Different small-dose sufentanil blunting cardiovascular responses to laryngoscopy and intubation in children: a randomized, double-blind comparison

Effect of Preadministration of Nalmefene on Sufentanil-Induced Cough During Induction of General Anesthesia in Patients Undergoing Breast Surgery: A Double-Blind Randomized Controlled Trial

Purpose

This study was designed to investigate the effects of preadministration of nalmefene before general anesthesia induction on sufentanil-induced cough (SIC) in patients undergoing breast surgery.

Patients and Methods

A total of 105 patients scheduled for elective breast surgery under general anesthesia were selected and randomly assigned into three groups: normal saline (Group C), low-dose nalmefene 0.1 μg·kg-1 (Group LN), and high-dose nalmefene 0.25 μg·kg-1 (Group HN). Sufentanil 0.5 μg·kg-1 was injected intravenously within 2 s after 5 min of intervention. The count and severity of cough within 2 min after sufentanil injection, as well as the time to first cough, were recorded. In addition, we also collected intraoperative hemodynamic data, postoperative pain scores, the incidence of receiving rescue analgesics, and side effects up to 24 h after surgery.

Results

Compared to Group C, the incidence of SIC was significantly lower in Group LN and HN (64.7% vs 30.3% and 14.7%, respectively; P < 0.001), but no significant difference was observed between the two groups (P=0.126). Compared to Group C, the risk factors decreased by 53.4% (95% confidence interval [CI] =0.181-0.735, P=0.008) in Group LN and by 75.9% (95% CI=0.432-0.898, P=0.001) in Group HN. Of the patients with SIC, less frequent SIC within 2 min after induction and a lower proportion of severe coughs were observed than Group C (P < 0.05), and no difference was detected between Group LN and HN. Additionally, the onset time to the first SIC did not differ significantly between the groups. Intraoperative hemodynamic data, postoperative pain scores, and side effects in the first 24 h did not differ among the groups.

Conclusion

Preadministration of nalmefene prior to induction of general anesthesia effectively suppressed SIC in patients undergoing breast surgery, without affecting intraoperative hemodynamic fluctuation and postoperative pain intensity.

Effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing resection of rectal carcinoma

BACKGROUND

Rectal carcinoma (RC) treatment primarily involves laparoscopic surgery, which may induce significant hemodynamic changes and weaken immune function. Certain anesthetic approaches using opioid drugs (including remifentanil and sufentanil) pose risks, such as hypotension.

AIM

To determine the effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing RC resection.

METHODS

A total of 211 patients one hundred and four patients with RC treated at the First Affiliated Hospital of Dalian Medical University between November 2018 and November 2022 were retrospectively analyzed. Among them, the remifentanil group included 45 patients receiving remifentanil with propofol anesthesia and the sufentanil group included 59 patients receiving sufentanil with propofol anesthesia. Changes in the hemodynamic index, oxidative stress index, general data, consumption of remifentanil, and use of vasoactive drugs were compared. The incidences of adverse reactions were calculated.

RESULTS

The two groups did not significantly differ in terms of operation, anesthesia, and extubation times (P > 0.05). At 1 min after intubation, the sufentanil group showed a notably higher heart rate, systolic blood pressure (SBP), diastolic blood pressure, and mean arterial pressure (MAP) compared with the remifentanil group (P < 0.05), whereas the sufentanil group showed a notably higher SBP and MAP compared with the remifentanil group at 5 min after pneumoperitoneum (P < 0.05). Thirty minutes after surgery, the remifentanil group showed significantly lower plasma cortisol, noradrenaline, and glucose levels than the sufentanil group (P < 0.001). The remifentanil group consumed significantly less remifentanil than the sufentanil group (P < 0.05), and the adoption frequency of ephedrine was lower in the remifentanil group than that in the sufentanil group (P < 0.05). The incidence of hypotension was notably higher in the sufentanil group than that in the remifentanil group (P < 0.05).

CONCLUSION

Remifentanil combined with propofol can improve hemodynamics and relieve oxidative stress in patients undergoing RC resection.

A Response Surface Analysis of the Combination of Dexmedetomidine and Sufentanil for Attenuating the Haemodynamic Response to Endotracheal Intubation

Purpose

Dexmedetomidine combined with opioids has been extensively used to blunt cardiovascular responses to endotracheal intubation. To determine their interaction, we aimed to develop a response surface model between dexmedetomidine and sufentanil.

Methods

One hundred and twenty patients undergoing scheduled gynaecological surgery were recruited. According to a simulation of slice design, patients received different dose pairs of dexmedetomidine (0 to 1.1 μg/kg) and sufentanil (.1 to .5 μg/kg). The mean arterial blood pressure and heart rate of patients were recorded just before endotracheal intubation, immediately after intubation, and during the first 3 min after intubation. The primary outcomes were haemodynamic changes. The full dose–response relationship between dexmedetomidine and sufentanil was analysed using a logit model.

Results

This response surface model revealed that the interaction between dexmedetomidine and sufentanil was additive. The dose pairs that could effectively attenuate the haemodynamic response to endotracheal intubation primarily ranged from .3 to .4 μg/kg and .5 to 1.1 μg/kg for sufentanil and dexmedetomidine, respectively.

Conclusion

When used propofol as the main hypnotic drug during anaesthesia induction, dexmedetomidine could effectively reduce the requirement of sufentanil in an additive manner. However, it is not an effective drug for ablating the cardiovascular response to endotracheal intubation when used alone. The clinical trial registry. The trial registry name: Chinese Clinical Trial Registry. Registration number: ChiCTR1800015273. URL: http://www.chictr.org.cn

Comparison of the Effects of Sufentanil and Fentanyl on Postoperative Sleep Quality of Children Undergoing Tonsillectomy and Adenotomy: A Randomized Controlled Trial

OBJECTIVE

The primary purpose was to compare the effects of sufentanil and fentanyl on the postoperative sleep quality. And the secondary purposes were to evaluate perioperative hemodynamics, postoperative pain and complications of children undergoing tonsillectomy and adenotomy.

METHODS

Seventy-six patients were randomly assigned to the sufentanil or fentanyl group. The subjective sleep quality was assessed by the Athens Insomnia Scale (AIS) on the night before surgery (Sleep preop 1), the first night after surgery (Sleep POD 1), and the third night after surgery (Sleep POD 3). The Faces Pain Scale-Revised (FPS-R) was used to evaluate the postoperative pain level 24 hours after surgery. The Observer's Assessment of Alertness and Sedation (OAA/S) scale was used to assess the level of sedation in children. Perioperative hemodynamics and adverse effects were also evaluated.

RESULTS

The AIS score in the sufentanil group was significantly lower at Sleep POD 1 and Sleep POD 3 (P < 0.001, respectively). Children in the sufentanil group had significantly lower FPS-R scores at 2, 4, and 6 hours after surgery (P = 0.004, P = 0.004, and P = 0.001, respectively). The intraoperative hemodynamic parameters were more stable (P < 0.05, respectively) and the OAA/S scores at 2 hours after surgery were lower in the sufentanil group (P < 0.05). There was no significant difference in the incidence of postoperative nausea and vomiting between the two groups (P = 0.435).

CONCLUSION

Children undergoing tonsillectomy and adenotomy after general anesthesia who received sufentanil had better postoperative sleep quality and less postoperative pain at 2, 4, and 6 hours post operation. Moreover, children who received sufentanil showed better hemodynamic stability during surgery. Therefore, sufentanil should be considered as a better choice to facilitate rapid recovery in children following tonsillectomy and adenotomy.

The optimal bolus dose of sufentanil for satisfactory laryngeal mask airway (LMA) insertion conditions in chinese pediatric patients: A prospective double-blind randomized controlled trial (CONSORT)

BACKGROUND

This study aimed to estimate the optimal dose of sufentanil, coadministered with 2.5 mg/kg propofol, for satisfactory laryngeal mask airway (LMA) insertion conditions in Chinese children and to determine the optimal bolus dose.

METHODS

Seventy-five Chinese children aged 2 to 6 years with the American Society of Anesthesiologists physical status I or II, undergoing elective minor surgery were recruited. They were randomly divided into 5 different dosage groups (0, 0.05, 0.1, 0.15, 0.2 μg/kg). A predetermined sufentanil diluted with 5 mL saline was injected 30 s, 200 s later, followed by 2.5 mg/kg propofol over 10 s. After that the insertion conditions were assessed, using a 6-category score. The duration of apnea was recorded. A Probit analysis was performed to determine the ED50 and ED95 with 95% confidence interval for optimal conditions.

RESULTS

There were less hemodynamic changes in all sufentanil groups than propofol-only group, with 0.2 μg/kg patients showing the most stable cardiovascular responses and best insertion conditions. However, the duration of apnea increased with the increasing dosage of sufentanil. From Probit analysis, the ED50 and ED95 of sufentanil for optimum score were 0.064 μg/kg and 0.177 μg/kg, respectively.

CONCLUSION

In combination with propofol for anesthesia induction in Chinese children, sufentanil 0.2 μg/kg could prevent patients from dramatic hemodynamic change, providing satisfactory LMA insertion conditions.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Pharmacological agents for reducing the haemodynamic response to tracheal intubation in paediatric patients: a systematic review

The primary aim of this review was to assess the effect of pharmacological agents administered to attenuate the haemodynamic response to tracheal intubation in paediatric patients up to 16 years of age undergoing elective surgery. Secondary aims were to identify adverse effects related to these agents, and the agents' roles in decreasing arrhythmias. A systematic search was conducted for articles listed in PubMed, CINAHL or the Cochrane database between January 1980 and June 2014. We included randomised controlled trials where the stated aim of the study included observing the effects of pharmacological agents on the haemodynamic response to tracheal intubation. The outcome measures were changes in mean, systolic and diastolic blood pressure and heart rate, adverse effects of drugs and arrhythmias. Sixteen publications with a total of 1408 children (ages two to 15 years) were identified. These studies varied in methodology and quality. Opioids were the commonest agents used and appeared to obtund the response in a dose-related manner. Fentanyl 2 µg/kg, remifentanil 1 µg/kg, sufentanil 0.1 and 0.2 µg/kg and alfentanil 25 µg/kg blunted the haemodynamic response. Remifentanil 3 µg/kg and sufentanil 0.3 µg/kg were the most effective in obliterating the response but led to hypotension in unstimulated patients. Opioid-related side-effects and arrhythmias were observed in few patients. We recommend that when required, the safe and effective doses identified in this review be used to obtund the haemodynamic response to intubation in paediatric patients, with close observation for the uncommon but recognised side-effects.

Effective Bolus Dose of Sufentanil to Attenuate Cardiovascular Responses in Laryngoscopic Double-Lumen Endobronchial Intubation

Background

Sufentanil is a potent opioid analgesic frequently used in clinical anesthesia. Double-lumen endobronchial intubation induces profound cardiovascular responses in comparison with ordinary endotracheal intubation because of the larger tube diameter and direct irritation of the carina.

Objectives

The purpose of this study was to determine the effective bolus dose of sufentanil to attenuate hemodynamic changes in response to laryngoscopic double-lumen endobronchial intubation.

Patients and Methods

We randomly assigned 72 patients aged 18 - 65 years and with an American Society of Anesthesiologists physical status of 1 or 2 to one of four sufentanil dose groups: NS, S0.1, S0.2, or S0.3. The respective doses for the groups were as follows: normal saline, 0.1 mcg/kg of sufentanil, 0.2 mcg/kg of sufentanil, and 0.3 mcg/kg of sufentanil. Blood pressure and heart rate were recorded during the pre-anesthesia period at baseline, pre-intubation, immediate post-intubation, and every minute during 5 minutes after intubation.

Results

Baseline mean arterial pressures in the NS, S0.1, S0.2, and S0.3 groups were 89.8 ± 12.1, 89.2 ± 10.9, 88.8 ± 13.6, and 90.7 ± 11.1, respectively. At immediate post-intubation, the mean arterial pressures in the NS, S0.1, S0.2, and S0.3 groups were 129.7 ± 14.7, 120.7 ± 14.2, 120.8 ± 17.2, and 96.7 ± 10.4, respectively. At immediate post-intubation, the mean arterial pressure in the NS, S0.1, and S0.2 groups significantly increased from baseline (P < 0.001), but the S0.3 group showed no difference. In the time point comparison at immediate post- intubation, the S0.3 group had a significantly lower mean arterial pressure than did the NS, S0.1, and S0.2 groups (P < 0.001).

Conclusions

We found that 0.3 mcg/kg of sufentanil attenuates cardiovascular responses to double-lumen endobronchial intubation without adverse effects.

Aspects of pharmacokinetics and pharmacodynamics of sufentanil in pediatric practice

Sufentanil is a potent synthetic opioid. Like other opioids, sufentanil creates a stable hemodynamic environment in cardiovascularly compromised pediatric patients. Clearance, expressed as per kilogram, is increased in children compared to adults. The P450 CYP3A4 enzyme is responsible for the major metabolic N-dealkylation pathway. Enzyme activity is reduced in neonates but the maturation of sufentanil clearance is not described. The free active fraction is affected by age because of the reduced α(1) -acid glycoprotein plasma concentrations in neonates. Intranasal administration of sufentanil is a possible option for premedication, procedural sedation and analgesia in children, as this option has been found to be safe and effective. Studies concerning the pharmacokinetics and dynamics of sufentanil administered as a bolus or continuous infusion in children are few.

Bolus dose remifentanil and sufentanil blunting cardiovascular intubation responses in children: a randomized, double-blind comparison

BACKGROUND AND OBJECTIVE

The present randomized controlled study was designed to compare the efficacy of remifentanil 2 microg kg(-1) and sufentanil 0.2 microg kg(-1) by bolus injection on the cardiovascular response to intubation in healthy children.

METHODS

One hundred and five children, ASA 1-2 and scheduled for elective plastic surgery under general anaesthesia, were randomly divided into one of two study groups to receive the following treatments in a double-blind manner: remifentanil 2 microg kg(-1) (group R) and sufentanil 0.2 microg kg(-1) (group S). Blood pressure and heart rate (HR) were recorded before anaesthesia induction (baseline values), immediately before intubation (postinduction values), at intubation and every minute for 5 min after intubation. The percentage changes in systolic blood pressure (SBP) and HR relative to baseline values were calculated. The incidences of SBP and HR percentage changes of more than 30% of baseline values during the observation were recorded.

RESULTS

As compared with baseline values, blood pressure and HR at intubation and their maximum values during the observation increased significantly in group S, but decreased significantly in group R. Blood pressure and HR at intubation and their maximum values during the observation were significantly different between the groups. There were significant differences between the groups in the percentage changes of SBP and HR relative to baseline values and their maximum percentage changes during the observation. The incidences of SBP and HR percentage increases of more than 30% of baseline values were not significantly different between the groups, but the incidences of SBP and HR percentage decreases of more than 30% of baseline values were significantly higher in group R than in group S.

CONCLUSION

In combination with propofol for anaesthesia induction in children, sufentanil 0.2 microg kg(-1) by bolus injection fails to depress the cardiovascular intubation response. Remifentanil 2 microg kg(-1) by bolus injection can completely abolish the cardiovascular intubation response, but causes more adverse cardiovascular depression.