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Friedrich S, Raub D, Teja BJ, Neves SE, Thevathasan T, Houle TT, Eikermann M. Effects of low-dose intraoperative fentanyl on postoperative respiratory complication rate: a pre-specified, retrospective analysis. Br J Anaesth 2019; 122:e180-e188. [PMID: 30982564 DOI: 10.1016/j.bja.2019.03.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fentanyl is one of the most frequently administered intraoperative drugs and may increase the risk of postoperative respiratory complications (PRCs). METHODS We performed a pre-specified analysis of 145 735 adult non-cardiac surgical cases under general anaesthesia. Using multivariable logistic regression, we evaluated the association of intraoperative fentanyl dose and PRCs within 3 days after surgery (defined as reintubation, respiratory failure, pneumonia, pulmonary oedema, or atelectasis). We examined effect modification by patient characteristics, surgical site, and anaesthetics used. RESULTS PRCs within 3 days after surgery occurred in 18 839 (12.9%) patients. In comparison with high intraoperative fentanyl doses [median: 3.85; inter-quartile range (IQR): 3.42-4.50 μg kg-1, quartile 4 (Q4)], low intraoperative fentanyl dose [median: 0.80, IQR: 0.00-1.14 μg kg-1, quartile 1 (Q1)] was significantly associated with lower odds of PRCs [Q1 vs Q4: 10.9% vs 16.2%; adjusted odds ratio (aOR) 0.79; 95% confidence intervals (CI) 0.75-0.84; P<0.001; adjusted absolute risk difference (aARD) -1.7%]. This effect was augmented by thoracic surgery (P for interaction <0.001; aARD -6.2%), high doses of inhalation anaesthetics (P for interaction=0.016; aARD -2.2%) and neuromuscular blocking agents (NMBAs) (P for interaction=0.001; aARD -3.4%). Exploratory analysis demonstrated that compared with no fentanyl, low-dose fentanyl was associated with lower rates of PRCs (decile 2 vs decile 1: aOR 0.82, CI 0.75-0.89, P<0.001). CONCLUSIONS Intraoperative low-dose fentanyl (about 60-120 μg for a 70 kg patient) was associated with lower risk of postoperative respiratory complications compared with both no fentanyl and high-dose fentanyl. Beneficial effects of low-dose fentanyl were magnified in specific patient subgroups. CLINICAL TRIAL REGISTRATION NCT03198208.
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Affiliation(s)
- S Friedrich
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D Raub
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B J Teja
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S E Neves
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - T Thevathasan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Universitätsklinikum Essen, Essen, Germany.
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Farhan H, Moreno-Duarte I, McLean D, Eikermann M. Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery? CURRENT ANESTHESIOLOGY REPORTS 2014; 4:290-302. [PMID: 25530723 PMCID: PMC4267566 DOI: 10.1007/s40140-014-0073-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuromuscular blocking agents are used to facilitate tracheal intubation in patients undergoing ambulatory surgery. The use of high-dose neuromuscular blocking agents to achieve muscle paralysis throughout the case carries an increased risk of residual post-operative neuromuscular blockade, which is associated with increased respiratory morbidity. Visually monitoring the train-of-four (TOF) fade is not sensitive enough to detect a TOF fade between 0.4 and 0.9. A ratio <0.9 indicates inadequate recovery. Quantitative neuromuscular transmission monitoring (e.g., acceleromyography) should be used to exclude residual neuromuscular blockade at the end of the case. Residual neuromuscular blockade needs to be reversed with neostigmine, but it's use must be guided by TOF monitoring results since deep block cannot be reversed, and neostigmine administration after complete recovery of the TOF-ratio can induce muscle weakness. The development and use of new selectively binding reversal agents (sugammadex and calabadion) warrants reevaluation of this area of clinical practice.
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Affiliation(s)
- Hassan Farhan
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Ingrid Moreno-Duarte
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Duncan McLean
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
- Universitaet Duisburg-Essen, Essen, Germany
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Murphy LD, Kovacs GJ, Reardon PM, Law JA. Comparison of the King Vision Video Laryngoscope with the Macintosh Laryngoscope. J Emerg Med 2014; 47:239-46. [DOI: 10.1016/j.jemermed.2014.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/30/2013] [Accepted: 02/09/2014] [Indexed: 02/07/2023]
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Manifold CA, Davids N, Villers LC, Wampler DA. Capnography for the nonintubated patient in the emergency setting. J Emerg Med 2013; 45:626-32. [PMID: 23871325 DOI: 10.1016/j.jemermed.2013.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 01/28/2013] [Accepted: 05/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Multiple studies illustrate the benefits of waveform capnography in the nonintubated patient. This type of monitoring is routinely used by anesthesia providers to recognize ventilation issues. Its role in the administration of deep sedation is well defined. Prehospital providers embrace the ease and benefit of monitoring capnography. Currently, few community-based emergency physicians utilize capnography with the nonintubated patient. OBJECTIVE This article will identify clinical areas where monitoring end-tidal carbon dioxide is beneficial to the emergency provider and patient. DISCUSSION Capnography provides real-time data to aid in the diagnosis and patient monitoring for patient states beyond procedural sedation and bronchospasm. Capnographic changes provide valuable information in such processes as diabetic ketoacidosis, seizures, pulmonary embolism, and malignant hyperthermia. CONCLUSIONS Capnography is a quick, low-cost method of enhancing patient safety with the potential to improve the clinician's diagnostic power.
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Affiliation(s)
- Craig A Manifold
- Department of Emergency Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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