with older children in groups II and III (P < 0.001). The relationship between remifentanil dose and age, weight or height was not linear. CONCLUSIONS: Younger children, especially those aged less than 3 years, tolerate a higher dose of remifentanil while still maintaining spontaneous respiration. TIVA with spontaneous ventilation is readily achieved in younger children and infants.     

Total intravenous anesthesia combined with epidural eptazocine

To reduce the doses of intravenous anesthetics (ketamine, diazepam, droperidol, and vecuronium) used in total intravenous anesthesia (TIVA), epidural administration of a ϰ-stimulating opioid, eptazocine, was combined with TIVA in 115 patients. Surgical procedures were uneventful under TIVA plus epidural eptazocine; significant depression of EEG and somatosensory-evoked potentials during anesthesia were observed without delay in recovery. The circulatory response and blood glucose level during and after anesthesia and surgery were stable, and there was no postanesthetic respiratory depression. On the other hand, in 46 patients given TIVA only, hypertension, tachycardia, and elevated blood glucose during and after anesthesia were observed: in 25 (54.3%) patients, a vasodepressor was required, and in 18 (39.1%) patients, nitrous oxide was needed. Therefore, epidural eptazocine may make it possible to use lower doses of anesthesia in TIVA, thus reducing the adverse effects associated with TIVA such as hypertension during surgery, intraoperative awareness, postanesthetic respiratory depression, delayed recovery from anesthesia, and neurological signs after anesthesia. This may be due to the ϰ-stimulating action of epidural eptazocine on the spinal cord and its σ-blocking action, as well as its lack of μ-action on the brain.     

右美托咪定对颅内动脉瘤栓塞术患者围术期的影响

目的观察右美托咪定对气管插管全麻下颅内动脉瘤栓塞术患者围术期的影响。方法选取湖北医药学院附属人民医院36例行颅内动脉瘤介人手术患者,随机分为D组和C组,每组各18例。D组在麻醉诱导前10min静脉泵注负荷量的右美托咪啶0．6μg／kg,继以0．4μg／（kg·h）持续泵注,C组以同样的方法泵注等量的生理盐水。两组均采用气管内插管全凭静脉麻醉。观察并记录人室（T0）、诱导前（T,）、插管前（T2）、插管后即刻（T3）、手术开始（T4）、弹簧圈放置时（T5）、术毕时（T6）、拔管前（T7）、拔管后即刻（T8）两组患者的平均动脉压（MAP）、心率（HR）、脉搏氧饱和度（SpO2）,记录术后恢复情况及不良反应,记录使用血管活性药物的种类和人数。结果与T0时比较,在T1时D组的MAP、HR明显减低（P〈0．05）;在T1、T3、T4、T7、T8时间点,D组MAP、HR与C组相比明显减低（P〈0．05）。与C组相比,D组的术后恢复时间没有显著差别,但不良事件发生率明显减少（P〈0．05）。结论在气管内插管全麻颅内动脉瘤栓塞术中应用右美托咪定有利于维持围麻醉期皿液动力学稳定,降低动脉瘤破裂风险．术后并发症少。