Remifentanil-propofol versus fentanyl-propofol for monitored anesthesia care during hysteroscopy

Comparison Between Esketamine and Alfentanil for Hysteroscopy: A Prospective, Double-Blind, Randomized Controlled Trial

Purpose

This study aimed to establish the 95% effective dose (ED95) of esketamine in combination with propofol for hysteroscopy and then to evaluate its efficacy and safety profile.

Patients and Methods

This prospective, double-blind, randomized controlled trial consisted of two cohorts. In cohort 1, 45 women aged 18-65 years undergoing hysteroscopy were randomly assigned to either group E (esketamine + propofol) or group A (alfentanil + propofol). Dixon's up-and-down method was used to determine the ED95 of esketamine and alfentanil. In cohort 2, 86 patients were randomized to group E and group A, with the calculated ED95 dose of the study drugs used for induction. The success rate of anesthesia using the ED95% dose, along with parameters related to anesthesia induction, recovery, and adverse events were also recorded.

Results

The ED95 of esketamine was 0.254 mg/kg (95% CI: 0.214-1.004), while that of alfentanil was 9.121 μg/kg (95% CI: 8.479-13.364). The anesthesia success rate was 93.0% in group E and 95.2% in group A (p = 0.664). After resuscitation, both groups achieved a 100% success rate. The induction time was significantly shorter in group E (60.0 [55.0-70.0] s) compared to group A (67.0 [61.0-79.3] s) (p = 0.006). Group E had lower rates of respiratory depression (p < 0.001), hypoxia (p = 0.006), minimum perioperative SpO2 (p = 0.010), and hypotension (p = 0.001). Esketamine had less effect on respiratory rate, heart rate, mean blood pressure, and end-tidal carbon dioxide compared to alfentanil (all p < 0.001). There were no significant differences in postoperative pain between the two groups.

Conclusion

This study determined the ED 95 dose of esketamine for intravenous general anesthesia during hysteroscopy. Esketamine showed less respiratory and hemodynamic depression, as well as fewer adverse effects compared to alfentanil. Esketamine is an ideal anesthetic agent compared to alfentanil for hysteroscopic anesthesia.

Trial Registration

www.chictr.org.cn, (ChiCTR2300077283); registered November 3, 2023.

Effect of Remimazolam Supplementation on Propofol Requirements During Hysteroscopy: A Double-Blind, Dose-Response Study

BACKGROUND

Propofol is commonly used for procedural sedation but may increase side effects in a dose-dependent manner. Remimazolam, an ultrashort-acting benzodiazepine, has been approved for procedural sedation but may delay awakening. This study tested the hypothesis that remimazolam as a supplement reduces effect-site propofol concentration (Ceprop) required to suppress response to cervical dilation in patients undergoing hysteroscopy.

METHODS

One hundred and fifty patients who were scheduled for hysteroscopy were randomized to receive 0, 0.05, 0.1, 0.15, or 0.2 mg·kg-1 intravenous remimazolam, followed by a bolus of sufentanil 0.15 μg⋅kg-1, and a target-controlled propofol infusion. The initial target Ceprop was 3.5 μg·mL-1 and was increased or decreased in subsequent patients by steps of 0.5 μg·mL-1 according to whether there was loss of response to cervical dilation in the previous patient. We used up-down sequential analysis to determine values of Ceprop that suppressed response to cervical dilation in 50% of patients (EC50).

RESULTS

The EC50 of propofol for suppressing response to cervical dilation was lower in patients given 0.1 mg·kg-1 (2.08 [95% confidence interval, CI, 1.88-2.28] μg·mL-1), 0.15 mg⋅kg-1 (1.83 [1.56-2.10] μg·mL-1), and 0.2 mg⋅kg-1 (1.43 [1.27-1.58] μg·mL-1) remimazolam than those given 0 mg⋅kg-1 (3.67 [3.49-3.86] μg·mL-1) or 0.05 mg⋅kg-1 (3.47 [3.28-3.67] μg·mL-1) remimazolam (all were P < .005). Remimazolam at doses of 0.1, 0.15, and 0.2 mg·kg-1 decreased EC50 of propofol by 43.3% (95% CI, 41.3%-45.5%), 50.3% (48.0%-52.8%), and 61.2% (58.7%-63.8%), respectively, from baseline (remimazolam 0 mg⋅kg-1). Propofol consumption was lower in patients given 0.1 mg⋅kg-1 (4.15 [3.51-5.44] mg·kg-1), 0.15 mg⋅kg-1 (3.54 [3.16-4.46] mg·kg-1), and 0.2 mg⋅kg-1 (2.74 [1.73-4.01] mg·kg-1) remimazolam than those given 0 mg⋅kg-1 (6.09 [4.99-7.35] mg·kg-1) remimazolam (all were P < .005). Time to anesthesia emergence did not differ significantly among the 5 groups.

CONCLUSIONS

For women undergoing hysteroscopic procedures, remimazolam at doses from 0.1 to 0.2 mg·kg-1 reduced the EC50 of propofol inhibiting response to cervical dilation and the total propofol requirement. Whether the combination could improve perioperative outcomes deserves further investigation.

Monitored Anesthesia Care Using Remimazolam and Ketamine Combination for Brief Gynecological Surgeries: A Report for Four Cases

Remimazolam is a benzodiazepine with rapid onset and recovery time. Ketamine provides analgesia and sedation without compromising hemodynamics. Combining both agents may provide good anesthesia and analgesia with fewer complications. We report four cases of monitored anesthesia care with a combination of remimazolam and ketamine for brief gynecological surgeries. We applied 0.5 mg/kg bolus ketamine and infused patients with remimazolam at 6 mg/kg/h for induction and 1 mg/kg/h for maintenance. Then, 25 µg of fentanyl was administered for analgesia 4 min before the procedure, and additional fentanyl was administered as needed. Remimazolam was discontinued shortly after surgery. We conducted satisfactory monitored anesthesia care with a combination of remimazolam and ketamine in all four cases.

Monitored anesthesia care with remimazolam for gynecological day surgeries: Case reports

Remimazolam is a newly approved benzodiazepine characterized by rapid onset, predictable maintenance, fast recovery, and availability of a reversal agent. We describe four cases of patients who received monitored anesthesia care with remimazolam for gynecological day surgery.

High-flow nasal oxygen reduces the incidence of hypoxia in sedated hysteroscopy for assisted reproduction

Backgrounds and aims

Pain is the main reason for hysteroscopy failure. In day-surgical settings, hysteroscopy procedures are commonly performed with the patient under sedation. Hypoxia is the most common adverse event during sedation and can lead to severe adverse events. This study aimed to compare the incidence of hypoxia when using high-flow nasal oxygen (HFNO) with that when using regular nasal oxygen in patients undergoing hysteroscopy with sedation.

Materials and methods

In this single-center, prospective, randomized, single-blinded study, 960 female patients undergoing elective diagnostic or operative hysteroscopy were randomly enrolled into the following two groups: the regular nasal group [O₂ (3–6 L/min) covered by an HFNO] and the HFNO group [O₂ (30–60 L/min)] from September 2021 to December 2021. All women were sedated with propofol (1.5 mg/kg) and remifentanil (1.5 μg/kg) in the operating room. The primary outcome was the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s).

Results

HFNO decreased the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s), subclinical respiratory depression (90% ≤ SpO₂ < 95%) and severe hypoxia (SpO₂ < 75% for any duration or 75% ≤ SpO₂ < 90% for ≥ 60 s) from 24.38 to 0.83%, from 11.25 to 1.46% and from 3.75 to 0%, respectively (P < 0.001).

Conclusion

In procedures conducted to treat female infertility, HFNO can reduce hypoxia during hysteroscopy in patients sedated with propofol, and it can prevent the occurrence of subclinical respiratory depression and severe hypoxia.

Procedural analgesic interventions in China: a national survey of 2198 hospitals

Background

Humane treatment requires the provision of appropriate sedation and analgesia during medical diagnosis and treatment. However, limited information is available about the status of procedural analgesic interventions in Chinese hospitals. Therefore, a nationwide survey was established to identify challenges and propose potential improvement strategies.

Methods

Forty-three members of the Pain Group of Chinese Society of Anesthesiology established and reviewed the questionnaire, which included (1) general information on the hospitals, (2) the sedation/analgesia rate in gastrointestinal endoscopy, labor, flexible bronchoscopy, hysteroscopy in China, (3) staff assignments, (4) drug use for procedural analgesic interventions, and (5) difficulties in procedural analgesic interventions. The data were obtained using an online questionnaire sent to the chief anesthesiologists of Chinese hospitals above Grade II or members of the Pain Group of Chinese Society of Anesthesiology.

Results

Valid and complete questionnaires were received from 2198 (44.0%) hospitals, of which 64.5% were Grade III. The overall sedation/analgesia rates were as follows: gastroscopy (50.6%), colonoscopy (53.7%), ERCP (65.9%), induced abortion (67.5%), labor (42.3%), hysteroscopy (67.0%) and fiber bronchoscopy (52.6%). Compared with Grade II hospitals, Grade III hospitals had a higher proportion of procedural analgesic interventions services except for induced abortion. On average (median [IQR]), each anesthesiologist performed 5.7 [2.3—11.4] cases per day, with 7.3 [3.2—13.6] performed in Grade III hospitals and 3.4 [1.8—6.8] performed in Grade II hospitals (z = -7.065, p < 0.001).

Conclusions

Chinese anesthesiologists have made great efforts to achieve procedural analgesic interventions, as evidenced by the increased rate. The uneven health care provided by hospitals at different levels and in different regions and the lack of anesthesiologists are the main barriers to optimal procedural analgesic interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01783-6.

ED50 of Propofol Combined with Nalbuphine on the Sedative Effect in Painless Hysteroscopy

INTRODUCTION

Nalbuphine has gradually become a commonly used clinical analgesic drug for painless hysteroscopy. The aim of our study was to identify the median effective dose (ED50) of propofol combined with nalbuphine for painless hysteroscopy.

METHODS

Sixty-one patients aged 18-60 years were recruited to undergo elective painless hysteroscopy. Patients were administered 0.1 μg/kg nalbuphine (group A) or 0.2 μg/kg nalbuphine (group B) intravenously 3 min before endoscopic placement. The Dixon sequential method was used with an initial intravenous propofol dose of 2 mg/kg, which varied by 0.5 mg per kilogram.

RESULTS

The ED50 of propofol was 1.729 mg/kg (95% confidence interval [CI] 1.526-1.856 mg/kg) in group A and 1.658 mg/kg (95% CI 1.359-1.799 mg/kg) in group B. The 95% effective dose (ED95) of propofol was 2.051 mg/kg (95% CI 1.899-3.331 mg/kg) in group A and 2.020 mg/kg (95% CI 1.849-3.832 mg/kg) in group B.

CONCLUSION

For safety and effective painless hysteroscopic, the ED50 values of propofol combined with nalbuphine were 1.729 mg/kg (0.1 mg/kg nalbuphine) and 1.658 mg/kg (0.2 mg/kg nalbuphine). The recommended dose of nalbuphine is therefore 0.1 mg/kg.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2100042342 ( http://www.chictr.org.cn/edit.aspx?pid=66342&htm=4 ; registration date 19 Jan 2021).

Comparison between remifentanil and other opioids in adult critically ill patients: A systematic review and meta-analysis

BACKGROUND AND AIMS

To identify the efficacy and safety of remifentanil when compared with other opioids in adult critically ill patients.

METHODS

We searched for studies in the Cochrane Library, MEDLINE, and EMBASE that had been published up to May 31st, 2019. Randomized clinical trials using remifentanil comparing with other opioids for analgesia were included. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Duration of mechanical ventilation was the primary outcome, and secondary outcomes included weaning time, intensive care unit (ICU), length of stay (LOS), hospital LOS, mortality, side effects, and costs.

RESULTS

Fifteen studies with 1233 patients were included. Remifentanil was associated with a significant reduction in the duration of mechanical ventilation in the adult ICU patients when compared with other opioids (P = .01). Remifentanil also reduced the weaning time (P = .02) and the ICU LOS when compared with other opioids (P = .01). There was no difference in the hospital LOS (P = .15), side effects (P = .39), and mortality (P = .79) between remifentanil and other opioids, what's more, remifentanil increased the costs of anesthesia (P < .001) but did not increase cost of hospitalization (P = .30) when comparing with other opioids.

CONCLUSIONS

Remifentanil reduced the duration of mechanical ventilation, weaning time, and ICU LOS when compared with other opioids in adult critically ill patients. Higher quality RCTs are necessary to prove our findings.

PROSPERO REGISTRATION NUMBER

CRD42016041438.

Comparison of 2 effect-site concentrations of remifentanil with midazolam during percutaneous transluminal balloon angioplasty under monitored anesthesia care: A randomized controlled study

BACKGROUND

Until now, target-controlled infusion of remifentanil with midazolam in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas has not been described. Here, we investigate 2 effect-site concentrations of remifentanil with intermittent bolus midazolam for percutaneous transluminal balloon angioplasty under monitored anesthesia care.

METHODS

A prospective, randomized controlled trial including patients who received a percutaneous transluminal balloon angioplasty between March 2019 and March 2021 was conducted. Group 1 and Group 2 were, respectively, administered an initial effect-site concentration of remifentanil of 1.0 and 2.0 ng/mL by a target-controlled infusion pump with Minto model. In both groups, maintenance of the effect-site concentration of remifentanil was adjusted upward and downward by 0.5 ng/mL with intermittent bolus midazolam to keep the Observer's Assessment of Alertness/Sedation scale between 2 and 4, mean arterial pressure and heart rate at baseline levels ± 30%, and patient comfort (remaining moveless). The primary outcome was to determine the appropriate effect-site concentration of remifentanil for the procedure in terms of patient comfort (remaining moveless), hemodynamic conditions, and adverse events. Secondary endpoints included the total dosage of anesthetics and total times of target-controlled infusion pump adjustments.

RESULTS

A total of 40 patients in Group 1 and 40 patients in Group 2 were eligible for analysis. Most parameters were insignificantly different between 2 groups, except Group 1 having higher peripheral oxygen saturation, while local anesthetic injection compared with Group 2. In addition, Group 1 patients had less apnea with desaturation (peripheral oxygen saturation < 90%; 0 vs 6, P = .034), less remifentanil consumption (189.65 ± 69.7 vs 243.8 ± 76.1 μg, P = .001), but more intraoperative movements affecting the procedure (14 vs 4; P = .016), total times of target-controlled infusion pump adjustment [2 (1-4) vs 1 (1-2), P < .001] compared with Group 2.

CONCLUSION

In percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas, target-controlled infusion with remifentanil Minto model target 2.0 ng/mL with 3 to 4 mg midazolam use provided appropriate hemodynamic conditions, sufficient sedation and analgesia, and acceptable apnea with desaturation.

Efficacy and safety of remimazolam besylate versus propofol during hysteroscopy: single-centre randomized controlled trial

Background

Remimazolam besylate is a newer benzodiazepine with characteristics of quick onset of effects, short maintenance and recovery times without accumulation in tissues. This trial was conducted to confirm the efficacy and safety of remimazolam besylate versus propofol during hysteroscopy.

Methods

Patients undergoing hysteroscopy were randomly assigned to either the remimazolam (Group R) or the propofol group (Group P). Group R was administered an induction dose of 0.2 mg/kg and a maintenance dosage of 1.0 mg/kg/h. In Group P, propofol was started at 1.5–2.0 mg/kg and then maintained at 3.0–6.0 mg/kg/h. After remimazolam besylate or propofol induction, remifentanil was infused using a target-controlled infusion system with a target concentration of 1.5 ng/ml and titrated during the procedure. The incidence rates of injection pain, low oxygen saturation (SpO₂) and adverse effects in both groups were compared.

Results

Eighty-two patients were included in this study. The incidence of adverse events in Group R (3.7%) was significantly lower than that in Group P (36.6%) (p < 0.001). The incidence of injection pain in Group P (80.5%) was much higher than that in Group R (2.4%) (p < 0.001). The incidence of other adverse events, such as low SpO₂, bradycardia, and hypotension in Group R was lower than that in Group P (p < 0.05).

Conclusions

Remimazolam besylate proves to be a safer alternative for anesthesia during hysteroscopy. Moreover, adverse events caused by propofol, such as low SpO₂ and injection pain, are largely avoided.

Trial registration

This study was approved by the Clinical Research Ethics Committee of Mengcheng County No. 1 People’s Hospital (2020MYL20003) and registered at http://www.chictr.org.cn (15/09/2020, ChiCTR-2000038252). The study protocol followed the CONSORT guidelines. The study protocol was performed in the relevant guidelines.

Inhalation of low-dose desflurane prevents the hemodynamic instability caused by target-controlled infusion of remifentanil and propofol during laparoscopic gynecological surgery: A randomized controlled trial

The objective of the present study was to determine whether the addition of inhaled desflurane is superior to remifentanil-propofol total intravenous anesthesia (TIVA) alone in patients undergoing laparoscopic gynecological surgery. A total of 60 patients who were scheduled to undergo laparoscopic gynecological surgery were prospectively enrolled and randomly allocated to receive either propofol-remifentanil (PR group; n=30) or combined propofol-remifentanil and low-dose desflurane (PRD group; n=30) for the maintenance of anesthesia. Hemodynamics [mean arterial pressure (MAP); heart rate (HR)], recovery parameters and complications were recorded. The results of the present study indicated that the addition of desflurane significantly reduced the amount of propofol and remifentanil that was administered in the PRD group, compared with that in the PR group. MAP and HR were significantly higher at T3 (5 min post-pneumoperitoneum), but significantly lower at T4 (removal of pneumoperitoneum needle) and T5 (post-operation immediately) in the PR group, compared with the PRD group. Moreover, MAP and HR were significantly altered at multiple time points within the PR group; however, they were relatively stable in the PRD group. There were no significant differences in the recovery parameters and complications between the two groups. In conclusion, combining low-dose desflurane with PR may represent an efficient anesthesia regimen to prevent the hemodynamic instability of TIVA in patients undergoing laparoscopic gynecological surgery.

Dexmedetomidine-remifentanil vs propofol-remifentanil for monitored anesthesia care during hysteroscopy: Randomized, single-blind, controlled trial

BACKGROUND

Although dexmedetomidine has been used as either the anesthetic agent for light sedation or as an adjunct to other sedatives, no study has investigated the usefulness of dexmedetomidine as the main sedative agent for invasive and painful procedures. The purpose of this study was to compare the safety of dexmedetomidine-remifentanil and propofol-remifentanil during monitored anesthesia care (MAC) for hysteroscopy.

METHODS

Female patients undergoing hysteroscopy were randomly assigned to either the dexmedetomidine (group D) or the propofol group (group P). The study drug (0.6 ml/kg; dexmedetomidine 2 μg/ml or propofol 4 mg/ml) was loaded for 10 minutes followed by 0.1 to 0.5 ml/kg/hour to maintain a bispectral index of 60 to 80 during the procedure. In both groups, remifentanil was infused using a target-controlled-infusion system with a target concentration of 2 ng/ml and titrated during the procedure. The incidence rates of intraoperative respiratory depression in both groups were compared. Postoperative pain and patients satisfaction were also compared.

RESULTS

A total of 69 female patients were included in this study. Dexmedetomidine significantly decrease the incidence of respiratory depression compared with propofol (15/34 [44.1%] vs 5/35 [14.3%], P = .006, group P and D, respectively). Postoperative pain and patients satisfaction score did not differ between the groups.

CONCLUSION

The combination of dexmedetomidine-remifentanil can reduce the incidence of respiratory depression without increasing hemodynamic complications compared with propofol-remifentanil for MAC during hysteroscopy.

Antinociceptive effects of magnesium sulfate for monitored anesthesia care during hysteroscopy: a randomized controlled study

Background

Opioids are the most effective antinociceptive agents, they have undesirable side effects such as respiratory depressant and postoperative nausea and vomiting. The purpose of the study was to evaluate the antinociceptive efficacy of adjuvant magnesium sulphate to reduce intraoperative and postoperative opioids requirements and their related side effects during hysteroscopy.

Methods

Seventy patients scheduled for hysteroscopy were randomly divided into 2 groups. Patients in the magnesium group (Group M) received intravenous magnesium sulfate 50 mg/kg in 100 ml of isotonic saline over 15 min before anesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (Group C) received an equal volume of isotonic saline as placebo. All patients were anesthetized under a BIS guided monitored anesthesia care with propofol and fentanyl. Intraoperative hemodynamic variables were recorded and postoperative pain scores were assessed with verbal numerical rating scale (VNRS) 1 min, 15 min, 30 min, 1 h, and 4 h after recovery of consciousness. The primary outcome of our study was total amount of intraoperative and postoperative analgesics administered.

Results

Postoperative serum magnesium concentrations in Group C were significantly decreased than preoperative levels (0.86 ± 0.06 to 0.80 ± 0.08 mmol/L, P = 0.001) while there was no statistical change in Group M (0.86 ± 0.07 to 0.89 ± 0.07 mmol/L, P = 0.129). Bradycardia did not occur in either group and the incidence of hypotension was comparable between the two groups. Total dose of fentanyl given to patients in Group M was less than the one administered to Group C [100 (75–150) vs 145 (75–175) μg, median (range); P < 0.001]. In addition, patients receiving magnesium displayed lower VNRS scores at 15 min, 30 min, 1 h, and 4 h postoperatively.

Conclusions

In hysteroscopy, adjuvant magnesium administration is beneficial to reduce intraoperative fentanyl requirement and postoperative pain without cardiovascular side effects. Our study indicates that if surgical patients have risk factors for hypomagnesemia, assessing and correcting magnesium level will be necessary.

Trial registration

ChiCTR1900024596. date of registration: July 18th 2019.

Comparison of Fentanyl, Remifentanil, Sufentanil and Alfentanil in Combination with Propofol for General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Opioid analgesics are commonly used along with propofol during general anesthesia. Due to the dearth of data on the quality of anesthesia achieved with this combination, the present meta-analysis was carried out.

METHODS

Electronic databases were searched for appropriate studies using a suitable search strategy. Randomized clinical trials comparing the combination of remifentanil/sufentanil/alfentanil with propofol with fentanyl and propofol, were included. The outcome measures were as follows: total propofol dose to achieve the desired general anesthesia; time of onset and duration of general anesthesia; depth of general anesthesia; and recovery time (time for eye-opening and time taken for extubation). Risk of bias was assessed and Forest plots were generated for eligible outcomes. The weighted mean difference [95% confidence intervals] was used as the effect estimate.

RESULTS

Fourteen studies were included in the systematic review and 13 were included in the metaanalysis. Statistically significant differences were observed for remifentanil in comparison to fentanyl when combined with propofol: Propofol dose (in mg) -76.18 [-94.72, -57.64]; time of onset of anesthesia (min) -0.44 [-0.74, -0.15]; time taken for eye-opening (min) -3.95 [-4.8, -3.1]; and time for extubation (min) -3.53 [-4.37, -2.7]. No significant differences were observed for either sufentanil or alfentanil about the dose of propofol required and due to scanty data, pooling of the data could not be attempted for other outcome measures for either sufentanil or alfentanil.

CONCLUSION

To conclude, we found that remifentanil has a statistically significant anesthetic profile than fentanyl when combined with propofol. Scanty evidence for both alfentanil and sufentanil precludes any such confirmation.

Hysteroscopic polypectomy: a comparison between 22 Fr and 26 Fr resectoscopes under paracervical block anesthesia, a randomized controlled study

Objective: The aim of this study was to compare 22 Fr unipolar resectoscope with the traditional 26 Fr unipolar resectoscope in endometrial polypectomy performed under paracervical block anesthesia. Methods: The trial took place in Gynecologic Unit, Department of Surgery, Tor Vergata University Hospital, Rome. Inclusion criteria were: diagnosis of endometrial polyps <3 cm at office hysteroscopy; agreement of patients to perform surgery under paracervical block anesthesia but not in office setting. Patients with ASA physical status classes III or more and with contraindication to operative hysteroscopy were excluded. Before the procedure, the recruited patients were randomly assigned to two groups, 35 to the 22 Fr unipolar resectoscope group (group A) and 35 to the 26 Fr unipolar resectoscope group (group B). Primary endpoint was the time spent for cervical dilatation and resection. Secondary endpoints were pain during and after surgery, efficacy of paracervical block, use of analgesic drugs during and after the procedure, patients' satisfaction, correlation between pain and menopause or parity. Statistical analysis was performed by the SPSS software, and the tests used were Pearson Chi-Square, One-way ANOVA and Mann-Whitney test. A p value <.05 was considered significant. Results: The mean time for cervical dilatation was two minutes in group A (26 Fr) and five minutes in group B (22 Fr, p = .001). Operative mean time was four minutes in group A and seven minutes in group B (p = .001). Pain during dilatation was analogous (VAS = 6, p = .054), while during the procedure it was higher in group B (VAS = 1 vs VAS = 2, p = .003). Sufentanil was administered during resection in 19 patients of group A and in 22 patients of group B (p = .754). General anesthesia was never necessary. Postoperative pain was higher in group B (p = .01). Nine patients of group B needed analgesics, as opposed to no patient of group A (p = .002). Conclusions: The 22 Fr unipolar resectoscope appears advantageous compared to the 26 Fr resectoscope in the resection of endometrial polyps <3 cm, in terms of cervical dilatation and operative time, pain and need of postoperative analgesics. Paracervical block is useful and safe in compliant patients at high risk for general anesthesia.

Inguinal hernia repair in day surgery: the role of MAC (Monitored Anesthesia Care) with remifentanil

BACKGROUND

The extension of indications for procedures in a Day Surgery (DS) setting has led to changes in the anesthetic and surgical treatment of Inguinal Hernias (IH). According to the recommendations of the European Hernia Society, the treatment of IH in DS units should be performed under Monitored Anesthesia Care (MAC).

PATIENTS AND METHODS

960 patients underwent IH repairs over a period of 24 months. The patients were randomly divided into two groups: R (remifentanil) and F (fentanyl); the group F was considered as a control group. The exclusion criteria in both group were: morbid obesity (BMI>40 or BMI>35 in association with high blood pressure or diabetes); coagulopathy; OSAS (obstructive sleep apnea syndrome) with AHI >10; cardiovascular, respiratory, renal, hepatic or metabolic disease; history of substances abuse; GERD-related esophagitis (gastro-esophageal reflux disease); chronic analgesic use; allergy to local anesthetic and ASA>III. Patients reported their level of pain on a verbal numeric scale (VNS), with scores ranging from 0 to 10. For each patient systolic and diastolic blood pressure (SBP and DBP), mean arterial pressure (MAP), heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded. The results are presented as the mean value ± standard deviations; statistical analysis was performed using Student's t-test.

RESULTS

Amongst the 960 procedures, complications or side effects related to the anesthetic techniques didn't occur; no procedure-related complications requiring mechanical ventilation support were reported. Our research focused on evaluating remifentanil effectiveness in pain control and its impact on hemodynamic stability and respiratory function. There was a significant difference between the two groups with regard to the VNS.

CONCLUSIONS

Remifentanil, is an excellent drug for pain control during intra-operative procedures, that allows an optimal hemodynamic stability for IH repairs in a DS setting, due to its pharmacokinetic and pharmacodynamic properties and few adverse effects.

Anesthesia for stem cell transplantation in autistic children: A prospective, randomized, double-blind comparison of propofol and etomidate following sevoflurane inhalation

The objective of the present study was to comparatively investigate the feasibility and safety of etomidate and propofol use following sevoflurane inhalation in autistic children during the intrathecal transplantation of stem cells. The patients selected were 60 autistic children with American Society of Anesthesiologists physical status I, who were aged between two and 12 years and scheduled for stem cell transplantation. The children received an inhalation induction of 8% sevoflurane, followed by intravenous injection of etomidate (0.2 mg/kg) in group E and propofol (2 mg/kg) in group P (n=30/group). Supplemental doses of 0.1 mg/kg etomidate or 1 mg/kg propofol were used until a deep sedation was obtained. The heart rate (HR), mean arterial pressure, oxygen saturation, respiratory rate, Ramsay sedation score (RSS) and recovery time were monitored continuously. Following anesthesia, blood pressure and HR measurements were significantly decreased in group P compared with the baseline (P<0.01) and group E values at the same time-points (P<0.05). The occurrence of adverse effects, such as respiratory depression, bradycardia, hypotension and pain on injection, was significantly higher in group P than that in group E, whereas the incidence of myoclonus in group E was significantly higher than that in group P (P<0.01). No significant differences in anesthesia induction, surgery duration, recovery time, RSS and physician satisfaction were observed between the two groups. In conclusion, sevoflurane-etomidate combinations resulted in more stable hemodynamic responses and relatively fewer adverse effects compared with propofol injection following sevoflurane inhalation and may therefore be more suitable for the induction of short-term anesthesia in autistic children during stem cell transplantation.

A prospective, randomized controlled trial of conscious sedation using propofol combined with inhaled nitrous oxide for dental treatment

PURPOSE

Adverse reactions during propofol sedation include a decrease in arterial blood pressure, propofol-induced pain on injection, and airway complications. The purpose of this study was to investigate whether combined use of intravenous propofol and inhaled nitrous oxide could decrease the hypotensive and other adverse effects of propofol.

PATIENTS AND METHODS

We designed and implemented a prospective, randomized controlled trial. Patients undergoing dental procedures requiring intravenous sedation were randomly allocated to 2 groups: group P comprised those receiving sedation with propofol alone, and group N+P comprised those receiving sedation with 40% nitrous oxide inhalation and propofol. During the dental procedures, the sedation level was maintained at an Observer's Assessment of Alertness/Sedation scale score of 4 by adjusting propofol's target plasma concentration. Nitrous oxide inhalation was the predictor variable, whereas the hemodynamic changes, amount and concentration of propofol, and adverse events were the outcome variables.

RESULTS

Eighty-eight patients were successfully analyzed without any complications. The total amount of propofol was significantly less in group N+P (249.8 ± 121.7 mg) than in group P (310.3 ± 122.4 mg) (P = .022), and the mean concentration of propofol was significantly less in group N+P (1.81 ± 0.34 μg/mL) than in group P (2.05 ± 0.44 μg/mL) (P = .006). The mean blood pressure reduction in group N+P (11.0 ± 8.0 mm Hg) was significantly smaller than that in group P (15.8 ± 10.2 mm Hg) (P = .034). Pain associated with the propofol injection and memory of the procedure were less in group N+P (P = .011 and P = .048, respectively). Nitrous oxide did not affect respiratory conditions or recovery characteristics.

CONCLUSIONS

The results of this study suggest that nitrous oxide inhalation combined with propofol sedation attenuates the hypotensive effect and pain associated with propofol injections, along with potentiating the amnesic effect.

Comparison between monitored anesthesia care with remifentanil under ilioinguinal hypogastric nerve block and spinal anesthesia for herniorrhaphy

Background

The use of monitored anesthesia care (MAC) as the technique of choice for a variety of invasive or noninvasive procedures is increasing. The purpose of this study to compare the outcomes of two different methods, spinal anesthesia and ilioinguinal-hypogastric nerve block (IHNB) with target concentrated infusion of remifentanil for inguinal herniorrhaphy.

Methods

Fifty patients were assigned to spinal anesthesia (Group S) or IHNB with MAC group (Group M). In Group M, IHNB was performed and the effect site concentration of remifentanil, starting from 2 ng/ml, was titrated according to the respiratory rate or discomfort, either by increasing or decreasing the dose by 0.3 ng/ml. The groups were compared to assess hemodynamic values, oxygen saturation, bispectral index (BIS), observer assessment alertness/sedation scale (OAA/S), visual analogue scale (VAS) for pain score and patients' and surgeon's satisfaction.

Results

BIS and OAA/S were not significantly different between the two groups. Hemodynamic variables were stable in Group M. Thirteen patients in the same group showed decreased respiratory rate without desaturation, and recovered immediately by encouraging taking deep breaths without the use of assist ventilation. Although VAS in the ward was not significantly different between the two groups, interestingly, patients' and surgeon's satisfaction scores (P = 0.0004, P = 0.004) were higher in Group M. The number of the patients who suffered from urinary retention was higher in Group S (P = 0.0021).

Conclusions

IHNB under MAC with remifentanil is a useful method for inguinal herniorrhaphy reflecting hemodynamic stability, fewer side effects and higher satisfaction. This approach can be applied for outpatient surgeries and patients who are unfit for spinal anesthesia or general anesthesia.

Comparison between local anaesthesia with remifentanil and total intravenous anaesthesia for operative hysteroscopic procedures in day surgery

BACKGROUND

This study aimed at comparing total i.v. anaesthesia (TIVA) with monitored anaesthesia care (MAC) during day-surgery operative hysteroscopy regarding: operation time, time to mobilization and discharge, and patient satisfaction.

METHODS

Ninety-one healthy women were randomized to MAC with paracervical local anaesthesia and remifentanil or to TIVA with propofol and remifentanil. Time from arrival to leaving the operating theatre, time from arrival in the recovery room to mobilization and discharge readiness, and patient satisfaction with MAC and TIVA were observed.

RESULTS

Time from arrival to leaving the operating theatre showed no significant difference between groups (P=0.6). The time to mobilization {MAC: 53 min [inter-quartile range (IQR) 40-83], TIVA: 69 min (IQR 52-96) (P=0.017)} and the total time from arrival to discharge readiness [MAC: 118 min (IQR 95-139), TIVA: 138 (IQR 120-158) (P=0.0009)] were significantly reduced for patients in the MAC group. More patients in the MAC group 45 (91.8%) than in the TIVA group 24 (64.9%) responded positively to the question: would you like to receive the same kind of anaesthesia for a similar procedure in the future? (P=0.003).

CONCLUSIONS

Paracervical local anaesthesia combined with remifentanil is suitable for operative hysteroscopy in day surgery.

Office based--is my anesthetic care any different? Assessment and management

Office-based anesthesia (OBA) is a unique and challenging venue, and, although the clinical outcomes have not been evaluated extensively, existing data indicate a need for increased regulation and additional education. Outcomes in OBA can be improved by education not only of anesthesiologists but also of surgeons, proceduralists, and nursing staff. Legislators must be educated so that appropriate regulations are instituted governing the practice of office-based surgery and the lay public must be educated to make wise, informed decisions about choice of surgery location. The leadership of societies, along with support from the membership, must play a key role in this educational process; only then can OBA become as safe as the anesthesia care in traditional venues.