The utility of bispectral index monitoring for prevention of rocuronium-induced withdrawal movement in children: A randomized controlled trial

Effect of injection pain and withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery: a prospective observational study

INTRODUCTION

The experience and perception of pain may vary among individuals.This prospective cohort study aimed to determine the impact of injection pain/withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery.

METHODS

A total of 100 patients aged 19-60 years received propofol and rocuronium injections for the induction of anaesthesia. The incidence of propofol injection pain (PIP) and rocuronium-induced withdrawal movement (RIWM), postoperative pain scores and total opioid consumption were evaluated, and the associations between PIP/RIWM and postoperative pain outcomes were determined.

RESULTS

Visual analogue scale (VAS) for pain after surgery and total opioid consumption after surgery were significantly higher in patients with PIP or RIWM than in patients without PIP or RIWM. The correlations of PIP/RIWM with VAS at 1 h, VAS at 24 h and total opioid consumption were significant and weakly positive ( r = 0.249, r = 0.234, r = 0.22 and r = 0.234, respectively). The RIWM correlated more positively with pain score compared to PIP at 1 h ( r = 0.408 vs. r = 0.234), PIP at 24 h ( r = 0.398 vs. r = 0.227) and with total opioid consumption for 48 h after surgery ( r = 0.457 vs. r = 0.234).

CONCLUSION

During anaesthesia induction, the occurrence of PIP and RIWM may predict the severity of postoperative pain and total opioid consumption, with RIWM emerging as a stronger predictor than PIP.

A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children

The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.

Impact of the Timing of Rocuronium Injection after Propofol Administration on Temporal Summation of Pain in Gynecologic Laparoscopic Surgery: A Prospective and Controlled Study

Purpose

Temporal summation of pain, which is defined as the perception of greater pain evoked by repetitive painful stimuli, varies among individuals. This study aimed at determining the impact of the timing of rocuronium after induction with propofol on the temporal summation of pain.

Methods

One hundred patients aged 19–60 years underwent gynecologic laparoscopic surgery. Patients were randomly assigned to one of the two groups: group PRi received immediate injections of rocuronium after propofol administration and group PRd received rocuronium injections when the bispectral index score (BIS) decreased to <60 after propofol administration. The grade of rocuronium-induced withdrawal movement (RIWM) according to the timing of propofol injection, the incidence and severity of propofol injection pain (PIP), rescue analgesics, visual analog scale (VAS) score after surgery for postoperative pain, patient-controlled analgesia (PCA) opioid consumption, association between PIP and the grade of RIWM, and associations between PIP, the grade of RIWM, and postoperative pain outcomes were measured.

Results

The differences between the incidence and severity of PIP in the two groups were not significant. The grade of the RIWM in the PRd group was significantly reduced compared with the PRi group. Rescue analgesics, severity for postoperative pain, and PCA opioid consumption were not significant. Correlations between the incidence and severity of PIP and the grade of RIWM were weakly negative. Correlations between the grade of RIWM and pain outcomes were moderately positive, but correlations between the severity for PIP and the postoperative pain outcomes were negligible.

Conclusion

The timing of rocuronium administration after propofol injection played a role in reducing RIWM. The grade of RIWM was significantly related to pain outcomes compared with the severity of PIP. Therefore, delayed rocuronium injection after induction with propofol reduced temporal summation of pain.

Effect of neuromuscular blockade on the bispectral index in critically ill patients

INTRODUCTION

It has been suggested that neuromuscular blockade (NMB) affects the capacity of bispectral index (BIS) monitoring to measure consciousness in sedated children. Our aim was to analyse the impact of NMB on BIS values in critically ill children.

METHODS

We conducted a prospective observational study of children monitored with a BIS system that received a continuous infusion of vecuronium. We analysed data on clinical, diagnostic and haemodynamic variables, sedatives, analgesics, muscle relaxants, and BIS parameters. We compared BIS parameters before the use of a muscle relaxant, during its administration, before its discontinuation and for the 24h following the end of the infusion.

RESULTS

The analysis included 35 patients (median age, 30 months). The most common diagnosis was heart disease (85%). The most frequent indication for initiation of NMB was low cardiac output (45%), followed by adaptation to mechanical ventilation (20%). Neuromuscular blockade did not produce a significant change in BIS values. We found a decrease was observed in electromyography (EMG) values at 6h (34.9±9.4 vs 31.2±7; P=.008) and 12h after initiation of NMB (34.9±9.4 vs 28.6±4.8; P =.006). We observed a small significant increase in BIS after discontinuation of NMB (from 42.7±11 to 48.4±14.5, P=.001), and 6 and 12h later (51.3±16.6; P=.015). There were no differences in the doses of sedatives or analgesics except for fentanyl, of which the dose was lowered after discontinuation of vecuronium.

CONCLUSION

Continuous NMB produces small changes on BIS values that are not clinically significant and therefore does not interfere with BIS consciousness monitoring in critically ill children.