Remifentanil provides hemodynamic stability and faster awakening time in transsphenoidal surgery

A Prospective Randomized Comparison of Postoperative Pain and Complications after Thyroidectomy under Different Anesthetic Techniques: Volatile Anesthesia versus Total Intravenous Anesthesia

While the postoperative outcome is favorable, post-thyroidectomy pain is considerable. Reducing the postoperative acute pain, therefore, is considered important. This study investigated whether the pain intensity and need for rescue analgesics during the immediate postoperative period after thyroidectomy differ according to the methods of anesthesia. Seventy-two patients undergoing total thyroidectomy under general anesthesia were examined. Patients were randomly assigned to undergo either total intravenous anesthesia with remifentanil and propofol (TIVA, n = 35) or propofol induction and maintenance with desflurane and nitrous oxide (volatile anesthesia [VA], n = 37). The mean administered dose of remifentanil was 1977.7 ± 722.5 μg in the TIVA group, which was approximately 0.268 ± 0.118 μg/min/kg during surgery. Pain scores based on a numeric rating scale (NRS) and the need for rescue analgesics were compared between groups at the postoperative anesthetic care unit (PACU). The immediate postoperative NRS values of the TIVA and VA groups were 5.7 ± 1.7 and 4.7 ± 2.3, respectively (P = 0.034). Postoperative morphine equianalgesic doses in the PACU were higher in the TIVA group than in the VA group (16.7 ± 3.8 mg vs. 14.1 ± 5.9 mg, P = 0.027). The incidence of immediate postanesthetic complications did not differ significantly between groups. In conclusion, more rescue analgesics were required in the TIVA group than in the VA group to adequately manage postoperative pain while staying in the PACU after thyroidectomy.

Analgosedation during flexible fiberoptic bronchoscopy: comparing the clinical effectiveness and safety of remifentanil versus midazolam/propofol

Background

There are limited data regarding the efficacy and safety of remifentanil sedation for diagnostic bronchoscopy. The aim of this study was to evaluate the clinical efficacy and safety of remifentanil by comparing it with those of conventional drugs, midazolam and propofol.

Methods

A retrospective study of 186 patients who underwent diagnostic bronchoscopy at Chonbuk National University Hospital was performed. Patients were classified into the remifentanil group and midazolam/propofol group according to the drugs used during bronchoscopy.

Results

Of the 186 patients, 111 patients received remifentanil and 75 received midazolam/propofol during the bronchoscopy. The proportion of patients who required bronchoscopy for endobronchial inspection alone was significantly higher in the midazolam/propofol group than in the remifentanil group (93.3% vs. 73.0%; p <  0.001). In contrast, the proportion of patients who required more invasive procedures, such as bronchoscopic biopsy, bronchoalveolar lavage, or transbronchial lung biopsy, was significantly higher in the remifentanil group than in the midazolam/propofol group (27.0% vs. 6.7%; p <  0.001). The recovery time was significantly shorter in the remifentanil group than in the midazolam/propofol group (mean 6.4 min vs. 11.6 min, p <  0.001). There were no significant differences between the groups with regard to safety events including desaturation, hypotension, and arrhythmia.

Conclusions

Despite the higher proportion of patients who underwent more invasive procedures in the remifentanil group than in the midazolam/propofol group, there was no significant difference in safety events between the groups. Those in the remifentanil group also demonstrated a faster recovery time than those in the midazolam/propofol group.

Effects of anesthesia on cerebral blood flow, metabolism, and neuroprotection

Administration of anesthetic agents fundamentally shifts the responsibility for maintenance of homeostasis from the patient and their intrinsic physiological regulatory mechanisms to the anesthesiologist. Continuous delivery of oxygen and nutrients to the brain is necessary to prevent irreversible injury and arises from a complex series of regulatory mechanisms that ensure uninterrupted cerebral blood flow. Our understanding of these regulatory mechanisms and the effects of anesthetics on them has been driven by the tireless work of pioneers in the field. It is of paramount importance that the anesthesiologist shares this understanding. Herein, we will review the physiological determinants of cerebral blood flow and how delivery of anesthesia impacts these processes.

Safety of transsphenoidal microsurgical approach in patients with an ACTH-secreting pituitary adenoma

PURPOSE

Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma.

METHODS

We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available.

RESULTS

The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively).

CONCLUSIONS

In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.