Effect of remifentanil infusion on the hemodynamic response during induction of anesthesia in hypertensive and normotensive patients: a prospective observational study

Efficacy and safety of a generic remifentanil formulation versus fentanyl and Ultiva during general anaesthesia: A phase III, prospective, multi-centric, observer-blind, randomised controlled trial

Background and Aims

Remifentanil and fentanyl are potent opioid analgesics commonly used during surgery due to their distinct pharmacological profiles. This study aimed to compare the efficacy and safety of a generic remifentanil (test drug) with fentanyl and Ultiva (innovator formulation) during general anaesthesia in the Indian population.

Methods

This phase III, multi-centre (n = 13), randomised, three-arm, comparative study was conducted from 24 November 2021 to 31 March 2022. Eligible subjects scheduled for elective therapeutic and diagnostic surgical procedures (n = 314) were randomised into generic remifentanil, Ultiva, and fentanyl groups. An independent anaesthetist blinded to treatment allocation assessed efficacy and safety parameters. The primary efficacy endpoint was haemodynamic response during specific activities (endotracheal intubation, skin incision, skin closure, and extubation).

Results

The study groups exhibited no significant differences in demographic and baseline characteristics. Heart rate was similar between the remifentanil and Ultiva groups measured during laryngeal intubation, skin incision, skin closure, and extubation (P > 0.05 in all four procedures). Heart rate was significantly higher in the fentanyl group in comparison to the remifentanil group during laryngeal intubation (P = 0.035), skin incision (P = 0.017), skin closure (P = 0.001), and extubation (P = 0.026). The need for vasopressor and anti-cholinergic drugs was similar between groups, and no subject required naloxone administration.

Conclusion

Our study's findings demonstrated that generic remifentanil is non-inferior to fentanyl and equivalent to Ultiva for general anaesthesia in Indian patients undergoing various surgical and diagnostic procedures. Remifentanil offers advantages in terms of optimum haemodynamic stability, fast equilibrating analgesia, and rapid emergence from sedation, making it a suitable alternative to fentanyl.

Index of Consciousness monitoring may effectively predict and prevent circulatory stress induced by endotracheal intubation under general anesthesia: a prospective randomized controlled trial

BACKGROUND

The primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA).

METHODS

We enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups.

RESULTS

The mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05).

CONCLUSION

This promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management.

TRAIL REGISTRATION

Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022).

Perioperative management of phaeochromocytoma with stress cardiomyopathy and aberrant vascular drainage

The following case discusses the surgical considerations for a patient presenting with cardiogenic shock secondary to a phaeochromocytoma crisis with stress cardiomyopathy. The patient underwent an interval laparoscopic adrenalectomy. Pneumoperitoneum insufflation was performed at lower pressures; manipulation of the adrenal tumour was minimised, and the adrenal vein was ligated early. However, as intraoperative blood pressure (BP) remained elevated and rising, further gentle dissection revealed an aberrant inferior phrenic vein draining the adrenal nodule. BP was finally reduced following ligation of the inferior phrenic vein, demonstrating the clinical significance of an unusual dual venous drainage from the adrenal nodule in this patient.

Comparison of Two Anesthetic Regimens on Extubation Time and Postoperative Recovery in Children Undergoing Ambulatory Adenoidectomy: A Retrospective Study

PURPOSE

This aim of this study was to compare two anesthetic regimens in terms of extubation time and postoperative recovery in children undergoing ambulatory adenoidectomy.

DESIGN

A retrospective cohort study with propensity score matching.

METHODS

The medical charts of 452 children aged between 3 and 8 years undergoing ambulatory adenoidectomy were retrieved for analysis, of which 438 were eligible to participate in this study. A majority (n = 327) were children exposed to a conventional propofol-pronounced general anesthetic regimen (high-dose propofol plus low-dose remifentanil, labeled as group P), while n = 111 were administered a modified remifentanil-pronounced anesthetic regimen (low-dose propofol plus high-dose remifentanil, namely group R). Propensity score matching was employed to adjust for confounders, resulting in 69 matched patients in each group. The primary endpoint of this study was extubation time. The secondary endpoints were total intraoperative fluid volume, length of stay in the postanesthesia care unit (PACU), postoperative pain rating, the incidence of emergence agitation, nausea and vomiting, as well as the level of consciousness (fully awake or waking by gentle patting) when transferred out of PACU, and any major complications (wound bleeding, reintubation, readmission, and overnight stay).

FINDINGS

No major complications were observed in both groups. Compared to group P, group R had significantly shorter extubation time (8.2 ± 1.4 minutes vs 13.3 ± 2.4 minutes, P < .001), shorter length of stay in the PACU (14.1 ± 3.1 minutes vs 20.2 ± 3.4 minutes, P < .001), and a higher proportion of cases being fully awake when transferred out of the PACU (91% vs 46%, P < .001). Lastly, the pain rating, frequency of oropharyngeal airway usage, incidence of emergence agitation, and nausea and vomiting were comparable between the two groups (P > .05 for all).

CONCLUSIONS

Remifentanil-pronounced anesthesia was superior to propofol-pronounced anesthesia in children undergoing ambulatory adenoidectomy, given that the former was associated with a faster recovery time from anesthesia without jeopardizing patient safety.