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Johnson KB, Egan TD. In Total Intravenous Anesthesia We Trust: Building Confidence in Total Intravenous Anesthesia Techniques. Anesth Analg 2023; 137:559-564. [PMID: 37590800 DOI: 10.1213/ane.0000000000006622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Ken B Johnson
- From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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Su H, Koomen JV, Eleveld DJ, Struys MMRF, Colin PJ. Pharmacodynamic mechanism-based interaction model for the haemodynamic effects of remifentanil and propofol in healthy volunteers. Br J Anaesth 2023; 131:222-233. [PMID: 37355412 DOI: 10.1016/j.bja.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/04/2023] [Accepted: 04/27/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Propofol and remifentanil are frequently combined for the induction and maintenance of general anaesthesia. Both propofol and remifentanil cause vasodilation and potentially reduce arterial BP. We aimed to develop a mechanism-based model that characterises the haemodynamic interactions between remifentanil and propofol. METHODS Data from two clinical trials in healthy volunteers were analysed using remifentanil-alone, propofol-alone, and combination groups. We evaluated remifentanil effects on haemodynamics using a previously developed mechanism-based haemodynamic model of propofol. The interaction between propofol and remifentanil was explored using the principles of the general pharmacodynamic interaction (GPDI) model. RESULTS Remifentanil alone increased the dissipation rate of total peripheral resistance by 50% at 3.0 ng ml-1. Additionally, the dissipation rates of HR and stroke volume were attenuated by 4.8% and 4.9% per 1 ng ml-1 increase in remifentanil concentration, respectively. The maximal effect of propofol alone in decreasing the production rate of total peripheral resistance was 78%, which decreased to 32% when combined with remifentanil 4 ng ml-1. The effects of remifentanil on HR and stroke volume were attenuated by propofol with maximum decreases of 11.9% and 21.2%, respectively. Goodness-of-fit plots and prediction-corrected visual predictive check plots showed good predictive performance of the models. CONCLUSIONS The structure of the previous mechanism-based haemodynamic model for propofol was able to describe the effects of remifentanil alone on haemodynamic variables. The GPDI model provided a good framework for characterising the pharmacodynamic interaction between remifentanil and propofol on haemodynamic properties. CLINICAL TRIAL REGISTRATION NCT02043938; NCT03143972.
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Affiliation(s)
- Hong Su
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jeroen V Koomen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Pharmacology, Toxicology and Kinetics, Dutch Medicines Evaluation Board, Utrecht, the Netherlands
| | - Douglas J Eleveld
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Pieter J Colin
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Scherrer V, Lamoureux F, Chaventre C, Thill C, Demailly Z, Selim J, Bauer F, Imbert L, Wurtz V, Compère V, Clavier T, Besnier E. Reliability of the Minto model for target-controlled infusion of remifentanil during cardiac surgery with cardiopulmonary bypass. Br J Anaesth 2022; 129:163-171. [PMID: 35750514 DOI: 10.1016/j.bja.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Minto pharmacokinetic model is used for target-controlled infusion of remifentanil. The reliability of this model has never been evaluated during normothermic cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to assess the predictive performance of the model during CPB to determine its reliability during cardiac surgery. METHODS This was a single-centre observational study. Arterial blood samples were drawn at five time points: T1, after tracheal intubation; T2, immediately before CPB; T3, 10 min after starting CPB; T4, 45 min after starting CPB; T5, 10 min after weaning off CPB. Prediction error (PE) and absolute prediction error (APE) were calculated for each sample and used to determine median prediction error (MDPE) and median absolute prediction error (MDAPE) per patient. Risk factors for APE >30% were assessed using multivariable analysis. Results are presented as medians with inter-quartile ranges. RESULTS Fifty-eight patients with 283 blood samples (110 during CPB) were included. In the pre-CPB period, MDPE and MDAPE were -17.3 [-32.9 to 2.3] and 24.6 [12-37.7]%, whereas during CPB, they were -1.8 [-15.6 to 11.1] and 14.0 [6.74-27.1]%, respectively. There was no statistically significant difference between measured and predicted remifentanil plasma concentrations during CPB. Age, preoperative albumin concentrations, temperature, and haemodilution were not independently associated with MDAPE >30%. CONCLUSIONS The Minto model accurately predicts plasma remifentanil concentrations during cardiac surgery with CPB. CLINICAL TRIAL REGISTRATION 2017-A03153-50.
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Affiliation(s)
- Vincent Scherrer
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Fabien Lamoureux
- Rouen University Hospital, Department of Pharmacology, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Céline Chaventre
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Caroline Thill
- Rouen University Hospital, Department of Biostatistics, Rouen, France
| | - Zoe Demailly
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Jean Selim
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Fabrice Bauer
- Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France; Rouen University Hospital, Department of Cardiac Surgery, Rouen, France
| | - Laurent Imbert
- Rouen University Hospital, Department of Pharmacology, Rouen, France
| | - Véronique Wurtz
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Vincent Compère
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, INSERM U1239, Rouen, France
| | - Thomas Clavier
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Emmanuel Besnier
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France.
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Thermodynamic Interpretation of a Machine-Learning-Based Response Surface Model and Its Application to Pharmacodynamic Synergy between Propofol and Opioids. MATHEMATICS 2022. [DOI: 10.3390/math10101651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Propofol and fentanyl are commonly used agents for the induction of anesthesia, and are often associated with hemodynamic disturbances. Understanding pharmacodynamic impacts is vital for parasympathetic and sympathetic tones during the anesthesia induction period. Inspired by the thermodynamic interaction between drug concentrations and effects, we established a machine-learning-based response surface model (MLRSM) to address this predicament. Then, we investigated and modeled the biomedical phenomena in the autonomic nervous system. Our study prospectively enrolled 60 patients, and the participants were assigned to two groups randomly and equally. Group 1 received propofol first, followed by fentanyl, and the drug sequence followed an inverse procedure in Group 2. Then, we extracted and analyzed the spectrograms of electrocardiography (ECG) and pulse photoplethysmography (PPG) signals after induction of propofol and fentanyl. Eventually, we utilized the proposed MLRSM to evaluate the relationship between anesthetics and the integrity/balance of sympathetic and parasympathetic activity by employing the power of high-frequency (HF) and low-frequency (LF) bands and PPG amplitude (PPGA). It is worth emphasizing that the proposed MLRSM exhibits a similar mathematical form to the conventional Greco model, but with better computational performance. Furthermore, the MLRSM has a theoretical foundation and flexibility for arbitrary numbers of drug combinations. The modeling results are consistent with the previous literature. We employed the bootstrap algorithm to inspect the results’ consistency and measure the various statistical fluctuations. Then, the comparison between the modeling and the bootstrapping results was used to validate the statistical stability and the feasibility of the proposed MLRSM.
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Bae J, Kwon M, Lee YH, Lee EK, Choi BM, Noh GJ. An allometric pharmacokinetic model and minimum effective analgesic concentration of fentanyl in patients undergoing major abdominal surgery. Br J Anaesth 2020; 125:976-985. [PMID: 32861508 DOI: 10.1016/j.bja.2020.06.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/29/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We aimed to characterise the population pharmacokinetics of fentanyl in adults and to determine the minimum effective concentration (MEC) and minimum effective analgesic concentration (MEAC) of i.v. fentanyl in patients after major abdominal open surgery. METHODS In the pharmacokinetic study, subjects received an intravenous bolus of fentanyl 100 μg during operation, and arterial blood was sampled at pre-set intervals. In addition, data from previously published fentanyl pharmacokinetic studies were incorporated to build a pharmacokinetic model. In the MEAC study, subjects were asked to rate their pain every 10 min using a VAS (0=no pain, 10=most severe pain) in the PACU. The first blood sample was obtained when wound pain was rated as ≥3 at rest or ≥5 during compression. Then, fentanyl 50 μg was administered every 10 min until the pain intensity had decreased to <3 at rest and <5 during compression, at which point the second blood was sampled and the first MEAC of fentanyl was measured. The same procedure was repeated to obtain a third sample (MEC) and a fourth sample (second MEAC). RESULTS In the population pharmacokinetic study (n=95), the plasma concentration of fentanyl over time was well-described by the three-compartment mammillary model using an allometric expression. The V1, V2, V3, Cl, Q1, and Q2 of a 70 kg subject were 10.1, 26.5, 206 L, 0.704, 2.38, and 1.49 L min-1, respectively. In the MEAC study (n=30), the median (inter-quartile range) MEC and MEAC were 0.72 (0.58-1.05) ng ml-1, and 0.99 (0.76-1.28) ng ml-1, respectively. CONCLUSION These results provide a scientific basis for the use of fentanyl for acute postoperative pain management in surgical patients. CLINICAL TRIAL REGISTRATION KCT0003273 (http://cris.nih.go.kr).
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Affiliation(s)
- Jayyoung Bae
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Miyoung Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Yong-Hun Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, Republic of Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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van den Berg JP, Absalom AR, Venema AM, Kalmar AF, Van Amsterdam K, Hannivoort LN, Proost JH, Meier S, Scheeren TWL, Struys MMRF, Vereecke HEM. Comparison of haemodynamic- and electroencephalographic-monitored effects evoked by four combinations of effect-site concentrations of propofol and remifentanil, yielding a predicted tolerance to laryngoscopy of 90. J Clin Monit Comput 2020; 35:815-825. [PMID: 32488680 PMCID: PMC8286956 DOI: 10.1007/s10877-020-00540-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/26/2020] [Indexed: 11/05/2022]
Abstract
This prospective study evaluates haemodynamic and electroencephalographic effects observed when administering four combinations of effect-site concentrations of propofol (CePROP) and remifentanil (CeREMI), all yielding a single predicted probability of tolerance of laryngoscopy of 90% (PTOL = 90%) according to the Bouillon interaction model. We aimed to identify combinations of CePROP and CeREMI along a single isobole of PTOL that result in favourable hypnotic and haemodynamic conditions. This knowledge could be of advantage in the development of drug advisory monitoring technology. 80 patients (18–90 years of age, ASA I–III) were randomized into four groups and titrated towards CePROP (Schnider model, ug⋅ml−1) and CeREMI (Minto model, ng⋅ml−1) of respectively 8.6 and 1, 5.9 and 2, 3.6 and 4 and 2.0 and 8. After eleven minutes of equilibration, baseline measurements of haemodynamic endpoints and bispectral index were compared with three minutes of responsiveness measurements after laryngoscopy. Before laryngoscopy, bispectral index differed significantly (p < 0.0001) between groups in concordance with CePROP. Heart rate decreased with increasing CeREMI (p = 0.001). The haemodynamic and arousal responses evoked by laryngoscopy were not significantly different between groups, but CePROP = 3.6 μg⋅ml−1 and CeREMI = 4 ng⋅ml−1 evoked the lowest median value for ∆HR and ∆SAP after laryngoscopy. This study provides clinical insight on the haemodynamic and hypnotic consequences, when a model based predicted PTOL is used as a target for combined effect-site controlled target- controlled infusion of propofol and remifentanil. Heart rate and bispectral index were significantly different between groups despite a theoretical equipotency for PTOL, suggesting that each component of the anaesthetic state (immobility, analgesia, and hypnotic drug effect) should be considered as independent neurophysiological and pharmacological phenomena. However, claims of (in)accuracy of the predicted PTOL must be considered preliminary because larger numbers of observations are required for that goal.
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Affiliation(s)
- J P van den Berg
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - A R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A M Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A F Kalmar
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - K Van Amsterdam
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - L N Hannivoort
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J H Proost
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - S Meier
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - H E M Vereecke
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Anaesthesia and Reanimation, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
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Age progression from vicenarians (20-29 year) to nonagenarians (90-99 year) among a population pharmacokinetic/pharmacodynamic (PopPk-PD) covariate analysis of propofol-bispectral index (BIS) electroencephalography. J Pharmacokinet Pharmacodyn 2020; 47:145-161. [PMID: 32100175 DOI: 10.1007/s10928-020-09678-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pharmacokinetic/pharmacodynamic (PK/PD) modeling has made an enormous contribution to intravenous anesthesia. Because of their altered physiological, pharmacological and pathological aspects, titrating general anesthesia in the elderly is a challenging task. METHODS Eighty patients were consecutively enrolled divided by decades from vicenarians (20-29 year) to nonagenarians (90-99 year) into eight groups. Using target controlled infusion (TCI) and electroencephalographic (EEG)-derived bispectral index (BIS) we set propofol plasma concentration (Cp) to gradually reach 3.5 μg mL-1 over 3.5-min. In each patient, we constructed a PK/PD model and conducted a population PK/PD (PopPK-PD) covariate analysis. RESULTS Age was significant covariate for baseline BIS effect (E0), inhibitory propofol concentration at 50% BIS decline (IC50) and maximum BIS decline (Emax). First-order rate constant Ke0 of 0.47 min-1 in vicenarians (20-29 year) gradually increased with age-progression to 1.85 min-1 in nonagenarians (90-99 year). Simulation modelling showed that clinically recommended Cp of 3.5 μg mL-1 for 20-29 year BIS 50 should be reduced to 3.0 for 30-49 year, 2.5 for 50-69 year and 2.0 for 80-89 year. CONCLUSION We quantified and graded EEG-BIS age-progression among different age groups divided by decades. We demonstrated deeper BIS values with decades' age progression. Our data has important implications for propofol dosing. The practical information for physicians in their daily clinical practice is using propofol Cp of 3.5 μg mL-1 might not yield BIS value of 50 in elderly patients. Our simulations showed that the recommended regimen of Cp 3.5 μg mL-1 for 20-29 year should be gradually decreased to 2.0 μg mL-1 for 80-89 year. CLINICAL TRIAL REGISTRY NUMBERS European Community Clinical Trials Database EudraCT (http://eudract.emea.eu) initial trial registration number: 2011-002847-81, and subsequently registered at www.clinicaltrials.gov; trial registration number: NCT02585284. Xijing Hospital of Fourth Military Medical University ethics committee approval number 20110707-4.
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Yi JM, Doh I, Lee SH, Kim SY, Lee YH, Lee EK, Lee SH, Choi BM, Noh GJ. Predictive performance of a new pharmacokinetic model for propofol in underweight patients during target-controlled infusion. Acta Anaesthesiol Scand 2019; 63:448-454. [PMID: 30690713 DOI: 10.1111/aas.13335] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND In a previous study, the modified Marsh and Schnider models respectively showed negatively- and positively-biased predictions in underweight patients. To overcome this drawback, we developed a new pharmacokinetic propofol model-the Choi model-for use in underweight patients. In the present study, we evaluated the predictive performance of the Choi model. METHODS Twenty underweight patients undergoing elective surgery received propofol via TCI using the Choi model. The target effect-site concentrations (Ces) of propofol were 2.5, 3, 3.5, 4, 4.5, and 2 μg/mL. Arterial blood samples were obtained at least 10 minutes after achieving pseudo-steady-state. Predicted propofol concentrations with the modified Marsh, Schnider, and Eleveld pharmacokinetic models were obtained by simulation (Asan pump, version 2.1.3; Bionet Co. Ltd., Seoul, Korea). The predictive performance of each model was assessed by calculation of four parameters: inaccuracy, divergence, bias, and wobble. RESULTS A total of 119 plasma samples were used to determine the predictive performance of the Choi model. Our evaluation showed that the pooled median (95% CI) bias and inaccuracy were 4.0 (-4.2 to 12.2) and 23.9 (17.6-30.3), respectively. The pooled biases and inaccuracies of the modified Marsh, Schnider, and Eleveld models were clinically acceptable. However, the modified Marsh and Eleveld models consistently produced negatively biased predictions in underweight patients. In particular, the Schnider model showed greater inaccuracy at a target Ce ≥ 3 µg/mL. CONCLUSION The new propofol pharmacokinetic model (the Choi model) developed for underweight patient showed adequate performance for clinical use.
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Affiliation(s)
- Jung-Min Yi
- Department of Anesthesiology and Pain Medicine; Catholic Kwandong University International St. Mary's Hospital; Incheon Korea
| | - Il Doh
- Center for Medical Metrology; Korea Research Institute of Standards and Science (KRISS); Daejeon Korea
| | - Seok-Hwan Lee
- Center for Thermometry and Fluid Flow Metrology; Korea Research Institute of Standards and Science (KRISS); Daejeon Korea
| | - Soo-Young Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Yong-Hun Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Eun-Kyung Lee
- Department of Statistics; Ewha Womans University; Seoul Korea
| | - Soo-Han Lee
- New Drug Development Center; Osong Medical Innovation Foundation; Chungcheongbuk-do Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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Park J, Choi S, Park J, Lee K, Yun H, Lee E, Choi B, Noh G. Population pharmacokinetic analysis of propofol in underweight patients under general anaesthesia. Br J Anaesth 2018; 121:559-566. [DOI: 10.1016/j.bja.2018.04.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 03/14/2018] [Accepted: 05/20/2018] [Indexed: 11/16/2022] Open
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Yoon SW, Choi GJ, Lee OH, Yoon IJ, Kang H, Baek CW, Jung YH, Woo YC. Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis. Dig Endosc 2018; 30:580-591. [PMID: 29526045 DOI: 10.1111/den.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/05/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Previous randomized controlled trials have reported conflicting findings comparing propofol combination therapy (PCT) with propofol monotherapy (PMT) for sedation of patients undergoing gastrointestinal endoscopy. Therefore, a systematic review was carried out to compare the efficacy and safety of PCT and PMT in such patients. METHODS We searched MEDLINE, EMBASE and CENTRAL databases to identify all randomized controlled trials that compared the efficacy and safety of PCT and PMT for sedation of patients undergoing gastrointestinal endoscopy. Primary endpoints were incidence of respiratory complications, hypotension and arrhythmia, dose of propofol used, and recovery time. Procedure duration and the satisfaction of patients and doctors were also evaluated. RESULTS A total of 2250 patients from 22 studies were included in the final analysis. The combined analysis did not show any difference between PCT and PMT in the incidence of respiratory complications (risk ratio [RR], 0.80; 95% CI, 0.52 to 1.23; I2 = 58.34%), hypotension (RR, 1.06; 95% CI, 0.63 to 1.78; I2 = 72.13%), arrhythmia (RR,1.40; 95% CI, 0.74 to 2.64; I2 = 43.71%), recovery time (standardized mean difference [SMD], 0.16; 95% CI, -0.49 to 0.81; I2 = 95.9%), procedure duration (SMD, 0.04; 95% CI, -0.05 to 0.14; I2 = 0.0%), patient satisfaction (SMD, 0.13; 95% CI, -0.26 to 0.52; I2 = 89.63%) or doctor satisfaction (SMD, 0.01; 95% CI, -0.15 to 0.17; I2 = 0.00%). However, the dose of propofol used was significantly lower in PCT than in PMT (SMD, -1.38; 95% CI, -1.99 to -0.77; I2 = 97.70%). CONCLUSION PCT showed comparable efficacy and safety to PMT with respect to respiratory complications, hypotension and arrhythmia, recovery time, procedure duration, patient satisfaction, and doctor satisfaction. However, the average dose of propofol used was higher in PMT.
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Affiliation(s)
- Sang Won Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Oh Haeng Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Il Jae Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chong Wha Baek
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong Hun Jung
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Rolle A, Paredes S, Cortínez LI, Anderson BJ, Quezada N, Solari S, Allende F, Torres J, Cabrera D, Contreras V, Carmona J, Ramírez C, Oliveros AM, Ibacache M. Dexmedetomidine metabolic clearance is not affected by fat mass in obese patients. Br J Anaesth 2018; 120:969-977. [PMID: 29661414 DOI: 10.1016/j.bja.2018.01.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/28/2017] [Accepted: 01/27/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Obesity has been associated with reduced dexmedetomidine clearance, suggesting impaired hepatic function or reduced hepatic blood flow. The aim of this study was to clarify the effect of obesity in dexmedetomidine metabolic clearance. METHODS Forty patients, ASA I-III, 18-60 yr old, weighing 47-126 kg, scheduled for abdominal laparoscopic surgery, were enrolled. Anaesthetic agents (propofol, remifentanil, and dexmedetomidine) were dosed based on lean body weight measured by dual X-ray absorptiometry. Serial venous samples were drawn during and after dexmedetomidine infusion. A pharmacokinetic analysis was undertaken using non-linear mixed-effect models. In the modelling approach, the total body weight, lean body weight, and adjusted body weight were first tested as size descriptors for volumes and clearances. Hepatic blood flow, liver histopathology, liver enzymes, and gene expression of metabolic enzymes (UGT2B10 and UGT1A4) were tested as covariates of dexmedetomidine metabolic clearance. A decrease in NONMEM objective function value (ΔOFV) of 3.84 points, for an added parameter, was considered significant at the 0.05 level. RESULTS A total of 637 dexmedetomidine serum samples were obtained. A two-compartmental model scaled to measured lean weight adequately described the dexmedetomidine pharmacokinetics. Liver blood flow was a covariate for dexmedetomidine clearance (ΔOFV=-5.878). Other factors, including fat mass, histopathological damage, and differential expression of enzymes, did not affect the dexmedetomidine clearance in the population studied (ΔOFV<3.84). CONCLUSIONS We did not find a negative influence of obesity in dexmedetomidine clearance when doses were adjusted to lean body weight. Liver blood flow showed a significant effect on dexmedetomidine clearance. CLINICAL TRIAL REGISTRATION NCT02557867.
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Affiliation(s)
- A Rolle
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - S Paredes
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - L I Cortínez
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - B J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - N Quezada
- Departamento de Cirugía Digestiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - S Solari
- Departamento de Laboratorio Clínico, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Allende
- Departamento de Laboratorio Clínico, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J Torres
- Departamento de Anatomía Patológica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - D Cabrera
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Ciencias Químicas y Biológicas, Facultad de Salud, Universidad Bernardo O'Higgins, Santiago, Chile
| | - V Contreras
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J Carmona
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C Ramírez
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A M Oliveros
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M Ibacache
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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From pharmacokinetics to pharmacodynamics - Are we ready for 3D software?☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201710000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tafur-Betancourt LA, Lema FE, Milla GMDM, Londoño A, Vargas JRN. From pharmacokinetics to pharmacodynamics – Are we ready for 3D software? COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Tafur-Betancourt LA, Lema F. E, Milla G. MDM, Londoño A, Navarro Vargas JR. De la farmacocinética a la farmacodinámica, ¿estamos listos para los software 3D? COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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The hidden world of drug interactions in anesthesia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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The hidden world of drug interactions in anesthesia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Liou JY, Ting CK, Mandell MS, Chang KY, Teng WN, Huang YY, Tsou MY. Predicting the Best Fit. Anesth Analg 2016; 123:299-308. [DOI: 10.1213/ane.0000000000001299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Comparison of propofol pharmacokinetic and pharmacodynamic models for awake craniotomy: A prospective observational study. Eur J Anaesthesiol 2016; 32:527-34. [PMID: 25774459 DOI: 10.1097/eja.0000000000000255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anaesthesia for awake craniotomy aims for an unconscious patient at the beginning and end of surgery but a rapidly awakening and responsive patient during the awake period. Therefore, an accurate pharmacokinetic/pharmacodynamic (PK/PD) model for propofol is required to tailor depth of anaesthesia. OBJECTIVE To compare the predictive performances of the Marsh and the Schnider PK/PD models during awake craniotomy. DESIGN A prospective observational study. SETTING Single university hospital from February 2009 to May 2010. PATIENTS Twelve patients undergoing elective awake craniotomy for resection of brain tumour or epileptogenic areas. INTERVENTION Arterial blood samples were drawn at intervals and the propofol plasma concentration was determined. MAIN OUTCOME MEASURES The prediction error, bias [median prediction error (MDPE)] and inaccuracy [median absolute prediction error (MDAPE)] of the Marsh and the Schnider models were calculated. The secondary endpoint was the prediction probability PK, by which changes in the propofol effect-site concentration (as derived from simultaneous PK/PD modelling) predicted changes in anaesthetic depth (measured by the bispectral index). RESULTS The Marsh model was associated with a significantly (P = 0.05) higher inaccuracy (MDAPE 28.9 ± 12.0%) than the Schnider model (MDAPE 21.5 ± 7.7%) and tended to reach a higher bias (MDPE Marsh -11.7 ± 14.3%, MDPE Schnider -5.4 ± 20.7%, P = 0.09). MDAPE was outside of accepted limits in six (Marsh model) and two (Schnider model) of 12 patients. The prediction probability was comparable between the Marsh (PK 0.798 ± 0.056) and the Schnider model (PK 0.787 ± 0.055), but after adjusting the models to each individual patient, the Schnider model achieved significantly higher prediction probabilities (PK 0.807 ± 0.056, P = 0.05). CONCLUSION When using the 'asleep-awake-asleep' anaesthetic technique during awake craniotomy, we advocate using the PK/PD model proposed by Schnider. Due to considerable interindividual variation, additional monitoring of anaesthetic depth is recommended. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 01128465.
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Short TG, Hannam JA, Laurent S, Campbell D, Misur M, Merry AF, Tam YH. Refining Target-Controlled Infusion: An Assessment of Pharmacodynamic Target-Controlled Infusion of Propofol and Remifentanil Using a Response Surface Model of Their Combined Effects on Bispectral Index. Anesth Analg 2016; 122:90-7. [PMID: 26683103 DOI: 10.1213/ane.0000000000000386] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Propofol and remifentanil are commonly combined for total IV anesthesia. The pharmacokinetics (PK), pharmacodynamics (PD), and drug interactions of the combination are well understood, but the use of a combined PK and PD model to control target-controlled infusion pumps has not been investigated. In this study, we prospectively tested the accuracy of a PD target-controlled infusion algorithm for propofol and remifentanil using a response surface model of their combined effects on Bispectral Index (BIS). METHODS Effect-site, target-controlled infusions of propofol and remifentanil were given using an algorithm based on standard PK models linked to a PD response surface model of their combined effects on BIS. The combination of a targeted BIS value and adjustable ratio of propofol to remifentanil was used to adjust infusion rates. The standard model performance measures of median performance error (bias) and median absolute performance error (inaccuracy), expressed as percentages, were used to assess accuracy of the infusions in a convenience sample of 50 adult patients undergoing surgery with general anesthesia. The influence of age and weight on the performance of the model was also assessed. RESULTS Patients had a mean (range) age of 48 (19-73) years, weight of 80 (45-169) kg, and body mass index of 28 (19-45) kg/m. The overall model had a bias of 8% (SD 24%) and inaccuracy of 25% (SD 13%). Performance was least accurate during the early induction phase of anesthesia. There was no significant bias in BIS predictions with increasing age (P = 0.44) or weight (P = 0.56). CONCLUSIONS The algorithm performed adequately in a clinical setting. The algorithm could be further refined, and assessment of its accuracy and utility in comparison to current clinical practice for giving IV anesthesia is warranted.
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Affiliation(s)
- Timothy G Short
- From the *Department of Anaesthesiology, University of Auckland, Auckland, New Zealand; †Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand; and ‡Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Hayashi K, Tanaka A. Effect-site concentrations of remifentanil causing bradycardia in hypnotic and non-hypnotic patients. J Clin Monit Comput 2015; 30:919-924. [PMID: 26462495 DOI: 10.1007/s10877-015-9794-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 10/09/2015] [Indexed: 11/26/2022]
Abstract
Although the induction of anaesthesia with remifentanil often causes bradycardia, the relationship between the effect-site concentration (Ce) of remifentanil and instantaneous heart rate (HR) has remained unclear. The present study examined the relationship between instantaneous HR and remifentanil Ce at the induction of anaesthesia with and without propofol hypnosis, to facilitate safe management of anaesthesia induction with remifentanil. Instantaneous HR was calculated every 5 s using an electrocardiographic real-time analysis system (MemCalc/Makin2; GMS, Tokyo, Japan). At the beginning of anaesthesia induction, continuous infusion of remifentanil (1 μg min-1 kg-1) preceded hypnosis with propofol in 13 patients [non-hypnosis group; mean age, 67.8 (17.5) years], while propofol bolus (30-50 mg) was injected together with continuous remifentanil medication in 18 patients [hypnosis group; mean age, 62.9 (16.5) years]. Remifentanil Ce was estimated every 5 s using the three-compartment model proposed by Minto et al. and the relationship between estimated remifentanil Ce and instantaneous HR was examined. In the hypnosis group, HR was significantly lower than basal HR when remifentanil Ce was increased to 3.5 ng ml-1 (p < 0.05), whereas no significant HR reduction was found in the non-hypnosis group until remifentanil Ce reached >5 ng ml-1 (p < 0.05). The induction of anaesthesia using remifentanil with propofol hypnotics significantly reduces HR even in a low remifentanil Ce insufficient to suppress the cardiovascular response at tracheal intubation. Preparations to treat bradycardia are recommended for the safe management of anaesthesia induction when remifentanil is combined with hypnotics.
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Affiliation(s)
- Kazuko Hayashi
- Department of Anesthesiology, Nantan General Hospital, Yagi Ueno 25, Nantan City, Kyoto, 629-0141, Japan.
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kawaramachi Hirokoji 465, Kyoto, 602-8566, Japan.
| | - Akiko Tanaka
- Department of Anesthesiology, Nantan General Hospital, Yagi Ueno 25, Nantan City, Kyoto, 629-0141, Japan
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Dexmedetomidine pharmacokinetics in the obese. Eur J Clin Pharmacol 2015; 71:1501-8. [DOI: 10.1007/s00228-015-1948-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
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Population pharmacokinetic and pharmacodynamic model of propofol externally validated in children. J Pharmacokinet Pharmacodyn 2015; 42:163-77. [DOI: 10.1007/s10928-015-9408-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 02/13/2015] [Indexed: 11/25/2022]
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Cortínez LI, De la Fuente N, Eleveld DJ, Oliveros A, Crovari F, Sepulveda P, Ibacache M, Solari S. Performance of propofol target-controlled infusion models in the obese: pharmacokinetic and pharmacodynamic analysis. Anesth Analg 2014; 119:302-310. [PMID: 24977639 DOI: 10.1213/ane.0000000000000317] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obesity is associated with important physiologic changes that can potentially affect the pharmacokinetic (PK) and pharmacodynamic (PD) profile of anesthetic drugs. We designed this study to assess the predictive performance of 5 currently available propofol PK models in morbidly obese patients and to characterize the Bispectral Index (BIS) response in this population. METHODS Twenty obese patients (body mass index >35 kg/m), aged 20 to 60 years, scheduled for laparoscopic bariatric surgery, were studied. Anesthesia was administered using propofol by target-controlled infusion and remifentanil by manually controlled infusion. BIS data and propofol infusion schemes were recorded. Arterial blood samples to measure propofol were collected during induction, maintenance, and the first 2 postoperative hours. Median performance errors (MDPEs) and median absolute performance errors (MDAPEs) were calculated to measure model performance. A PKPD model was developed using NONMEM to characterize the propofol concentration-BIS dynamic relationship in the presence of remifentanil. RESULTS We studied 20 obese adults (mean weight: 106 kg, range: 85-141 kg; mean age: 33.7 years, range: 21-53 years; mean body mass index: 41.4 kg/m, range: 35-52 kg/m). We obtained 294 arterial samples and analyzed 1431 measured BIS values. When total body weight (TBW) was used as input of patient weight, the Eleveld allometric model showed the best (P < 0.0001) performance with MDPE = 18.2% and MDAPE = 27.5%. The 5 tested PK models, however, showed a tendency to underestimate propofol concentrations. The use of an adjusted body weight with the Schnider and Marsh models improved the performance of both models achieving the lowest predictive errors (MDPE = <10% and MDAPE = <25%; all P < 0.0001). A 3-compartment PK model linked to a sigmoidal inhibitory Emax PD model by a first-order rate constant (ke0) adequately described the propofol concentration-BIS data. A lag time parameter of 0.44 minutes (SE = 0.04 minutes) to account for the delay in BIS response improved the fit. A simulated effect-site target of 3.2 μg/mL (SE = 0.17 μg/mL) was estimated to obtain BIS of 50, in the presence of remifentanil, for a typical patient in our study. CONCLUSIONS The Eleveld allometric PK model proved to be superior to all other tested models using TBW. All models, however, showed a trend to underestimate propofol concentrations. The use of adjusted body weight instead of TBW with the traditional Schnider and Marsh models markedly improved their performance achieving the lowest predictive errors of all tested models. Our results suggest no relevant effect of obesity on both the time profile of BIS response and the propofol concentration-BIS relationship.
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Affiliation(s)
- Luis I Cortínez
- From the *Departmento de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; †Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; ‡Departmento de Cirugía, Escuela de Medicina, Pontificia Universidad Católica de Chile; §Departamento de Anestesiología, Facultad de Medicina, Clínica Alemana-Universidad del Desarrollo; and ‖Departmento de Laboratorio Clínico, Escuela de Medicina, Pontificia, Universidad Católica de Chile, Santiago, Chile
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Sahinovic MM, Eleveld DJ, Kalmar AF, Heeremans EH, De Smet T, Seshagiri CV, Absalom AR, Vereecke HEM, Struys MMRF. Accuracy of the Composite Variability Index as a Measure of the Balance Between Nociception and Antinociception During Anesthesia. Anesth Analg 2014; 119:288-301. [DOI: 10.1213/ane.0000000000000274] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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El Hamd MA, Wada M, Ikeda R, Kawakami S, Kuroda N, Nakashima K. Simultaneous determination of propofol and remifentanil in rat plasma by liquid chromatography-tandem mass spectrometry: application to preclinical pharmacokinetic drug-drug interaction analysis. Biomed Chromatogr 2014; 29:325-7. [DOI: 10.1002/bmc.3281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/22/2014] [Accepted: 05/29/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamed A. El Hamd
- Graduate School of Biomedical Sciences; Nagasaki University; 1-14 Bunkyo-machi Nagasaki 852-8131 Japan
| | - Mitsuhiro Wada
- Graduate School of Biomedical Sciences; Nagasaki University; 1-14 Bunkyo-machi Nagasaki 852-8131 Japan
| | - Rie Ikeda
- Graduate School of Biomedical Sciences; Nagasaki University; 1-14 Bunkyo-machi Nagasaki 852-8131 Japan
| | - Shigeru Kawakami
- Graduate School of Biomedical Sciences; Nagasaki University; 1-14 Bunkyo-machi Nagasaki 852-8131 Japan
| | - Naotaka Kuroda
- Graduate School of Biomedical Sciences; Nagasaki University; 1-14 Bunkyo-machi Nagasaki 852-8131 Japan
| | - Kenichiro Nakashima
- Faculty of Pharmaceutical Sciences; Nagasaki International University; 2825-7 Huis Ten Bosch Sasebo Nagasaki 859-3298 Japan
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Assessment of the performance of the Marsh model in effect site mode for target controlled infusion of propofol during the maintenance phase of general anaesthesia in an unselected population of neurosurgical patients. Eur J Anaesthesiol 2013; 30:627-32. [DOI: 10.1097/eja.0b013e328363157a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhou H. Population-Based Assessments of Clinical Drug-Drug Interactions: Qualitative Indices or Quantitative Measures? J Clin Pharmacol 2013; 46:1268-89. [PMID: 17050792 DOI: 10.1177/0091270006294278] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Population-based assessments of drug-drug interactions have become more common since the introduction and acceptance of the population pharmacokinetic approach. Unlike traditional methods, population-based studies provide clinically relevant results that can be applied directly to a target patient population. Furthermore, population-based studies do not demand the traditional requirements of intensive pharmacokinetic sampling, rigorous inpatient stays, or stringent assessment schedules. As such, the population-based approach can effectively be used to confirm known drug-drug interactions and further characterize anticipated interactions. A prospectively designed analysis can also reveal drug-drug interactions that might otherwise have gone undetected with traditional methods. Ultimately, these results could help to alleviate clinicians' concerns about using widely marketed drugs in combination therapies and also reduce patients' risk of experiencing unacceptable side effects. This article intends to provide a balanced overview of the population-based approach and its merits, drawbacks, and potential utility in the assessment of drug-drug interactions during clinical drug development.
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Affiliation(s)
- Honghui Zhou
- Pharmacokinetics, Modeling & Simulation, Clinical Pharmacology & Experimental Medicine, Centocor Research & Development, Malvern, PA 19087, USA
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Yufune S, Takamatsu I, Masui K, Kazama T. Effect of remifentanil on plasma propofol concentration and bispectral index during propofol anaesthesia. Br J Anaesth 2011; 106:208-14. [DOI: 10.1093/bja/aeq334] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Weiss M, Reekers M, Vuyk J, Boer F. Circulatory model of vascular and interstitial distribution kinetics of rocuronium: a population analysis in patients. J Pharmacokinet Pharmacodyn 2010; 38:165-78. [DOI: 10.1007/s10928-010-9186-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 11/13/2010] [Indexed: 11/29/2022]
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Population pharmacokinetics and pharmacodynamics in anesthesia, intensive care and pain medicine. Curr Opin Anaesthesiol 2010; 23:479-84. [PMID: 20610985 DOI: 10.1097/aco.0b013e32833a1d2f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Population modeling is a relatively new pharmacological discipline, the development of which has largely been stimulated by the need for accurate models for the pharmacokinetics and dynamics of anesthetic agents. RECENT FINDINGS Population-based modeling is now considered superior to older, more traditional modeling methods. Nonlinear mixed-effect modeling - a commonly used population-based modeling approach - estimates intraindividual and interindividual variability, limits the influence of outlying samples and individuals through the use of Bayesian statistical analysis, and provides a potential means of optimizing drug delivery regimens, especially when used to define pharmacokinetic-dynamic models for target-controlled infusion systems. In addition to being used for pharmacokinetic modeling, in which the influence of factors such as age, weight and illness can be studied, it is a powerful tool for the study of the influence of multiple factors on drug pharmacodynamics. SUMMARY Nonlinear mixed-effect population-based modeling has become the gold standard method of pharmacokinetic and pharmacodynamic analysis during new drug development and during subsequent pharmacological studies. Population-based modeling techniques have been applied to numerous aspects of drug delivery in anesthesia, intensive care and pain medicine.
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Abstract
BACKGROUND Midazolam, at sedative levels, increases blood propofol concentrations by 25%. We evaluated the reverse interaction and determined the influence of propofol on the pharmacokinetics of midazolam. METHODS Eight healthy male volunteers were studied on 2 occasions in a random crossover manner. During session A, volunteers received midazolam 0.035 to 0.05 mg x kg(-1) IV for 1 minute followed by an infusion of 0.035 to 0.05 mg x kg(-1) x h(-1) for 59 minutes. During session B, in addition to this midazolam infusion scheme, a target-controlled infusion of propofol (constant C(T): 0.6 or 1.0 microg x mL(-1)) was given from 15 minutes before the start until 6 hours after termination of the midazolam infusion. Arterial blood samples for propofol and midazolam concentration analysis were taken until 6 hours after termination of the midazolam infusion. Nonlinear mixed-effect models examining the influence of propofol and hemodynamic variables on midazolam pharmacokinetics were constructed using Akaike's information-theoretic criterion for model selection. RESULTS In the presence of a mean blood propofol concentration of 1.2 microg x mL(-1), the plasma midazolam concentration was increased by 26.9% + or - 9.4% compared with midazolam given as a single drug. Propofol (C(blood): 1.2 microg x mL(-1)) reduced midazolam central volume of distribution from 5.37 to 2.98 L, elimination clearance from 0.39 to 0.31 L x min(-1), and rapid distribution clearance from 2.77 to 2.11 L x min(-1). Inclusion of heart rate further improved the pharmacokinetic model of midazolam. CONCLUSIONS Propofol reduces the distribution and clearance of midazolam in a concentration-dependent manner. In addition, inclusion of heart rate as a covariate improved the pharmacokinetic model of midazolam predominantly through a reduction in the intraindividual variability.
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Vuyk J, Lichtenbelt BJ, Olofsen E, van Kleef JW, Dahan A. Mixed-Effects Modeling of the Influence of Midazolam on Propofol Pharmacokinetics. Anesth Analg 2009; 108:1522-30. [DOI: 10.1213/ane.0b013e31819e4058] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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The Relationship Between Bispectral Index and Propofol During Target-Controlled Infusion Anesthesia: A Comparative Study Between Children and Young Adults. Anesth Analg 2008; 106:1109-16, table of contents. [DOI: 10.1213/ane.0b013e318164f388] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tirel O, Wodey E, Harris R, Bansard JY, Ecoffey C, Senhadji L. Variation of bispectral index under TIVA with propofol in a paediatric population. Br J Anaesth 2008; 100:82-7. [PMID: 18070785 DOI: 10.1093/bja/aem339] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In this prospective observational study, we aim to explore the relationship between age and bispectral index (BIS) values at different plasma concentrations of propofol. METHODS Fifty children aged from 3 to 15 yr were included. Anaesthesia was induced using a target-controlled infusion of propofol with the Kataria pharmacokinetic model together with a bolus of remifentanil followed by a continuous infusion rate at 0.2 microg kg(-1) min(-1). Target plasma propofol concentration was initially stabilized to 6 microg ml(-1) and continued for 6 min. The target was then decreased and stabilized to 4 microg ml(-1) and then to 2 microg ml(-1). BIS values, plasma propofol concentration, and EEG were continuously recorded. In order to explore the relationship between variations in propofol concentration and the EEG bispectrum, we used a multiple correspondence analysis (MCA). Results are shown in median (range). RESULTS We found no statistical difference between BIS values with propofol 6 microg ml(-1) [23 (12-40)] and 4 microg ml(-1) [28 (9-67)]. At 2 microg ml(-1), BIS was significantly different [52 (24-71)], but a significant correlation between the age of children and BIS values was found (r2=0.66; P<0.01). There was little change in children's position between 6 and 4 microg ml(-1) in the structure model of the MCA. From 4 to 2 microg ml(-1), the position of children moved only on axis 2. CONCLUSIONS These results showed the difficulty to interpret BIS values because of the absence of significant change for higher plasma propofol concentration variation or because of the link with age for the lower plasma concentration.
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Affiliation(s)
- O Tirel
- INSERM, U642, F-35000 Rennes, France.
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Shim MS, Kim JD, Choi HK, Yoo SB, Ryu SJ, Kim KH, Kim SH, Chang TH. Optimal Dose of Remifentanil and Propofol TCI for Minimizing Cardiovascular Changes to Tracheal Intubation during Total Intravenous Anesthesia. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.4.389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Min Seong Shim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Joo Duk Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Hyung Kyu Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Soo Bong Yoo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Sie Jeong Ryu
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Kyung Han Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Se Hwan Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
| | - Tae Ho Chang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kosin University, Busan, Korea
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Wang LP, McLoughlin P, Paech MJ, Kurowski I, Brandon EL. Low and moderate remifentanil infusion rates do not alter target-controlled infusion propofol concentrations necessary to maintain anesthesia as assessed by bispectral index monitoring. Anesth Analg 2007; 104:325-31. [PMID: 17242088 DOI: 10.1213/01.ane.0000252966.03103.89] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We investigated whether the EC(50) (the effective concentration that is required to achieve a response in 50% of patients) of propofol necessary to lower the Bispectral Index (BIS) value to 50 or less was reduced by coadministration of different remifentanil infusion rates. METHOD Seventy-two adult ASA I or II patients undergoing endotracheal intubation and target-controlled infusion (TCI) propofol anesthesia were allocated to six groups by stratified randomization. Group B received remifentanil 0.1 mug x kg(-1) x min(-1), Group C 0.15 microg x kg(-1) x min(-1), Group D 0.2 microg x kg(-1) x min(-1), Group E 0.3 microg x kg(-1) x min(-1) and Group F 0.4 microg x kg(-1) x min(-1). Group A served as control and received no remifentanil. The response of the first patient to propofol TCI at 4 microg/mL determined the effect-site concentration of propofol for the next patient in the same remifentanil group (Dixon's "up-and-down" method). If BIS was >50, the next patient received more propofol, and if BIS was < or =50, the next patient received less propofol. The hemodynamic effects of the combinations were also studied. RESULTS The EC50 varied from 2.4 to 2.9 microg/mL. No additive effect of remifentanil on the EC50 of propofol was observed. However, there was a wider variation in the response to propofol when the patients received no remifentanil. There was a decrease in heart rate in the remifentanil groups. CONCLUSION Infusion of remifentanil did not reduce propofol requirements in the unstimulated anesthetized patient. Propofol TCI levels should not be reduced because remifentanil is coinfused.
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Affiliation(s)
- Lars P Wang
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.
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Lee JH, Jeon WJ, Shim JH, Cho SY, Yeom JH, Shin WJ, Kim KH. What is an Optimal Effect Site Concentration of Remifentanil for Minimizing the Hemodynamic Change to Endotracheal Intubation using Light Wand? Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.3.278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jeoung Hyuk Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Woo Jae Jeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jae Hang Shim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Yoon Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jong Hoon Yeom
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Woo Jong Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Kyoung Hun Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
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Dunn MJG, Mitchell R, Souza CD, Drummond G. Evaluation of propofol and remifentanil for intravenous sedation for reducing shoulder dislocations in the emergency department. Emerg Med J 2006; 23:57-8. [PMID: 16373806 PMCID: PMC2564132 DOI: 10.1136/emj.2004.021410] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the combination of propofol and remifentanil for sedation to reduce shoulder dislocations in an ED. METHODS Eleven patients with anterior glenohumeral dislocation were given propofol 0.5 mg/kg and remifentanil 0.5 microg/kg iv over 90 seconds and then further doses of 0.25 mg/kg and 0.25 microg/kg, respectively, if needed. Another practitioner attempted reduction using the Milch technique. RESULTS Reduction was achieved in all patients within four minutes of giving sedation (range 0.3-4; mean 1.6). Seven required one attempt at shoulder reduction, three required two attempts, and one required three attempts. Mean time to recovery of alert status was three minutes (range 1-6). The mean pain score during the reduction was 1.7 out of 10 (range 0-5). Nine patients had full recall, one had partial recall, and one had no recall at all. Eight patients were "very satisfied" with the sedation and three were "satisfied". There were no respiratory or haemodynamic complications that required treatment. CONCLUSIONS Propofol and remifentanil provide excellent sedation and analgesia for the reduction of anterior glenohumeral dislocation, enabling rapid recovery.
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Affiliation(s)
- M J G Dunn
- Emergency Department, The Royal Infirmary of Edinburgh at Little France, Edinburgh, EH16 4SA, UK.
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Wietasch JKG, Scholz M, Zinserling J, Kiefer N, Frenkel C, Knüfermann P, Brauer U, Hoeft A. The performance of a target-controlled infusion of propofol in combination with remifentanil: a clinical investigation with two propofol formulations. Anesth Analg 2006; 102:430-7. [PMID: 16428538 DOI: 10.1213/01.ane.0000189821.81675.b4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Target-controlled infusion (TCI) incorporates the pharmacokinetic variables of an IV drug to facilitate safe and reliable administration. In this clinical study we investigated the performance of propofol TCI in combination with remifentanil. Fifty-four adult patients scheduled for general surgery lasting longer than 1 h received a combined TCI of propofol (Marsh parameter set; propofol randomly either dissolved with long- or middle-/long-chain triglycerides) and remifentanil. Arterial propofol plasma concentrations and hemodynamic and derived electroencephalogram variables were determined at various stages before, during, and after surgery. Measured propofol plasma concentrations exceeded the predicted values by 59%, and 48% when recalculated with the Schnider parameter set. Pharmacokinetic population analysis showed a small central volume of distribution (3.55 L) and reduced clearance (1.31 L/min) for propofol. ASA status and sex were the only variables that had a significant influence on propofol pharmacokinetics. In a second step, a new pharmacokinetic variable set for propofol was determined in the first 27 patients. Post hoc performance analysis of the remaining 27 patients showed improved accuracy using the new variable set. Our results show that when remifentanil and propofol are combined, the Marsh and Schnider parameter sets systematically underestimate propofol plasma concentrations. Presented, in part, at the Annual Meeting of the European Society of Anesthesiologists, Amsterdam, The Netherlands, June 1, 1999, and the Annual Meeting of the American Society of Anesthesiologists, Dallas, Texas, October 12, 1999.
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Affiliation(s)
- J K Götz Wietasch
- Department of Anesthesiology, University Medical Center Groningen, The Netherlands.
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Abstract
Remifentanil (Ultiva), a 4-anilidopiperidine derivative of fentanyl, is an ultra-short-acting micro-opioid receptor agonist indicated to provide analgesia and sedation in mechanically ventilated intensive care unit (ICU) patients.Analgesia-based sedation with remifentanil is a useful option for mechanically ventilated patients in the ICU setting. Its unique properties (e.g. organ-independent metabolism, lack of accumulation, rapid offset of action) set it apart from other opioid agents. Remifentanil is at least as effective as comparator opioids such as fentanyl, morphine and sufentanil in providing pain relief and sedation in mechanically ventilated ICU patients. Moreover, it allows fast and predictable extubation, as well as being associated with a shorter duration of mechanical ventilation and quicker ICU discharge than comparators in some studies. In addition, remifentanil is generally well tolerated in this patient population. Thus, remifentanil is a welcome addition to the currently available pharmacological agents employed in the management of mechanically ventilated ICU patients.
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Mustola ST, Baer GA, Neuvonen PJ, Toivonen KJ. Requirements of propofol at different end-points without adjuvant and during two different steady infusions of remifentanil. Acta Anaesthesiol Scand 2005; 49:215-21. [PMID: 15715624 DOI: 10.1111/j.1399-6576.2004.00582.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Some reports show no interaction between propofol and opioids, whereas others state such interactions. We evaluated the influence of remifentanil on propofol requirements at certain anesthesia end-points. METHODS Elective surgical patients were randomly assigned to three groups of 15 patients each. Premedication was with oral diazepam 0.1 mg kg(-1). Patients were blindly given equal volumes of saline or remifentanil (7.5 or 30 microg kg(-1). h(-1)) 1 min before induction of anesthesia with infusion of propofol, 30 mg kg(-1). h(-1). We recorded times to, propofol requirements, and bispectral index at loss of counting (LC), loss of verbal command (LVC), loss of reaction to tetanic stimulation (LRT), and onset of burst suppression pattern (BSP) of electroencephalography. RESULTS In the remifentanil groups end-points were attained significantly faster and with lower doses of propofol than in the saline group. BIS-values were significantly different at LRT and BSP end-points. CONCLUSIONS We conclude that remifentanil infusion started before induction of propofol anesthesia significantly reduces propofol requirements at all end-points. The results suggest that remifentanil accelerates the hypnotic onset of propofol.
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Affiliation(s)
- S T Mustola
- Department of Anesthesiology, Central Hospital of South Karelia, Lappeenranta, Finland.
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Abstract
Remifentanil (Ultiva), a fentanyl derivative, is an ultra-short acting, nonspecific esterase-metabolised, selective mu-opioid receptor agonist, with a pharmacodynamic profile typical of opioid analgesic agents. Notably, the esterase linkage in remifentanil results in a unique and favourable pharmacokinetic profile for this class of agent. Adjunctive intravenous remifentanil during general anaesthesia is an effective and generally well tolerated opioid analgesic in a broad spectrum of patients, including adults and paediatric patients, undergoing several types of surgical procedures in both the inpatient and outpatient setting. Remifentanil is efficacious in combination with intravenous or volatile hypnotic agents, with these regimens generally being at least as effective as fentanyl- or alfentanil-containing regimens in terms of attenuation of haemodynamic, autonomic and somatic intraoperative responses, and postoperative recovery parameters. The rapid offset of action and short context-sensitive half-time of remifentanil, irrespective of the duration of the infusion, makes the drug a valuable opioid analgesic option for use during balanced general inhalational or total intravenous anaesthesia (TIVA) where rapid, titratable, intense analgesia of variable duration, and a fast and predictable recovery are required.
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Hoymork SC, Raeder J, Grimsmo B, Steen PA. Bispectral index, serum drug concentrations and emergence associated with individually adjusted target-controlled infusions of remifentanil and propofol for laparoscopic surgery. Br J Anaesth 2004; 91:773-80. [PMID: 14633743 DOI: 10.1093/bja/aeg258] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Target-controlled infusions (TCI) are used to simplify administration and increase precision of i.v. drugs during general anaesthesia. However, there is a limited relationship between preset targets and measured concentrations of drugs and between measured concentrations and measures of brain function, such as the bispectral index (BIS). METHODS We set out to evaluate the performance of TCI devices for propofol (Diprifusor) and remifentanil (Remifusor, prototype), during laparoscopic cholecystectomy in 21 patients. We also checked if there was any correlation between serum concentrations of propofol and BIS during individually adjusted anaesthesia. RESULTS The Diprifusor and Remifusor had a median absolute performance error of 60% and 25% respectively. Propofol concentrations were underpredicted by a median of 60%, and remifentanil concentrations were slightly overpredicted by a median of 7%. When anaesthesia was adjusted to keep BIS values between 45 and 60, no correlation existed between measured concentrations of propofol and the corresponding BIS values, although both BIS and serum propofol concentration discriminated well between the awake and asleep states. Emergence was rapid and uneventful in all patients. Female patients had a more rapid emergence than male patients (6.6 and 11.6 min respectively). CONCLUSIONS TCI devices for remifentanil and propofol result in large variation in measured serum concentrations. The lack of correlation between BIS and serum concentrations of propofol adds to the debate about whether BIS measures hypnosis as a graded state during surgery. This study confirms that women wake up faster than men, but provides no explanation for this repeatedly shown difference.
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Affiliation(s)
- S C Hoymork
- Department of Anaesthesia, Ullevaal University Hospital, N-0407 Oslo, Norway.
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Abstract
Eines der Grundprinzipien der modernen Anästhesie ist die Kombination unterschiedlicher Pharmaka aus verschiedenen Substanzgruppen. Zusätzlich sehen sich Anästhesisten häufig mit der umfangreichen medikamentösen Dauertherapie chronisch kranker Patienten konfrontiert. Werden zwei oder mehrere Medikamente gleichzeitig appliziert, kann sich der pharmakologische Effekt von der Summe der einzeln verabreichten Substanzen unterscheiden. Das kann erwünscht, aber für den Patienten auch potenziell gefährlich sein. Die Wahrscheinlichkeit einer unerwünschten Arzneimittelwechselwirkung steigt exponentiell mit der Anzahl der verabreichten Medikamente und kann sowohl auf pharmazeutischer, pharmakodynamischer wie pharmakokinetischer Ebene entstehen. Obwohl die Fülle der Interaktionsmöglichkeiten enorm und die Komplexität der Arzneimittelwechselwirkungen schwer greifbar und zu identifizieren sind, gelten ernsthafte Medikamenteninteraktionen in der Anästhesie allgemein als vorhersehbar. Neben der Erkennung der Risikofaktoren wie Leber- und Niereninsuffizienz, ASA-Status sowie metabolische und endokrine Veränderungen des Patienten sind grundlegende Kenntnisse und ein Verständnis der allgemeinen und speziellen Pharmakologie notwendig, um unerwünschte Arzneimittelwechselwirkungen zu verhindern.
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Affiliation(s)
- A S Milde
- Klinik für Anaesthesiologie Universitätsklinikum Heidelberg, Germany.
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Servin F. Curr Opin Anaesthesiol 2003; 16:367-372. [DOI: 10.1097/00001503-200308000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
PURPOSE OF REVIEW Remifentanil has now reached maturity, as reflected by the increasing number of clinical papers relating to its use. Its position among anaesthetic drugs is now better understood, and this review will attempt to place it in the context of current clinical practice. RECENT FINDINGS AND SUMMARY Propofol reduces the initial distribution of remifentanil, leading to higher concentrations during induction. Propofol and remifentanil administered together at sedative doses display a major synergistic interaction on the respiratory drive. Remifentanil accelerates the penetration of sevoflurane to its site of effect. The risk of intraoperative awareness seems to be low when remifentanil is associated to very low concentrations of hypnotic drugs, but this field warrants further investigation. Acute tolerance to opioids and its prevention remain controversial. SUMMARY Remifentanil is the opioid of choice for tracheal intubation without muscle relaxants. It provides an alternative to regional anaesthesia in labour pain control. Target-controlled infusion may further improve the administration of remifentanil.
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