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Hoymork SC, Hval K, Jensen EW, Raeder J. Can the cerebral state monitor replace the bispectral index in monitoring hypnotic effect during propofol/remifentanil anaesthesia? Acta Anaesthesiol Scand 2007; 51:210-6. [PMID: 17330331 DOI: 10.1111/j.1399-6576.2006.01213.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 2004, the cerebral state monitor, CSM, was launched as a low-cost alternative to the bispectral index, BIS, for monitoring depth of sleep during anaesthesia. We tested whether the two monitors would reflect hypnosis equally during propofol/remifentanil anaesthesia. METHODS During laparoscopy or breast/surface surgery, 55 non-paralyzed patients were monitored simultaneously with the BIS and the CSM. Trend curves for the indexes [BIS and cerebral state index (CSI)] were compared for congruence. The difference between the two indexes for the entire course was quantified, and the ability of the two monitors to separate awake from asleep during induction was described. RESULTS In the majority of the patients, 87%, there was a good fit between the indexes. There were major deviations in seven patients, in whom CSI indicated that the patients were awake during parts of the course despite clinical sleep, correctly identified with the BIS. Both indexes separated awake from asleep during induction in the individual patient, but the overlap in values between patients was more pronounced for CSI. CONCLUSION CSM and BIS show some important differences in measuring hypnotic state during clinical propofol/remifentanil anaesthesia.
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Affiliation(s)
- S C Hoymork
- Department of Anaesthesia, Ullevaal University Hospital and University of Oslo, Faculty Division of Ullevaal University Hospital, Oslo, Norway.
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Cho JE, Kim WO, Jun NH, Yang SY, Kil HK. Comparison of Maintenance and Emergence of Anesthesia in Total Intravenous Anesthesia with Propofol and Remifentanil for Thyroidectomy and Mastectomy. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.2.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jang Eun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Won Oak Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesiology and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Na Hyung Jun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - So Young Yang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesiology and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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McGaughran L, Voss LJ, Oliver R, Petcu M, Schaare P, Barnard JPM, Sleigh JW. Rapid measurement of blood propofol levels: a proof of concept study. J Clin Monit Comput 2006; 20:109-15. [PMID: 16779624 DOI: 10.1007/s10877-006-9014-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 02/21/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite many advantages over traditional volatile anaesthetic techniques, propofol total intravenous anaesthesia (TIVA) makes up a small percentage of general anaesthetics administered. One of the reasons for this is the absence of a clinically useful method for measuring blood propofol concentrations. We have designed and tested a prototype system for rapidly measuring blood plasma levels of propofol using solid phase extraction (SPE) methodology, coupled with colorimetric and spectrometric techniques. METHODS Multiple venous blood samples were taken from 17 subjects during induction of anaesthesia with propofol. Samples were analysed in duplicate on both the prototype system and using High Performance Liquid Chromatography (HPLC). The prototype monitor response was calibrated against known methanol-based propofol standards and an estimate of the plasma concentration of propofol derived from regression analysis of the standard responses. RESULTS Bland Altman analysis from a total of 87 samples gave 95% limits of agreement between the two methods of -0.34 to 0.42 microg mL(-1) (with no significant bias). The mean absolute prediction error was 8.9(7.5)%. The run time per sample on the prototype system was 4.5 min, including sample preparation. CONCLUSION The results show that this methodology may be suitable for rapid and accurate clinical monitoring of propofol levels during general anaesthesia.
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Affiliation(s)
- L McGaughran
- Auckland University of Technology, Auckland, New Zealand
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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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Takizawa D, Hiraoka H, Sato E, Aso T, Aso C, Kunimoto F, Goto F. The effect of gynecologic laparoscopy on propofol concentrations administered by the target-controlled infusion system. J Anesth 2006; 20:57-9. [PMID: 16421681 DOI: 10.1007/s00540-005-0355-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 08/31/2005] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to assess the effect of gynecologic laparoscopy on propofol concentrations administered by the target-controlled infusion (TCI) system. Thirteen patients undergoing gynecologic laparoscopy (intraabdominal pressure of 10 mmHg) were enrolled in this study. Anesthesia was induced with vecuronium 0.1 mg.kg(-1) and propofol, then maintained by 60% nitrous oxide and sevoflurane in oxygen and a constant infusion of propofol. Propofol was administered to all subjects by means of a target-controlled infusion to achieve propofol plasma concentration at 6.0 microg.ml(-1) at intubation and 2.0 microg.ml(-1) after intubation. Before and during laparoscopy, plasma propofol concentration was determined using high-performance liquid chromatograhy. Cardiac output (CO) and effective liver blood flow (LBF) were also measured using indocyanine green as an indicator. Before and during pneumoperitoneum, there were no significant differences in propofol concentrations between each point. Propofol concentrations were well achieved to predicted concentrations administered by the TCI system during gynecologic laparoscopy under propofol and sevoflurane anesthesia.
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Affiliation(s)
- Daisuke Takizawa
- Department of Anesthesiology, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
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Buchanan FF, Myles PS, Leslie K, Forbes A, Cicuttini F. Gender and recovery after general anesthesia combined with neuromuscular blocking drugs. Anesth Analg 2006; 102:291-7. [PMID: 16368846 DOI: 10.1213/01.ane.0000181321.55422.c6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Previous studies suggest that women recover faster from general anesthesia than men, but it is unclear whether this is a result of a gender effect or differences in the pattern of drug administration or type of surgery. We performed a subset analysis comparing recovery characteristics from general anesthesia combined with neuromuscular blocking drugs of female and male patients, at risk of awareness, enrolled in a large trial testing the effectiveness of bispectral index (BIS) monitoring. We used multivariate statistical methods to adjust for differences in baseline characteristics, duration and extent of surgery, and anesthetic drug administration in 1079 patients (584 male, 495 female). Female patients had higher BIS values than male patients despite similar amounts of anesthetic drug administration (time-averaged mean [sd] BIS: male 44.6 [7.1] versus female 46.4 [6.6]; P = 0.005). Time to eye opening after anesthesia and time to eligibility to discharge from the postanesthesia care unit were less in women than men (male 13.9 [13.2] min versus female 10.6 [11.6] min; P < 0.001; male 133 [209] min versus female 78 [106] min; P < 0.001, respectively). These differences persisted after multivariate adjustment (both P < or = 0.001). Gender has an independent effect on recovery times in patients undergoing general anesthesia combined with neuromuscular blocking drugs, with women recovering faster than men. Higher BIS values during maintenance of anesthesia in women, despite similar amounts of anesthetic drug administration, suggests that women are less sensitive to the hypnotic effect of anesthetic drugs than men and may help explain faster recovery times in women.
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Affiliation(s)
- Frank F Buchanan
- Department of Anesthesia and Pain Management, Alfred Hospital, Melbourne, Australia.
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Valjus M, Ahonen J, Jokela R, Korttila K. Response Entropy is not more sensitive than State Entropy in distinguishing the use of esmolol instead of remifentanil in patients undergoing gynaecological laparoscopy. Acta Anaesthesiol Scand 2006; 50:32-9. [PMID: 16451148 DOI: 10.1111/j.1399-6576.2005.00876.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Monitoring of analgesia remains a challenge during general anaesthesia. Activation of Response Entropy (RE) to painful stimuli has been suggested to be a sign of inadequate analgesia. We evaluated the ability of RE to be more sensitive than State Entropy (SE) in measuring nociception in patients undergoing gynaecological laparoscopy. Our hypothesis was that while keeping SE at a predetermined level, RE would be higher in patients receiving a beta-blocking agent (esmolol) instead of an opioid (remifentanil) during a propofol/nitrous oxide anaesthesia. METHODS Fifty-one women aged between 22-53 years were randomly assigned to receive esmolol (n=25) or remifentanil (n=26). SE was kept at 50+/-5. RE and SE were recorded at an interval of 30 s to 2 min and the areas under the RE and SE value-time curves (AUCRE and AUCSE) were calculated during the time of intubation and start of surgery as well as during the entire anaesthesia. The difference between RE and SE recordings in both groups was determined by subtracting the AUCSE from the corresponding AUCRE. Movements of the patients were recorded. RESULTS No significant differences were detected in any of the several AUC values between the groups. The difference between RE and SE recordings was similar in both groups. Every patient in the esmolol group moved some time during the procedure interfering with surgery while no one in the remifentanil group moved. CONCLUSION In patients undergoing gynaecological laparoscopic day-case surgery, RE seems not to be more sensitive than SE in guiding the use of opioids during general anaesthesia.
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Affiliation(s)
- M Valjus
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
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Abstract
BACKGROUND It has repeatedly been shown that female patients wake up faster from propofol anaesthesia than male patients. The reason for this is not clear. It is possible that female patients have a more rapid decline in plasma propofol concentration after termination of an infusion, or there could be gender differences in the sensitivity to propofol, making women wake up at higher concentrations. We tested the hypothesis that women wake up faster because of a more rapid decline in plasma propofol. METHODS Sixty adult patients (30 female and 30 male; ASA I or II) undergoing lower limb surgery under regional anaesthesia, were enrolled in an open study. Propofol was given as the only hypnotic drug, administered by the plasma target control system (TCI) Diprifusor, titrated to bispectral index (BIS) values of 40-60. Blood samples for propofol measurements were taken just before the propofol infusion was stopped and when the patients woke up. RESULTS The female patients woke up faster than the male patients (5.6 vs 8.2 min, P=0.003). The plasma propofol concentration declined more rapidly in the women (P=0.02). An additional significant finding was that the TCI algorithm had a better fit for the women than for the men, with a median prediction error (MDPE) of 2% in the female patients compared with 40% in the male patients (P<0.001). At emergence the men had a significantly higher measured propofol concentration than the women (P=0.05). CONCLUSION The female patients had a more rapid decline in plasma propofol at the end of infusion. Gender differences in pharmacokinetics could explain the faster emergence for female patients after propofol anaesthesia, and gender differences in propofol sensitivity may also be present.
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Affiliation(s)
- S C Hoymork
- Department of Anaesthesia, Ullevaal University Hospital, N-0407 Oslo, Norway.
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Kodaka M, Johansen JW, Sebel PS. The Influence of Gender on Loss of Consciousness with Sevoflurane or Propofol. Anesth Analg 2005; 101:377-381. [PMID: 16037147 DOI: 10.1213/01.ane.0000154534.71371.4f] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Studies have suggested that hypnotic requirements for general anesthesia and emergence may be influenced by gender. In this study, we examined the effect of gender on the hypnotic requirement for loss of consciousness (LOC) using either a volatile (sevoflurane) or an IV (propofol) anesthetic. One-hundred-fifteen unpremedicated, ASA physical status I-II patients, aged 18-40 yr old, received either sevoflurane by mask to a predetermined end-tidal concentration (%ET(sevo)) or propofol by target-controlled infusion (effect site) while breathing spontaneously. After sufficient time for equilibration, LOC was assessed by lack of response to mild prodding. The up-down method of Dixon was used to determine the hypnotic target concentration at 50% response (LOC(50)). No statistically significant difference in LOC(50) was noted between men and women for sevoflurane (0.83% +/- 0.1% and 0.92% +/- 0.09% ET, respectively). Men required significantly more propofol than women (2.9 +/- 0.2 versus 2.7 +/- 0.1 microg/mL, respectively). However, there was no difference in the bispectral index (BIS) at LOC for men or women with either hypnotic anesthetic. This investigation identified a small, statistically significant difference in hypnotic requirement at LOC(50) between men and women with propofol but not with sevoflurane. As defined by BIS, men and women had equivalent hypnotic states at LOC(50), indicating that gender had no clinically significant effect on hypnotic requirements. However, BIS at a defined clinical end-point (LOC(50)) was significantly different between the sevoflurane and propofol groups, suggesting that neurophysiological effects of these anesthetics may be different. IMPLICATIONS Gender affects the dosing requirements for, and response to, many drugs used in anesthetic practice. Loss of consciousness is an early clinical marker of hypnotic drug effect. We found no significant difference to either an inhaled (sevoflurane) or IV (propofol) anesthetic related to patient gender.
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Affiliation(s)
- Mitsuharu Kodaka
- Department of Anesthesiology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
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Fodale V, Praticó C, Tescione M, Lucanto T, Tanania S, Santamaria LB. Comparative Cost-Analysis of a Propofol-Cisatracurium-Based Anesthesia With Remifentanil or Fentanyl for Laparoscopic Surgery. Surg Laparosc Endosc Percutan Tech 2005; 15:149-52. [PMID: 15956899 DOI: 10.1097/01.sle.0000166963.64521.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To compare the intraoperative costs of intravenous propofol-based anesthesia for laparoscopic cholecystectomy, a total of 42 patients were randomly assigned to receive remifentanil or fentanyl as adjuvant using the bispectral index anesthesia monitoring. The average anesthesia calculated costs per hour (and per minute) were 79.45 (1.32) in the fentanyl group and 65.36 (1.09) in the remifentanil group. The calculated mean cost per patient was 76.56 in the fentanyl group and 58.86 in the remifentanil group. In conclusion, for propofol-cisatracurium-based anesthesia for laparoscopic surgery, when applying the bispectral index to guide the administration of hypnotic anesthetic drugs and ensure an adequate and stable depth of anesthesia, the cost of anesthesia is lower using remifentanil as an adjuvant rather than fentanyl. The clinical relevance is that it could be the intravenous anesthesia technique of choice in laparoscopic surgery for cholecystectomy from a cost-minimization standpoint.
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Affiliation(s)
- Vincenzo Fodale
- University of Messina, Department of Neuroscience Psychiatric and Anesthesiological Sciences, Policlinico Universitario G. Martino, Messina, Italy.
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Frölich MA, Dennis DM, Shuster JA, Melker RJ. Precision and bias of target controlled propofol infusion for sedation † †Presented in abstract format at the World Congress of Anaesthesiology, Paris, 2004. Br J Anaesth 2005; 94:434-7. [PMID: 15681587 DOI: 10.1093/bja/aei081] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this study is to test precision and systematic bias of a target controlled infusion (TCI) of propofol in human volunteers at two sedative concentrations. METHODS We studied the 'Diprifusor' model (Marsh Pharmacokinetics and a Graseby 3400 infusion pump) in 18 human volunteers at two sedative target plasma concentrations (0.5 and 1.0 microg ml(-1)). Twenty minutes after infusion start or change and 20 min after discontinuation of the infusion plasma propofol concentrations were measured using liquid chromatography-mass spectroscopy (LC-MS). Plasma propofol concentrations were compared with concentrations predicted by the TCI system. Agreement of those two measures (precision and bias) was determined using regression analysis. RESULTS We found little systematic bias but poor precision. When setting the TCI system to deliver a plasma concentration of 1.0 microg ml(-1) one can predict the actual plasma concentration with 95% confidence only within a range of 0.44-1.38 microg ml(-1). CONCLUSIONS This finding helps to explain differences in responses to propofol sedation; pharmacokinetic variability appears to be an important factor.
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Affiliation(s)
- M A Frölich
- Department of Anesthesiology, University of Florida Colleges of Medicine and Engineering, Gainesville, Florida, USA.
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Han TH, Lee JH, Kwak IS, Kil HY, Han KW, Kim KM. The relationship between bispectral index and targeted propofol concentration is biphasic in patients with major burns. Acta Anaesthesiol Scand 2005; 49:85-91. [PMID: 15675988 DOI: 10.1111/j.1399-6576.2004.00532.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many pathophysiologic alterations in major burns can cause changes in the distribution of, and perhaps response to, drugs commonly used in anesthesia practice. This study was conducted to assess changes in bispectral index (BIS) caused by increasing the target propofol effect-site concentration during a target-controlled infusion (TCI) in major burns. METHODS Eighteen patients, ASA physical status 2 or 3, aged from 20 to 55 years old, weighing 50-70 kg, with major burns, scheduled for elective early escharectomy less than a week after injury were recruited. A further 18 ASA physical status class 1 or 2, non-burns, age, sex- and weight-matched adult patients scheduled for elective surgery under general anesthesia were recruited as controls. During anesthesia induction, target propofol effect-site concentrations were increased by increments of 0.5 microg ml(-1) up to 4.5 microg ml(-1). The BIS responses to each target concentration using TCI were compared in both groups. RESULTS In the burns group, significantly greater BIS values relating to increasing propofol TCI were noted at deeper anesthesia when compared with controls; at > or =3.5 microg ml(-1); mean BIS remained at a plateau of about 50. Patients with burns had higher cardiac indices, and lower hemoglobin and albumin concentrations than the controls. They consumed more vecuronium to maintain the same degree of neuromuscular blockade than the controls. CONCLUSIONS In major burns, the final biphasic BIS responses appeared to be determined by numerous other variables such as BIS algorithm, TCI performance, and altered propofol pharmacokinetics and pharmacodynamics. According to our results the importance of an individually tailored approach, including careful anesthetic titration, based upon the patient's clinical condition and responses can not be overemphasized.
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Affiliation(s)
- T-H Han
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, Korea.
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Abstract
Efforts to develop new hypnotic compounds continue, although several have recently failed in development. Propofol has been reformulated in various presentations with and without preservatives. Pharmacokinetic and pharmacodynamic differences exist between some of these preparations, and it is currently unclear whether any have substantial advantages over the original presentation. The use of target-controlled infusion (TCI) has been extended to include paediatric anaesthesia and sedation. Application of TCI to remifentanil is now licensed. Linking of electroencephalogram (EEG) monitoring to TCI for closed-loop anaesthesia remains a research tool, although commercial development may follow. The availability of stereoisomer ketamine and improved understanding of its pharmacology have increased non-anaesthetic use of ketamine as an adjunct analgesic. It may be useful in subhypnotic doses for postsurgical patients with pain refractory to morphine administration.
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Affiliation(s)
- J R Sneyd
- Peninsula Medical School, Portland Square, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK.
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Literature watch. J Endourol 2004; 18:397-405. [PMID: 15259189 DOI: 10.1089/089277904323056979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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