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Cho E, Roh YH, Moon J, Kim Y, Shin S. Effective bolus dose of remimazolam for i-gel ® insertion in nonparalyzed patients: a dose-finding study. Can J Anaesth 2024:10.1007/s12630-024-02762-w. [PMID: 38671251 DOI: 10.1007/s12630-024-02762-w] [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: 07/05/2023] [Revised: 02/19/2024] [Accepted: 03/02/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE Remimazolam is a recently developed ultra-short-acting benzodiazepine used for anesthesia induction and maintenance. Nevertheless, the effective bolus dose of remimazolam for i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK) insertion without the use of neuromuscular blocking agents (NMBAs) has not been well established. METHODS This study included 25 adult patients scheduled for surgery under general anesthesia who were eligible for i-gel use. Anesthesia was induced with predetermined bolus doses of remimazolam, starting at 0.3 mg·kg-1 for the first patient, without the use of NMBAs. All patients concurrently received remifentanil using target-controlled infusion (TCI) at a fixed effect-site concentration (Ce) of 3.0 ng·mL-1. Insertion of the i-gel was attempted 90 sec after remimazolam administration, and insertion conditions were assessed. Subsequent doses of remimazolam were decreased or increased by 0.05 mg·kg-1, depending on the success or failure of i-gel insertion. RESULTS The mean (standard deviation) 50% effective dose (ED50) of a remimazolam bolus for successful i-gel insertion as determined by the modified Dixon's up-and-down method was 0.100 (0.027) mg·kg-1. The ED50 and ED95 estimated by isotonic regression were 0.111 (83% confidence interval [CI], 0.096 to 0.131) mg·kg-1 and 0.182 (95% CI, 0.144 to 0.195) mg·kg-1, respectively. None of the patients required treatment for hypotension or bradycardia during anesthesia induction. CONCLUSION Based on the ED95 of remimazolam bolus dose determined in our study, we recommend using 0.182 mg·kg-1 of remimazolam in combination with remifentanil TCI at a Ce of 3.0 ng·mL-1 for successful i-gel insertion without NMBAs in adult patients. This regimen seems effective with a low risk of hemodynamic instability during anesthesia induction. STUDY REGISTRATION ClinicalTrials.gov ( NCT05298228 ); first submitted 6 March 2022.
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Affiliation(s)
- Eunah Cho
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jisu Moon
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yangjin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Nishimoto H, Kurita T, Shimizu M, Morita K, Nakajima Y. Predicted effect-site concentrations of remimazolam for i-gel insertion: a prospective randomized controlled study. J Clin Monit Comput 2024:10.1007/s10877-024-01135-4. [PMID: 38438706 DOI: 10.1007/s10877-024-01135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/03/2024] [Indexed: 03/06/2024]
Abstract
This study is the first to report 50% and 95% effect-site concentrations (EC50 and EC95, respectively) of the new short-acting benzodiazepine, remimazolam, for the successful insertion of i-gels with co-administration of fentanyl. Thirty patients (38 ± 5 years old, male/female = 4/26) were randomly assigned into five groups to receive one of five different remimazolam doses (0.1, 0.15, 0.2, 0.25, and 0.3 mg/kg bolus followed by infusion of 1, 1.5, 2, 2.5, and 3 mg/kg/h, respectively, for 10 min), which were designed to maintain a constant effect-site concentration of remimazolam at the time of i-gel insertion. At 6 min after the start of remimazolam infusion, all patients received 2 µg/kg fentanyl. i-gel insertion was attempted at 10 min and the success or failure of insertion were assessed by the patient response. Probit analysis was used to estimate the EC50 and EC95 values of remimazolam with 95% confidence intervals (CIs). In the five remimazolam dose groups, two, two, four, five, and six of the six patients in each group had an i-gel successfully inserted. Two patients in the lowest remimazolam dose group were conscious at the time of i-gel insertion and were counted as failures. The EC50 and EC95 values of remimazolam were 0.88 (95% CI, 0.65-1.11) and 1.57 (95% CI, 1.09-2.05) µg/ml, respectively. An effect-site concentration of ≥ 1.57 µg/ml was needed to insert an i-gel using remimazolam anesthesia, even with 2 µg/kg fentanyl. Trial registration: The study was registered in Japan Registry of Clinical Trials on 19 April 2021, Code jRCTs041210009.
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Affiliation(s)
- Hisako Nishimoto
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
| | - Tadayoshi Kurita
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Mikihiro Shimizu
- Center for Clinical Research, Hamamatsu University Hospital, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Koji Morita
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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Ziqiang F, Keyu H, Yun X, Li L, Yiping B. Effect of esketamine on the EC50 of remifentanil for blunting cardiovascular responses to endotracheal intubation in female patients under general anesthesia: a sequential allocation dose-finding study. BMC Anesthesiol 2024; 24:67. [PMID: 38383307 PMCID: PMC10880282 DOI: 10.1186/s12871-024-02454-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/11/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND This study aimed to investigate the effect of esketamine on the dose-effect relationship between remifentanil and the cardiovascular response to endotracheal intubation during target-controlled infusion (TCI) of propofol. METHODS Patients underwent elective gynecological laparoscopic surgery under general anesthesia with endotracheal intubation, aged 18-65 years, American Society of Anesthesiologists class I or II, 18 kg/m2 ≤ body mass index ≤ 30 kg/m2, were randomly divided into the control (group C) and esketamine groups (group E). Before anesthesia induction, group E received an intravenous injection of 0.3 mg/kg of esketamine, while group C received an equal dose of physiological saline. TCI of propofol to the effect-site concentration (EC) of 3.0 μg/mL, and then TCI of remifentanil to the effect room and intravenous injection of rocuronium 0.6 mg/kg after MOAA/S was 0. Endotracheal intubation was performed after 2 min. Dixon's modified sequential method was used, and the initial EC of remifentanil was 3.0 ng/mL. The EC of remifentanil was determined according to the intubation response of the previous patient, with an adjacent concentration gradient of 0.3 ng/mL. The EC50 and EC95 values and their 95% confidence intervals (CIs) were determined using probit regression analysis. RESULTS The EC50 for cardiovascular response inhibition to endotracheal intubation using remifentanil was 3.91 ng/mL (95% CI: 3.59-4.33 ng/mL) and EC95 was 4.66 ng/mL (95% CI: 4.27-6.23 ng/mL) with TCI of propofol 3.0 μg/mL. After intravenous administration of 0.3 mg/kg of esketamine, the EC50 of remifentanil was 3.56 ng/mL (95% CI: 3.22-3.99 ng/mL) and EC95 was 4.31 ng/mL (95% CI: 3.91-5.88 ng/mL). CONCLUSIONS Combined with TCI of propofol 3.0 μg/mL for anesthesia induction, esketamine significantly reduced the EC50 and EC95 of remifentanil to inhibit the cardiovascular response to endotracheal intubation. TRIAL REGISTRATION The trial was registered in the Chinese Clinical Trials Registry ( www.chictr.org.cn ; registration number: ChiCTR2200064932; date of registration:24/10/2022).
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Affiliation(s)
- Fan Ziqiang
- Southwest Medical University, Luzhou, 646000, Sichuan Province, China
- Chongqing University Fuling Hospital, Fuling, Chongqing, 408000, China
| | - He Keyu
- Chongqing University Fuling Hospital, Fuling, Chongqing, 408000, China
| | - Xue Yun
- Chongqing University Fuling Hospital, Fuling, Chongqing, 408000, China
| | - Liu Li
- Southwest Medical University, Luzhou, 646000, Sichuan Province, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Bai Yiping
- Southwest Medical University, Luzhou, 646000, Sichuan Province, China.
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, 646000, Sichuan Province, China.
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China, Sichuan Province, 646000.
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Oh JY, Park SY, Moon JY, Park JH, Joe HB. The Effect of Sex on the Remimazolam Dosage Required for Successful i-gel Supraglottic Airway Insertion with Remifentanil in Non-Paralyzed Patients: An Up-and-Down Sequential Allocation Trial. J Clin Med 2024; 13:670. [PMID: 38337364 PMCID: PMC10856389 DOI: 10.3390/jcm13030670] [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: 12/04/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: The physiological and pharmacological variations between men and women are known to influence drug efficacy. The objective of this study was to determine the 50% and 95% effective doses (ED50 and ED95) of remimazolam required for i-gel supraglottic airway (ISA) insertion under remifentanil infusion without neuromuscular blocking agents (NMBAs) in both males and females. (2) Methods: Patients aged 19-65 years, scheduled for general anesthesia using ISA, were enrolled in this study. Patients were divided into two groups based on their sex. The anesthesia process began with a remifentanil infusion targeting an effect-site concentration of 3.0 ng/mL, accompanied by a remimazolam injection. The initial remimazolam dose was 0.25 mg/kg, and it was adjusted with a step size of 0.05 mg/kg based on the outcome of ISA insertion in the preceding patient. (3) Results: The ED50 of remimazolam (mean ± standard error) was 0.28 ± 0.02 mg/kg in the male group and 0.18 ± 0.02 mg/kg in the female group (p < 0.001). Additionally, ED95, which was calculated using the isotonic regression method, was significantly comparable between the male and female groups (male: 0.35 mg/kg, 95% confidence interval [CI] = 0.34-0.35; female: 0.29 mg/kg, 95% CI = 0.25-0.30). (4) Conclusions: This study showed that both the ED50 and the ED95 of remimazolam for successful ISA insertion was higher for men than that for women. Therefore, while using remimazolam alongside remifentanil infusion without NMBAs for ISA insertion, one should consider the patient's sex for appropriate dosing.
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Affiliation(s)
- Ju-Yeon Oh
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.-Y.O.); (S.-Y.P.); (J.-Y.M.)
| | - Sung-Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.-Y.O.); (S.-Y.P.); (J.-Y.M.)
| | - Jung-Yoon Moon
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.-Y.O.); (S.-Y.P.); (J.-Y.M.)
| | - Ji-Hyun Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon 16499, Republic of Korea;
| | - Han-Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.-Y.O.); (S.-Y.P.); (J.-Y.M.)
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Choi JJ, Jung WS, Chang YJ, Yoo S, Kwak HJ. Effective concentration of remifentanil for successful i-gel insertion during remimazolam induction. Korean J Anesthesiol 2023; 76:235-241. [PMID: 36314044 DOI: 10.4097/kja.22606] [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: 09/16/2022] [Accepted: 10/26/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Remifentanil can be used as adjuvants during remimazolam induction without neuromuscular blockade. We evaluated the 95% effective concentration (EC) of remifentanil effect-site concentration (Ce) for the successful insertion of an i-gel using the biased-coin up-and-down method in adult patients during remimazolam induction. METHODS Forty 19-65 year-old patients scheduled to undergo surgery using i-gel were enrolled. Anesthesia was induced using remimazolam infusion (12 mg/kg/h). Simultaneously, remifentanil was infused at a predetermined Ce. After 5 min of anesthesia induction, the i-gel was inserted. The 95% EC (EC95) of remifentanil in each patient was determined using a biased-coin up-and-down method based on a successful insertion in a preceding patient. The step size of remifentanil Ce was 0.4 ng/ml. If the insertion failed, remifentanil Ce was increased in the next patient. Following successful insertions, the corresponding concentration decreased in subsequent patients with a probability of 1/19 or was maintained with a probability of 18/19. The time from remimazolam infusion initiation to a bispectral index (BIS) < 60 (time to BIS60) and hemodynamic variables were measured and recorded. RESULTS The EC95 (95% CI) of Ce was 2.07 (1.94, 2.87) ng/ml. The overall time to BIS60 was 154.0 ± 39.9 s. No patient experienced significant hypotension or bradycardia during remimazolam induction. CONCLUSIONS The EC95 of remifentanil Ce was 2.07 (1.94, 2.87) ng/ml for successful i-gel insertion during remimazolam induction at 12 mg/kg/h without hemodynamic instability in adult patients. Future studies should measure remifentanil Ce in elderly patients or using remimazolam at various infusion doses.
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Affiliation(s)
- Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Wol Seon Jung
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Seungbeom Yoo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Oh J, Park SY, Lee GY, Park JH, Joe HB. Effective dose of remimazolam co-administered with remifentanil to facilitate I-gel insertion without neuromuscular blocking agents: an up-and-down sequential allocation trial. BMC Anesthesiol 2023; 23:81. [PMID: 36927413 PMCID: PMC10018909 DOI: 10.1186/s12871-023-02041-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Remimazolam is a new anesthetic drug developed and is an ultra-short-acting agent with rapid onset and offset. The pharmacology of this drug seems to be ideal for short surgeries eligible for I-gel insertion. Therefore, this study aimed to determine the optimal bolus dose of remimazolam for I-gel insertion when co-administered with remifentanil without neuromuscular blocking agents (NMBAs). METHODS Patients aged 19-65 years with American Society of Anesthesiologists physical status I or II scheduled for general anesthesia were enrolled. The first dose of remimazolam was 0.15 mg/kg and remifentanil was co-administered at an effect-site concentration (Ce) of 3.0 ng/mL. The dose of remimazolam for the following patient was decreased or increased by 0.05 mg/kg depending on the success or failure of I-gel insertion in the previous patient. RESULTS The remimazolam bolus dose required for successful I-gel insertion in 50% of adult patients using modified Dixon's up-and-down method with remifentanil Ce 3.0 ng/mL and no NMBAs was 0.280 ± 0.048 mg/kg. Isotonic regression analysis showed that the 50% and 95% effective doses were 0.244 (83% confidence interval [CI] 0.213-0.313) mg/kg and 0.444 (95% CI 0.436-0.448) mg/kg, respectively. The mean time to loss of consciousness (Modified Observer's Assessment of Alertness/Sedation score < 2) was 52.2 s. Three patients (12.0%) showed a reduction in systolic blood pressure of more than 30% from baseline. CONCLUSIONS Selecting the appropriate dose of remimazolam/remifentanil without NMBAs makes it feasible to insert the I-gel. TRIAL REGISTRATION This study protocol was registered at http://cris.nih.go.kr (KCT0007801, 12th, October, 2022).
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Affiliation(s)
- Juyeon Oh
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Ga Yun Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea
| | - Ji Hyun Park
- Office of Biostatics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea
| | - Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea.
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Meng W, Kang F, Dong M, Wang S, Han M, Huang X, Wang S, Li J, Yang C. Remifentanil requirement for i-gel insertion is reduced in male patients with Parkinson's disease undergoing deep brain stimulator implantation: an up-and-down sequential allocation trial. BMC Anesthesiol 2022; 22:197. [PMID: 35751029 PMCID: PMC9229424 DOI: 10.1186/s12871-022-01735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Laryngeal mask airways have been widely used in clinical practice. The aim of this study was to investigate whether the remifentanil requirement for facilitation of i-gel insertion in Parkinson’s disease (PD) patients undergoing deep brain stimulation (DBS) surgery was different from that in non-PD (NPD) patients undergoing intracranial surgery. Study design An up-and-down sequential allocation trial. Methods Male patients aged between 40 and 64 years old were enrolled. The first patient in each group (PD and NPD) group received an effect-site concentration (Ce) of remifentanil (Minto pharmacokinetic model) of 4.0 ng.ml−1 during a target-controlled infusion (TCI) of 3.5 μg.ml−1 propofol (Marsh pharmacokinetic model). The next dose of remifentanil was determined by the response of the previous patient. The Ce of remifentanil required for i-gel insertion in 50% of patients (EC50) was estimated by the modified Dixon’s up-and-down method and by probit analysis. Results The PD group included 24 patients and the NPD group included 23. The EC50 of remifentanil for i-gel insertion during a TCI of 3.5 μg.ml−1 propofol estimated by the modified Dixon’s up-and-down method in PD patients (2.38 ± 0.65 ng.ml−1) was significantly lower than in NPD patients (3.21 ± 0.49 ng.ml−1) (P = 0.03). From the probit analysis, the EC50 and EC95 (effective Ce in 95% of patients) of remifentanil were 1.95 (95% CI 1.52–2.36) ng.ml−1 and 3.12 (95% CI 2.53–5.84) ng.ml−1 in PD patients and 2.85 (95% CI 2.26–3.41) ng.ml−1 and 4.57 (95% CI 3.72–8.54) ng.ml−1 in NPD patients, respectively. Conclusions The remifentanil requirement for successful i-gel insertion is reduced in male PD patients undergoing DBS implantation during propofol TCI induction. Clinicians should closely monitor the remifentanil requirement in patients with PD. Trial registration Registered at http://www.chictr.org.cn (ChiCTR1900021760).
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Affiliation(s)
- Wenjun Meng
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Fang Kang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Meirong Dong
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Song Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Mingming Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Xiang Huang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Juan Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China.
| | - Chengwei Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China.
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Vide S, Castro A, Antunes P, Lima D, Larson M, Gambús P, Amorim P. Pharmacodynamic modelling of the effect of remifentanil using the Pupillary Pain Index. J Clin Monit Comput 2020; 34:319-324. [PMID: 31119519 DOI: 10.1007/s10877-019-00323-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
Using a targeted controlled infusion of remifentanil during total intravenous anesthesia, we investigated the effect-site concentrations of remifentanil that correlate with different values of the Pupillary Pain Index and which concentrations were necessary for achieving a Pupillary Pain Index ≤ 4 and its usefulness in titrating opioids. The Pupillary Pain Index was measured in 54 patients prior to surgery under different remifentanil effect-site concentrations and subsequently modeled. One hundred and twenty-eight measurements were taken at different remifentanil concentrations while titrating propofol for a similar depth of hypnosis using a BIS monitor. Our modeled Hill equation revealed a remifentanil of 2.96 ng/mL for a PPI of 4, and the probability model a Ce of 3.22 ng/mL for the probability of 50% of patients achieving a PPI score ≤ 4. For the probability of 80% of patients achieving a PPI score ≤ 4 the Ce of remifentanil was 4.39 ng/mL. We conclude that concentrations of remifentanil that have been shown to suppress movement in response to noxious stimulation correspond to a Pupillary Pain Index ≤ 4.
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Affiliation(s)
- Sérgio Vide
- Department of Anesthesia, Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, R. de Dr. Eduardo Torres, 4464-513, Matosinhos, Portugal. .,Center for Clinical Research in Anesthesia, Serviço de Anestesiologia, Centro Hospitalar do Porto, Porto, Portugal. .,Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Anesthesiology Department, Hospital CLINIC de Barcelona, Barcelona, Spain. .,Pain Research Group, i3S-Instituto de Investigação e Inovação em Saúde, Porto, Portugal. .,Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Ana Castro
- IBMC, Instituto de Biologia Molecular e Celular, Porto, Portugal
| | - Pedro Antunes
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Deolinda Lima
- Pain Research Group, i3S-Instituto de Investigação e Inovação em Saúde, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Department of Anesthesia, Hospital de São Teotónio, Viseu, Portugal
| | - Merlin Larson
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), San Francisco, San Francisco, CA, USA
| | - Pedro Gambús
- Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Anesthesiology Department, Hospital CLINIC de Barcelona, Barcelona, Spain.,Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), San Francisco, San Francisco, CA, USA.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), NeuroImmunology Research Group, Barcelona, Spain
| | - Pedro Amorim
- Center for Clinical Research in Anesthesia, Serviço de Anestesiologia, Centro Hospitalar do Porto, Porto, Portugal
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Schiefer JL, Lipensky A, Fuchs PC, Heitzmann W, Schulz A. Patients' satisfaction with anesthesia in enzymatic debridement from a surgical perspective. Burns 2020; 46:1073-1082. [PMID: 31901406 DOI: 10.1016/j.burns.2019.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Various clinical studies found that enzymatic debridement (EDNX) is superior to tangential excision after severe burns. The current study evaluates patients' satisfaction with pain management in EDNX with special respect to different anesthesia techniques. METHODS Between 2015 and 2016, all patients at a department of plastic surgery were asked to complete a German-wide validated pain questionnaire. In a retrospective study design, satisfaction with pain management was compared between the control group (diagnosis from the whole field of plastic surgery except burns) and the EDNX group (burns treated with EDNX only). Analgosedation, general, regional and local anesthesia were chosen for pain management. RESULTS In the control group 403 patients (153 females, 250 males, medium age 53 years) could be included The EDNX group included 88 patients (20 females, 68 males, medium age 38 years). The mean burn size was 5.3% TBSA. Between 0.5%-10.5% of the surface was treated with EDNX. EDNX patients could be treated under analgosedation and regional anesthesia, by topical anesthesia creme and without any anesthesia. They reported less pain during stress (p = 0.04) and were less frequently affected by motion (p = 0.024) and nausea (<0.001). However, they felt that they need more information about alternative anesthetic treatments (<0.001). CONCLUSION EDNX can be performed sufficiently either under analgosedation, regional or local anesthesia. Thus, side effects of general anesthesia can be reduced and treatment costs can be decreased. However, it was found that neither after topical anesthetic creme nor after hand block pain treatment was sufficient.
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Affiliation(s)
- J L Schiefer
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - A Lipensky
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - P C Fuchs
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - W Heitzmann
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - A Schulz
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany.
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Wang H, Gao X, Wei W, Miao H, Meng H, Tian M. The optimum sevoflurane concentration for supraglottic airway device Blockbuster™ insertion with spontaneous breathing in obese patients: a prospective observational study. BMC Anesthesiol 2017; 17:156. [PMID: 29179689 PMCID: PMC5704385 DOI: 10.1186/s12871-017-0449-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway management of the obese patient presenting for surgery is more likely to be a challenging problem. Supraglottic airway device has been adopted as a bridge to connect ventilation and tracheal intubation in obese patients who would be suffered with difficult intubation. The optimum sevoflurane concentration for supraglottic airway device insertion allowing spontaneous breathing in 50% of obese patients (ED50) is not known. The purpose of this study was to determine the ED50 of sevoflurane for supraglottic airway device Blockbuster™ insertion with spontaneous breathing in obese patients requiring general anesthesia. METHODS Thirty elective obese patients (body mass index 30-50 kg/m2) undergoing bariatric surgery were recruited in this study. The predetermined target sevoflurane concentration (initiating at 2.5% with 0.5% as a step size) was sustained for >5 min using a modified Dixon's up-and-down method, and then the supraglottic airway device Blockbuster™ was inserted. The patient's response to supraglottic airway device insertion was classified as either 'movement' or 'no-movement'. The ED50 of sevoflurane were determined by calculating the midpoint concentration of crossover point from 'movement' or 'no-movement' response. RESULTS The ED50 of sevoflurane for supraglottic airway device Blockbuster™ insertion in obese patients calculated using up-and-down method were 2.50 ± 0.60%. The ED50 and ED95 (95% confidence interval) obtained by probit regression analysis were 2.35 (1.28-3.42) % and 4.03 (3.16-17.83) % for supraglottic airway device Blockbuster™ insertion, respectively. CONCLUSION We conclude that the optimum end-tidal sevoflurane concentration required for the supraglottic airway device Blockbuster™ insertion allowing spontaneous breathing in 50% of obese patients (ED50) is 2.5 ± 0.6%. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-IPR-16009071 , Registered on 24 August 2016.
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Affiliation(s)
- Haixia Wang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xue Gao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Wei
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huihui Miao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hua Meng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ming Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Wang HX, Miao HH, Gao X, Wei W, Ding GN, Zhang Y, Tian M. Optimum end-tidal concentration of sevoflurane to facilitate supraglottic airway device insertion with propofol at induction allowing spontaneous respiration in obese patients: A prospective observational study. Medicine (Baltimore) 2017; 96:e8902. [PMID: 29382022 PMCID: PMC5709021 DOI: 10.1097/md.0000000000008902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Obese patients are more likely to encounter with difficult airway management, and supraglottic airway device has been adopted to facilitate tracheal intubation. The optimum anesthetic concentration for obese patients to insert a supraglottic airway device with spontaneous respiration has not been investigated. This study was designed to determine the end-tidal concentration of sevoflurane that would provide acceptable condition for supraglottic airway device insertion with propofol at induction in obese patients without using neuromuscular blockade.Thirty elective obese patients [body mass index (BMI) 30-50 kg/m] scheduled for bariatric surgery were enrolled in this study. Sevoflurane was inhaled at a concentration of 5% after infusion of 1 mg/kg propofol (within 1 minute) according to lean body weight. The target concentration of sevoflurane was initiated at 2.5% with 0.5% as a step size using a modified Dixon up-and-down method. Five minutes after target concentration achieved, the insertion of supraglottic airway device was attempted.The minimum alveolar concentration of sevoflurane for successful insertion of supraglottic airway device calculated using up-and-down method were 2.25 (0.53) % for obese patients. The values of the effective concentration of sevoflurane for successful supraglottic airway device insertion in 50% (EC50) and 95% (EC95) of the obese patients obtained by probit regression analysis were 2.09% (95% confidence interval 1.48-2.68) and 3.31% (95% confidence interval 2.70-8.12), respectively.We conclude that sevoflurane at a minimum alveolar concentration of 2.25% can provide optimal conditions for insertion of supraglottic airway device with spontaneous respiration in obese patients with 1 mg/kg propofol at induction.
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Joe HB, Kim JY, Kwak HJ, Oh SE, Lee SY, Park SY. Effect of sex differences in remifentanil requirements for the insertion of a laryngeal mask airway during propofol anesthesia: A prospective randomized trial. Medicine (Baltimore) 2016; 95:e5032. [PMID: 27684878 PMCID: PMC5265971 DOI: 10.1097/md.0000000000005032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Remifentanil can improve insertion of a laryngeal mask airway (LMA) during induction with propofol. Recently, it has been suggested that there is a sex difference in opioid requirements for this procedure. The purposes of this study were to determine the effective effect-site concentration (Ce) of remifentanil for the facilitation of LMA insertion in male and female patients during propofol anesthesia without neuromuscular blockade and to evaluate whether there are sex differences in the Ce of remifentanil required for successful LMA insertion. METHODS Forty-eight patients (24 male, 24 female) with American Society of Anesthesiologists physical status 1 or 2, aged 20 to 60 years, scheduled for minor orthopedic surgery under general anesthesia were enrolled. Anesthesia was induced by target-controlled infusion (TCI) of propofol and remifentanil. The target Ce of propofol was 5 μg/mL initially and was reduced to 3.5 μg/mL after loss of consciousness. The Ce of remifentanil given to each patient was determined by the response of the previously tested patient using 0.5 ng/mL as a step size. The 1st patient was tested at a Ce of 3.0 ng/mL of remifentanil. Successful LMA insertion was defined as smooth insertion without patient movement or significant resistance to mouth opening. RESULTS The effective Ce of remifentanil required for successful LMA insertion on 50% of occasions (effective effect-site concentration for 50% [EC50]) as estimated by Dixon method was significantly lower in women (2.18 ± 0.35 ng/mL) than in men (2.82 ± 0.53 ng/mL) (P = 0.02). Using the isotonic regression method, the effective Ce of remifentanil required for successful LMA insertion on 95% of occasions (EC95) (95% confidence interval [CI]) was significantly lower in women (3.38 [3.0-3.48] ng/mL) than in men (3.94 [3.80-3.98] ng/mL). CONCLUSION The Ce of remifentanil required to facilitate successful LMA insertion is higher during propofol induction by TCI in men than in women. When using remifentanil for LMA insertion, patient sex should be taken into account for appropriate dosing.
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Affiliation(s)
- Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Namdong-gu, Incheon, Republic of Korea
| | - Sang Eon Oh
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, World Cup-ro, Yeongtong-gu, Suwon
- Correspondence: Sung Yong Park, Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World Cup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea (e-mail: )
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Choi JJ, Kim JY, Lee D, Chang YJ, Cho NR, Kwak HJ. Male patients require higher optimal effect-site concentrations of propofol during i-gel insertion with dexmedetomidine 0.5 μg/kg. BMC Anesthesiol 2016; 16:20. [PMID: 27004426 PMCID: PMC4804608 DOI: 10.1186/s12871-016-0186-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 03/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pharmacokinetics and pharmacodynamics of an anesthetic drug may be influenced by gender. The purpose of this study was to compare effect-site half maximal effective concentrations (EC50) of propofol in male and female patients during i-gel insertion with dexmedetomidine 0.5 μg/kg without muscle relaxants. METHODS Forty patients, aged 20-46 years of ASA physical status I or II, were allocated to one of two groups by gender (20 patients per group). After the infusion of dexmedetomidine 0.5 μg/kg over 2 min, anesthesia was induced with a pre-determined effect-site concentration of propofol by target controlled infusion. Effect-site EC50 values of propofol for successful i-gel insertion were determined using the modified Dixon's up-and-down method. RESULTS Mean effect-site EC50 ± SD of propofol for successful i-gel insertion was significantly higher for men than women (5.46 ± 0.26 μg/ml vs. 3.82 ± 0.34 μg/ml, p < 0.01). The EC50 of propofol in men was approximately 40% higher than in women. Using isotonic regression with a bootstrapping approach, the estimated EC50 (95% confidence interval) of propofol was also higher in men [5.32 (4.45-6.20) μg/ml vs. 3.75 (3.05-4.43) μg/ml]. The estimated EC95 (95% confidence interval) of propofol in men and women were 5.93 (4.72-6.88) μg/ml and 4.52 (3.02-5.70) μg/ml, respectively. CONCLUSIONS During i-gel insertion with dexmedetomidine 0.5 μg/kg without muscle relaxant, male patients had higher effect-site EC50 for propofol using Schnider's model. Based on the results of this study, patient gender should be considered when determining the optimal dose of propofol during supraglottic airway insertion. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02268656. Registered August 26, 2014.
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Affiliation(s)
- Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesiology and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Dongchul Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Noo Ree Cho
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea.
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Choi JB, Kwak HJ, Lee KC, Lee SR, Lee SY, Kim JY. Comparison of remifentanil EC50 for facilitating i-gel and laryngeal mask airway insertion with propofol anesthesia. J Anesth 2016; 30:377-83. [PMID: 26758073 DOI: 10.1007/s00540-015-2133-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/24/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Each supraglottic airway requires different anesthetic depth because it has a specific structure and different compressive force in the oropharyngeal cavity. We designed the study to compare the effect-site concentration (Ce) of remifentanil in 50 % of patients (EC50) for successful insertion of the i-gel second-generation supraglottic airway device with that for laryngeal mask airway (LMA) insertion during target-controlled infusion (TCI) of propofol. METHODS Forty-one female patients were randomized to the i-gel group (n = 20) or the LMA group (n = 21). Anesthesia was induced with propofol Ce of 5 μg/ml and the predetermined remifentanil Ce, and the i-gel or LMA was inserted 5 min later. The remifentanil Ce was estimated by modified Dixon's up-and-down method (initial concentration: 3.0 ng/ml, step size: 0.5 ng/ml). The patient's response to device insertion was classified as either "success (no movement)" or "failure (movement)". RESULTS Using the Dixon's up-and-down method, EC50 of remifentanil Ce for the i-gel (1.58 ± 0.41 ng/ml) was significantly lower than that for LMA (2.25 ± 0.55 ng/ml) (p = 0.038). Using isotonic regression, EC50 (83 % CI) of remifentanil in the i-gel group [1.50 (1.37-1.80) ng/ml] was statistically lower than that in the LMA group [2.00 (1.82-2.34) ng/ml]. EC95 (95 % CI) of remifentanil in the i-gel group [2.38 (1.48-2.50) ng/ml] was statistically lower than that in the LMA group [3.35 (2.58-3.48) ng/ml]. CONCLUSIONS We found that EC50 of remifentanil Ce for i-gel insertion (1.58 ng/ml) was significantly lower than that for LMA insertion (2.25 ng/ml) in female patients during propofol TCI without neuromuscular blockade.
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Affiliation(s)
- Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, Incheon, Korea
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, Incheon, Korea
| | - Se Ryeon Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon, 443-721, Korea
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon, 443-721, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon, 443-721, Korea.
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Zaballos M, Bastida E, Agustí S, Portas M, Jiménez C, López-Gil M. Effect-site concentration of propofol required for LMA-Supreme™ insertion with and without remifentanil: a randomized controlled trial. BMC Anesthesiol 2015; 15:131. [PMID: 26438179 PMCID: PMC4595052 DOI: 10.1186/s12871-015-0115-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 09/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A new supraglottic device, the LMA-Supreme™, has recently become available for clinical use. Information on anaesthetic and co-adjuvant requirements for insertion of the LMA-Supreme™ is limited. The present study aimed to evaluate the optimal effect-site concentration of propofol in 50 % (EC50) of adults necessary for successful insertion of the LMA-Supreme™ and to examine remifentanil's effect on propofol requirements. METHODS Fifty-eight elective patients (aged 18-60 years; ASA (American Society Anaesthesiologists) physical status classification I and II) scheduled for day surgery were randomly assigned to one of two groups: propofol with saline or propofol with remifentanil. Anaesthesia was induced by target-controlled infusion according to predetermined effect-site concentrations of propofol and remifentanil (5 ng.mL(-1)). The EC50 was calculated using Dixon's up-and-down method. Ten minutes following drug administration, LMA-Supreme™ insertion was attempted without the use of muscle relaxant drugs. RESULTS In the propofol + saline group, the EC50 of propofol required for LMA-Supreme™ insertion was 6.32 ± 0.67 μg.mL(-1) (95 % CI, 5.69-6.94 μg.mL(-1)). With the addition of remifentanil at an effect-site concentration of 5 ng.mL(-1), the EC50 of propofol required for LMA-Supreme™ insertion was 2.50 ± 0.80 μg.mL(-1) (95 % CI, 1.82-3.17 μg.mL(-1); p < 0.0001). CONCLUSIONS The propofol requirement for smooth insertion of the LMA-Supreme™ was 60 % less when remifentanil (5 ng.mL(-1)) was co-administered. CLINICAL TRIAL REGISTRATION Identified as NCT01974648 at www.clinicaltrials.gov .
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Affiliation(s)
- Matilde Zaballos
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain. .,Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Emilia Bastida
- Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Salomé Agustí
- Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Maite Portas
- Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Consuelo Jiménez
- Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Maite López-Gil
- Department of Anaesthesia, Head Department of Anaesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
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Gopinath MV, Ravishankar M, Nag K, Kumar VH, Velraj J, Parthasarathy S. Estimation of effect-site concentration of propofol for laryngeal mask airway insertion using fentanyl or morphine as adjuvant. Indian J Anaesth 2015; 59:295-9. [PMID: 26019354 PMCID: PMC4445151 DOI: 10.4103/0019-5049.156874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC50) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant. METHODS Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was classified as failure. For subsequent patients, the target EC was increased/decreased depending on previous patients' response. Dixons up and down method was used to determine the EC50. The EC50 is defined as the mean of crossover midpoints in each pair of failure to success. RESULTS The EC50 of propofol in the fentanyl group for LMA insertion was 5.95 ± 0.6 μg/ml and morphine group was 5.75 ± 0.8 μg/ml. No significant difference in insertion conditions was noticed between the two groups (P = 0.3). CONCLUSION We conclude that there was no significant difference in propofol EC50 for insertion of LMA and insertion conditions were similar when fentanyl or morphine was used as an adjuvant drug.
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Affiliation(s)
- M V Gopinath
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - M Ravishankar
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Kusha Nag
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Vr Hemanth Kumar
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - J Velraj
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - S Parthasarathy
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Dose of rocuronium for rapid tracheal intubation following remifentanil 2 μg kg-1 and propofol 2 mg kg-1. Eur J Anaesthesiol 2014; 30:550-5. [PMID: 23698704 DOI: 10.1097/eja.0b013e3283622ba0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Full relaxation is not mandatory for successful tracheal intubation. OBJECTIVE We tried to find the dose of rocuronium that gave acceptable intubation conditions in a rapid sequence intubation with remifentanil and propofol. DESIGN A dose-finding study of rocuronium using a modified Dixon's up-and-down method. SETTING A single tertiary care teaching hospital. PARTICIPANTS Patients undergoing elective surgery under general anaesthesia. INTERVENTIONS After premedication with midazolam and glycopyrrolate, anaesthesia was induced using remifentanil 2 μg kg and propofol 2 mg kg, and a predetermined dose of rocuronium was administered. The dose of rocuronium was determined by a modified Dixon's up-and-down method starting from 0.8 mg kg with an interval of 0.1 or 0.05 mg kg. Intubation was performed 60 s after the start of the rocuronium injection. Intubation conditions were graded as excellent, good or poor. Excellent or good were regarded as clinically acceptable. MAIN OUTCOME MEASURE A dose of rocuronium needed for acceptable intubation condition in 50% of patients (ED50) during rapid tracheal intubation after induction of anaesthesia with remifentanil and propofol. RESULTS Twenty-eight patients were enrolled to obtain six crossovers. The ED50 of rocuronium was 0.20 mg kg (95% confidence interval, CI 0.17 to 0.23 mg kg) by a modified Dixon's up-and-down method. CONCLUSION After induction of anaesthesia with remifentanil 2 μg kg and propofol 2 mg kg, the ED50 of rocuronium for acceptable intubation condition was 0.20 mg kg (95% CI, 0.17 to 0.23 mg kg) for rapid sequence intubation. Thus, we recommend that the intubation dose should be 0.8 mg kg. TRIAL REGISTRATION Clinical trial registration KCT0000094.
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Ryu J, Oh AY, Baek JS, Kim JH, Park SH, Noh JM. Remifentanil dose for laryngeal mask airway insertion with a single standard dose of propofol during emergency airway management in elderly patients. Korean J Anesthesiol 2014; 66:278-82. [PMID: 24851162 PMCID: PMC4028554 DOI: 10.4097/kjae.2014.66.4.278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study determined the dose of remifentanil to use during insertion of a Classic™ laryngeal mask airway (LMA, The Laryngeal Mask Co., Nicosia, Cyprus) in elderly patients during emergency airway management when combined with a single dose of propofol. METHODS Patients aged 65-80 years were enrolled. Anesthesia was induced with propofol 1 mg/kg, and then a blinded dose of remifentanil was infused over 30 s after confirming the patient's loss of consciousness. The dose of remifentanil was determined using Dixon's up-and-down method, starting at 0.5 µg/kg (a step size of 0.1 µg/kg). Insertion of the LMA was attempted 60 s after loss of consciousness. RESULTS In total, 23 patients were recruited and the mean age ± standard deviation was 72 ± 3 years. The effective dose for successful LMA insertion in 50% of the patients (ED50) was 0.20 ± 0.05 µg/kg. No patient needed more than 0.3 µg/kg. CONCLUSIONS Remifentanil 0.20 ± 0.05 µg/kg with propofol 1 mg/kg resulted in excellent LMA insertion in 50% of elderly patients without significant hemodynamic changes during emergency airway management.
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Affiliation(s)
- Junghee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hosptial, Seongnam, Korea
| | - Ah Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hosptial, Seongnam, Korea
| | - Ji-Seok Baek
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hosptial, Seongnam, Korea
| | - Jin-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hosptial, Seongnam, Korea
| | - Sang-Heon Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hosptial, Seongnam, Korea
| | - Jae-Mun Noh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hosptial, Seoul, Korea
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Wang SY, Mei Y, Sheng H, Li Y, Han R, Quan CX, Hu ZH, Ouyang W, Liu ZQ, Duan KM. Tramadol combined with fentanyl in awake endotracheal intubation. J Thorac Dis 2013; 5:270-7. [PMID: 23825758 DOI: 10.3978/j.issn.2072-1439.2013.03.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 03/26/2013] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To explore the feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation. METHODS Using Dixon's up-and-down sequential design, the study enrolled patients from each of the 20-49, 50-60 and 70-and-above age groups scheduled for elective surgery under general anesthesia. The feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation, guided by fiberoptic bronchoscopy, were verified. RESULTS After intravenous injection with fentanyl 2.2 μg/kg and tramadol 2.0 mg/kg in the 20-49 age group, fentanyl 1.6 μg/kg and tramadol 1.9 mg/kg in the 50-69 age group and fentanyl 1 μg/kg and tramadol 1.8 mg/kg in those at the age of 70 or above, the patients achieved conscious sedation without obvious respiratory depression. Meanwhile, under these dosages, the patients could easily tolerate the thyrocricocentesis airway surface anesthesia and fiberoptic bronchoscope guided tracheal intubation. Postoperative follow-up showed that most patients had memory of the intubation process but without significant discomfort. No awake endotracheal intubation-related side effect was noted. CONCLUSIONS Fiberoptic bronchoscope guided nasotracheal intubation can be successfully completed with background administration of fentanyl and tramadol. However, the specific dosages need to be tailored in different age of patients.
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Affiliation(s)
- Sai-Ying Wang
- Institution of Pharmacology, Central South University, China; ; Department of Anesthesiology, the 3rd Xiangya Hospital of Central South University, China
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Kwak HJ, Chae YJ, Lee KC, Kim JY. Target-controlled infusion of remifentanil for laryngeal mask airway insertion during sevoflurane induction in adults. J Int Med Res 2013; 40:1476-82. [PMID: 22971499 DOI: 10.1177/147323001204000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This randomized, double-blind study investigated the suitable target effect-site concentration of remifentanil for laryngeal mask airway (LMA) insertion during inhalation induction with sevoflurane. METHODS Patients aged 18 - 60 years were randomly assigned to one of three groups receiving infusions of normal saline (control group), or infusions with target effect-site remifentanil concentrations of either 1 ng/ml (R1 group) or 2 ng/ml (R2 group), 1 min after the induction of anaesthesia with sevoflurane. LMA insertion was attempted 2 min after induction. Insertion conditions were graded using a six-variable, three-point scale (excellent, intermediate or poor). RESULTS A total of 102 patients were included. The proportion of patients ranked as excellent for the LMA insertion was significantly higher in groups R1 and R2 compared with the control group. The incidence of apnoea was significantly more frequent in the R2 group than in the control or R1 groups. CONCLUSIONS Compared with 1 ng/ml remifentanil or normal saline, target-controlled infusion of 2 ng/ml remifentanil significantly improved the LMA insertion conditions during sevoflurane inhalational induction, although apnoeic episodes were more frequently observed.
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Affiliation(s)
- H J Kwak
- Department of Anaesthesiology and Pain Medicine, Gachon University of Science and Medicine, Gil Medical Centre, Incheon, Republic of Korea
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Kim SH, Choi EM, Chang CH, Kim HK, Chung MH, Choi YR. Comparison of the effect-site concentrations of remifentanil for Streamlined Liner of the Pharynx Airway (SLIPA) versus laryngeal mask airway SoftSealTM insertion during target-controlled infusion of propofol. Anaesth Intensive Care 2011; 39:611-7. [PMID: 21823378 DOI: 10.1177/0310057x1103900412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was designed to determine the optimal dose of remifentanil required for the successful insertion of Streamlined Liner of the Pharynx Airway (SLIPA) and to compare it to that required for laryngeal mask airway (LMA) insertion in patients receiving a propofol infusion at a standard effect-site concentration. Fifty-eight patients scheduled to undergo general anaesthesia were randomly assigned to either the SLIPA (n = 29) or LMA (n = 29) group. All patients were premedicated with midazolam 0.05 mg x kg(-1) and glycopyrrolate 0.004 mg x kg(-1) intramuscularly. After the administration of lignocaine 1 mg x kg(-1) intravenously, a propofol infusion was started at an effect-site concentration of 3.5 microg x ml(-1) with a remifentanil infusion without a neuromuscular blocking agent. The remifentanil dose was determined by the modified up-and-down method starting in each group at 4 ng x ml(-1). Six minutes after induction, the airway device was inserted. Airway device insertion was classified as 'success' or 'failure' based on patient response. From the isotonic regression analysis and bootstrap distribution, the EC50 of remifentanil for SLIPA and LMA were 0.93 ng x ml(-1) (95% confidence interval [CI] 0.81 to 1.50 ng x ml(-1) and 1.36 ng x ml(-1) (95% CI 1.19 to 2.06 ng x ml(-1)) respectively, and the EC95 for SLIPA and LMA insertions were 1.90 ng x ml(-1) (95% CI 1.39 to 1.95) and 2.43 ng x ml(-1) (95% CI 1.80 to 2.46 ng x ml(-1)) respectively. Using the 83% CIs from the bootstrap distribution, EC50 for SLIPA was significantly less than that of LMA (0.83 to 1.23 vs 1.26 to 2.00, respectively) (P < 0.05). These findings suggest that the insertion of SLIPA needs about a 32% lower depth of anaesthesia than LMA insertion.
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Affiliation(s)
- S H Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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Wong THK, Critchley LAH, Lee A, Khaw KS, Ngan Kee WD, Gin T. Fentanyl dosage and timing when inserting the laryngeal mask airway. Anaesth Intensive Care 2010; 38:55-64. [PMID: 20191778 DOI: 10.1177/0310057x1003800111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The study objective was to show that fentanyl given five minutes prior to induction improved insertion conditions for the Classic Laryngeal Mask Airway. Previous work had shown fentanyl at 90 seconds to be unpredictable. A probit analysis design was used in which success/failure rates of different doses of fentanyl were measured and dose-response curves drawn from which the ED50 and ED95 with 95% confidence intervals were determined. Adult Chinese patients with American Society of Anesthesiologists physical status classification I or II and requiring anaesthesia for minor surgery with a laryngeal mask were recruited. They were randomly assigned to one of six dosage groups: 0.25, 0.5, 1.0, 1.5, 2.0 and 3.0 microg x kg1. Fentanyl was given prior to propofol 25 mg x kg(-1), and insertion was assessed 90 seconds later using six categories of patient response. Ninety-six patients, aged 18 to 63 years, were studied. The six dosage groups were similar As the fentanyl dose increased, fewer patients responded to insertion (P < 0.01). Dose-responses could be predicted for all categories, except resistance to insertion and laryngospasm. Probit analysis predicted an ED50 of 0.5 microg x kg(-1) and ED, of 7.5 microg x kg(-1) for ideal insertion conditions (i.e., no swallowing, gagging, body movement or laryngospasm). Commonly used fentanyl doses of 1 to 2 microg x kg(-1) only prevented patients responding to insertion in 70 to 80% of cases. When using propofol 2.5 mg x kg(-1), administering fentanyl five minutes before laryngeal mask insertion does not provide ideal insertion conditions in 95% of cases unless excessively large doses are used. An ideal dose of fentanyl that produces optimum insertion conditions could not be determined.
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Affiliation(s)
- T H K Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Bouvet L, Da-Col X, Rimmelé T, Allaouchiche B, Chassard D, Boselli E. Optimal remifentanil dose for laryngeal mask airway insertion when co-administered with a single standard dose of propofol. Can J Anaesth 2010; 57:222-9. [PMID: 20063135 DOI: 10.1007/s12630-009-9249-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 12/08/2009] [Indexed: 10/20/2022] Open
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