Depth of anaesthesia monitoring during procedural sedation and analgesia: a systematic review protocol

The Evaluation of Reference Values of Plasma and Effect-Site Concentrations of Propofol and Remifentanil During Extubation in Patients Who Had Hysteroscopy Procedures

Aim

This study aimed to assess the correlation of plasma concentration (Cp) and effect-site concentration (Ce) of propofol and remifentanil with level of consciousness and evaluate their reference values during extubation in patients scheduled day-case operative hysteroscopy under propofol-remifentanil anesthesia.

Methods

Propofol (Marsh model) and remifentanil (Minto model) were simultaneously administered using a target-controlled infusion (TCI) pump for the induction and maintenance of anesthesia. The Cp and Ce of propofol (PCp and PCe) and remifentanil (RCp and RCe) before anesthesia induction, at the end of surgery, and at the time of extubation were respectively recorded. Predictive performance was assessed using the jackknife method.

Results

At the time of extubation, PCp was 1.17 ± 0.168 (95% CI: 1.14-1.20 μg/mL), PCe was 1.7 ± 0.212 (95% CI: 1.65-1.74 μg/mL), RCp was 0.769 ± 0.12 (95% CI: 0.75-0.79μg/mL), and RCe was 0.972 ± 0.179 (95% CI: 0.94 -1.01 μg/mL). The Pk values of PCp, PCe, RCp and RCe were 0.999, 0.993, 1.00 and 0.995, separately. Postoperative decreases in PCp (r = 0.089, p < 0.001), PCe (r = 0.087, p= 0.001), RCp (r = 0.072, p < 0.000) and RCe (r = 0.077, p < 0.001) were significantly correlated with the recovery time.

Conclusion

PCp, PCe, RCp and RCe, together with OAA/S Scale and the recovery of spontaneous respiration might be potential reference indicators for extubation in day-surgery hysteroscopy following general anesthesia using TCI.

Depth of anaesthesia monitoring during procedural sedation and analgesia: A systematic review and meta-analysis

OBJECTIVES

Processed electroencephalogram-based depth of anaesthesia monitoring devices provide an additional method to monitor level of consciousness during procedural sedation and analgesia. The objective of this systematic review was to determine whether using a depth of anaesthesia monitoring device improves the safety and efficacy of sedation.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases (CENTRAL; Medline; CINAHL) were searched up to May 2015.

REVIEW METHODS

Randomised controlled trials that compared use of a depth of anaesthesia monitoring device to a control group who received standard monitoring during procedural sedation and analgesia were included. Study selection, data extraction and risk of bias assessment (Cochrane risk of bias tool) were performed by two reviewers. Safety outcomes were hypoxaemia, hypotension and adverse events. Efficacy outcomes were amount of sedation used, duration of sedation recovery and rate of incomplete procedures.

RESULTS

A total of 16 trials (2138 participants) were included. Evidence ratings were downgraded to either low or moderate quality due to study limitations and imprecision. Meta-analysis of 8 trials (766 participants) found no difference in hypoxaemia (RR 0.87; 95% CI=0.67-1.12). No statistically significant difference in hypotension was observed in meta-analysis of 8 trials (RR 0.96; 95% CI=0.54-1.7; 942 participants). Mean dose of propofol was 51mg lower for participants randomised to depth of anaesthesia monitoring (95% CI=-88.7 to -13.3mg) in meta-analysis of results from four trials conducted with 434 participants who underwent interventional endoscopy procedures with propofol infusions to maintain sedation. The difference in recovery time between depth of anaesthesia and standard monitoring groups was not clinically significant (standardised mean difference -0.41; 95% CI=-0.8 to -0.02; I²=86%; 8 trials; 809 participants).

CONCLUSIONS

Depth of anaesthesia monitoring did impact sedation titration during interventional procedures with propofol infusions. For this reason, it seems reasonable for anaesthetists to utilise a depth of anaesthesia monitoring device for select populations of patients if it is decided that limiting the amount of sedation would be beneficial for the individual patient. However, there is no need to invest in purchasing extra equipment or training staff who are not familiar with this technology (e.g. nurses who do not routinely use a depth of anaesthesia monitoring device during general anaesthesia) because there is no high quality evidence suggestive of clear clinical benefits for patient safety or sedation efficacy.

Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy

Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.