Is there a learning curve associated with the use of remifentanil?

Remifentanil-assisted local anaesthesia: application to continence surgery

Remifentanil, an ultrarapid-acting opioid, as an intravenous infusion, generally in combination with a sedative/amnesic (for example midazolam) and local anaesthesia can provide an effective assisted local anaesthetic technique (Remi-ALA) for tension-free vaginal tapes or equivalent continence procedures in urogynaecology. Excellent analgesia for the local anaesthetic injections and tape insertion is provided as well as optimal patient cooperation for clinicians who wish to perform cough testing after tape insertion. Dose-related respiratory depression and, less commonly, bradycardia are possible side-effects, potentially more likely in older women (particularly over 70 years).

Psoas compartment block (PCB) in children: Part II--generation of an institutional learning curve with a new technique

BACKGROUND

Literature concerning institutional learning processes for anesthesia procedures in pediatric anesthesia is rare. Until recently only small series of psoas compartment blocks (PCB) in children have been reported. We report on a series of 100 consecutive blocks using new landmarks and the institutional learning process.

METHODS

In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. Residents unfamiliar with PCB were instructed by one single staff member without manual intervention. Failure was defined as a bloody tap, more than one skin perforation with the needle or relinquishing the procedure to senior staff. To evaluate the institutional learning process the cumulative sum (CUSUM) statistical technique was used. CUSUM analysis was performed using an acceptable failure rate of 10%. A learning curve using a bootstrap technique and a least square fit model was also used.

RESULTS

Although all blocks were clinically successful, only in 64% was a single attempt sufficient. In 16% vascular puncture occurred. Surprisingly the CUSUM analysis showed a clear institutional learning phenomenon. Applying a strict definition for a successful block, more than 100 PCB in an institution may be necessary. Using the generated learning curve, for a success rate of 70% a case load of at least 55 attempts is required.

CONCLUSIONS

Although the described new technique had a very high success rate with a low complication rate, PCB in children is not easily implemented into clinical practice when strict criteria of success were used, despite a well-controlled environment. Training programs could use CUSUM to track the progress of their institutional learning in order to guarantee adequate experience.

Postoperative pain management after supratentorial craniotomy

The aim of this study was to compare the analgesic efficacy of three different postoperative treatments after supratentorial craniotomy. Sixty-four patients were allocated prospectively and randomly into three groups: paracetamol (the P group, n = 8), paracetamol and tramadol (the PT group, n = 29), and paracetamol and nalbuphine (the PN group, n = 27). General anesthesia was standardized with propofol and remifentanil using atracurium as the muscle relaxant. One hour before the end of surgery, all patients received 30 mg/kg propacetamol intravenously then 30 mg/kg every 6 hours. Patients in the PT group received 1.5 mg/kg tramadol 1 hour before the end of surgery. For patients in the PN group, 0.15 mg/kg nalbuphine was injected after discontinuation of remifentanil, because of its mu-antagonist effect. Postoperative pain was assessed in the fully awake patient after extubation (hour 0) and at 1, 2, 4, 8, and 24 hours using a visual analog scale (VAS). Additional tramadol (1.5 mg/kg) or 0.15 mg/kg nalbuphine was administered when the VAS score was > or = 30 mm. Analgesia was compared using the Mantha and Kaplan-Meier methods. Adverse effects of the drugs were also measured. The three groups were similar with respect to the total dose of remifentanil received (0.27 +/- 0.1 mircog/kg/min). In all patients, extubation was obtained within 6 +/- 3 minutes after remifentanil administration. Postoperative analgesia was ineffective in the P group; therefore, inclusions in this group were stopped after the eighth patient. Postoperative analgesia was effective in the two remaining groups because VAS scores were similar, except at hour 1, when nalbuphine was more effective (P = .001). Nevertheless, acquiring such a result demanded significantly more tramadol than nalbuphine (P < .05). More cases of nausea and vomiting were observed in the PT group but the difference was not significant (P < .06). In conclusion, pain after supratentorial neurosurgery must be taken into account, and paracetamol alone is insufficient in bringing relief to the patient. Addition of either tramadol or nalbuphine to paracetamol seems necessary to achieve adequate analgesia, with, nevertheless, a larger dose of tramadol to fulfill this objective.