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Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, de Boer HD, Sorbello M, Jankovic R, Kranke P. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2023; 40:82-94. [PMID: 36377554 DOI: 10.1097/eja.0000000000001769] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n = 24 000) to the finally relevant clinical studies ( n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).
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Affiliation(s)
- Thomas Fuchs-Buder
- From the Department of Anaesthesiology, Intensive Care and Peri-operative Medicine, CHRU de Nancy, Nancy, France (TF-B), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (C-S.R), Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany (HL), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AA), Department of Anaesthesiology & Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (A-MH), Department of Anesthesiology, CUB Hôpital Erasme, Bruxelles, Belgium (DS), Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany (JH), Department of Anesthesia and Intensive Care, Hôpital Bichat-Claude Bernard, Université de Paris, Paris, France (DL), Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospitals of Wuerzburg, Wuerzburg, Germany (MP, PK), Department of Anesthesiology Pain Medicine & Procedural Sedation and Analgesia Martini General Hospital Groningen, Groningen, The Netherlands (HDDB), Anesthesia and Intensive Care, AOU Policlinico - San Marco, Catania, Italy (MS), Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia (RJ)
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Mitos G, Thoma G, Tsaousi G. Propofol/Fentanyl/Rocuronium or Sevoflurane Inhalational Induction for Intubation? Cureus 2021; 13:e19510. [PMID: 34912647 PMCID: PMC8666135 DOI: 10.7759/cureus.19510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Anesthesia induction and airway instrumentation are critical parts of anesthesia administration. Intravenous induction is time convenient but necessitates immediate commencement of ventilation. Inhalational sevoflurane induction takes longer but preserves spontaneous respiration. The primary aim of this study is to evaluate the intubation quality features achieved by sevoflurane as the sole induction agent compared with the standard intravenous induction, involving the use of muscle relaxants. Methods Sixty patients were randomly allocated into two groups: the Inhalational Vital Capacity Induction With Sevoflurane (IVCIS) group (n = 30) in which patients were intubated after sevoflurane inhalational anesthesia with the vital capacity technique and the Standard Intravenous Induction With Propofol, Fentanyl, and Rocuronium (SIPFR) group (n = 30) after propofol 1.5 mg/kg, fentanyl 2 μg/kg, and rocuronium 0.5 mg/kg administration intravenously. Group IVCIS patients were intubated when bispectral index (BIS) < 60 and end-expiratory sevoflurane ≥ 2 minimum alveolar concentration for > eight minutes. Scoring systems were used to evaluate induction and intubation conditions. The Statistical Package for the Social Sciences (SPSS) software version 25.0 (IBM Corp., Armonk, NY) was used for data analysis. Results Intubating and induction conditions were of equal quality in both groups. Sevoflurane induction duration was markedly prolonged. Heart rate was higher in IVCIS group patients throughout the induction, especially during laryngoscopy. Less blood pressure fluctuations were recorded in IVCIS group patients. Conclusions Inhalational vital capacity induction with sevoflurane provided acceptable intubating conditions and exhibited a safe hemodynamic profile, albeit the duration was more than 12 minutes.
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Affiliation(s)
- Giakoumis Mitos
- Anesthesiology, G. Papanikolaou General Hospital, Thessaloniki, GRC
| | - Giannoula Thoma
- Intensive Care Unit, St. Paul General Hospital, Thessaloniki, GRC
| | - Georgia Tsaousi
- Clinic of Anesthesiology and Intensive Care, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
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Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
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Lundstrøm L, Duez C, Nørskov A, Rosenstock C, Thomsen J, Møller A, Strande S, Wetterslev J. Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review. Br J Anaesth 2018; 120:1381-1393. [DOI: 10.1016/j.bja.2017.11.106] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 10/15/2017] [Accepted: 11/15/2017] [Indexed: 12/20/2022] Open
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Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, Strande S, Wetterslev J. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. Cochrane Database Syst Rev 2017; 5:CD009237. [PMID: 28513831 PMCID: PMC6481744 DOI: 10.1002/14651858.cd009237.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tracheal intubation during induction of general anaesthesia is a vital procedure performed to secure a patient's airway. Several studies have identified difficult tracheal intubation (DTI) or failed tracheal intubation as one of the major contributors to anaesthesia-related mortality and morbidity. Use of neuromuscular blocking agents (NMBA) to facilitate tracheal intubation is a widely accepted practice. However, because of adverse effects, NMBA may be undesirable. Cohort studies have indicated that avoiding NMBA is an independent risk factor for difficult and failed tracheal intubation. However, no systematic review of randomized trials has evaluated conditions for tracheal intubation, possible adverse effects, and postoperative discomfort. OBJECTIVES To evaluate the effects of avoiding neuromuscular blocking agents (NMBA) versus using NMBA on difficult tracheal intubation (DTI) for adults and adolescents allocated to tracheal intubation with direct laryngoscopy. To look at various outcomes, conduct subgroup and sensitivity analyses, examine the role of bias, and apply trial sequential analysis (TSA) to examine the level of available evidence for this intervention. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, LILACS, advanced Google, CINAHL, and the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and www.centerwatch.com, up to January 2017. We checked the reference lists of included trials and reviews to look for unidentified trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared the effects of avoiding versus using NMBA in participants 14 years of age or older. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. We conducted random-effects and fixed-effect meta-analyses and calculated risk ratios (RRs) and their 95% confidence intervals (CIs). We used published data and data obtained by contacting trial authors. To minimize the risk of systematic error, we assessed the risk of bias of included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied TSA. MAIN RESULTS We identified 34 RCTs with 3565 participants that met our inclusion criteria. All trials reported on conditions for tracheal intubation; seven trials with 846 participants described 'events of upper airway discomfort or injury', and 13 trials with 1308 participants reported on direct laryngoscopy. All trials used a parallel design. We identified 18 dose-finding studies that included more interventions or control groups or both. All trials except three included only American Society of Anesthesiologists (ASA) class I and II participants, 25 trials excluded participants with anticipated DTI, and obesity or overweight was an excluding factor in 13 studies. Eighteen trials used suxamethonium, and 18 trials used non-depolarizing NMBA.Trials with an overall low risk of bias reported significantly increased risk of DTI with no use of NMBA (random-effects model) (RR 13.27, 95% CI 8.19 to 21.49; P < 0.00001; 508 participants; four trials; number needed to treat for an additional harmful outcome (NNTH) = 1.9, I2 = 0%, D2 = 0%, GRADE = moderate). The TSA-adjusted CI for the RR was 1.85 to 95.04. Inclusion of all trials resulted in confirmation of results and of significantly increased risk of DTI when an NMBA was avoided (random-effects model) (RR 5.00, 95% CI 3.49 to 7.15; P < 0.00001; 3565 participants; 34 trials; NNTH = 6.3, I2 = 70%, D2 = 82%, GRADE = low). Again the cumulative z-curve crossed the TSA monitoring boundary, demonstrating harmful effects of avoiding NMBA on the proportion of DTI with minimal risk of random error. We categorized only one trial reporting on upper airway discomfort or injury as having overall low risk of bias. Inclusion of all trials revealed significant risk of upper airway discomfort or injury when an NMBA was avoided (random-effects model) (RR 1.37, 95% CI 1.09 to 1.74; P = 0.008; 846 participants; seven trials; NNTH = 9.1, I2 = 13%, GRADE = moderate). The TSA-adjusted CI for the RR was 1.00 to 1.85. None of these trials reported mortality. In terms of our secondary outcome 'difficult laryngoscopy', we categorized only one trial as having overall low risk of bias. All trials avoiding NMBA were significantly associated with difficult laryngoscopy (random-effects model) (RR 2.54, 95% CI 1.53 to 4.21; P = 0.0003; 1308 participants; 13 trials; NNTH = 25.6, I2 = 0%, D2= 0%, GRADE = low); however, TSA showed that only 6% of the information size required to detect or reject a 20% relative risk reduction (RRR) was accrued, and the trial sequential monitoring boundary was not crossed. AUTHORS' CONCLUSIONS This review supports that use of an NMBA may create the best conditions for tracheal intubation and may reduce the risk of upper airway discomfort or injury following tracheal intubation. Study results were characterized by indirectness, heterogeneity, and high or uncertain risk of bias concerning our primary outcome describing difficult tracheal intubation. Therefore, we categorized the GRADE classification of quality of evidence as moderate to low. In light of defined outcomes of individual included trials, our primary outcomes may not reflect a situation that many clinicians consider to be an actual difficult tracheal intubation by which the patient's life or health may be threatened.
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Affiliation(s)
- Lars H Lundstrøm
- Nordsjællands HospitalDepartment of AnaesthesiologyHillerødDenmark3400
| | | | - Anders K Nørskov
- Nordsjællands HospitalDepartment of AnaesthesiologyHillerødDenmark3400
| | | | - Jakob L Thomsen
- Herlev Hospital, University of CopenhagenDepartment of AnaesthesiologyHerlevDenmark
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenThe Cochrane Anaesthesia, Critical and Emergency Care GroupHerlev RingvejHerlevDenmark2730
| | - Søren Strande
- Gentofte HospitalDepartment of Anaesthesiology and Intensive CareKildegårdsvej 28HellerupCopenhagenDenmark2900
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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González Obregón MP, Rivera Díaz RC, Ordóñez Molina JE, Rivera Díaz JS, Velásquez Ossa LF, Pineda Ibarra C, Serna Gutiérrez J, Franco Botero V. [Tracheal intubation quality under remifentanil-propofol with sevoflurane compared with remifentanil-propofol with rocuronium: a randomized double-blind clinical trial]. ACTA ACUST UNITED AC 2010; 57:351-6. [PMID: 20645486 DOI: 10.1016/s0034-9356(10)70247-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether intubation conditions under remifentanil-propofol plus sevoflurane rather than a nondepolarizing neuromuscular blocker are similar to those obtained when a neuromuscular blocker is used. MATERIAL AND METHODS In this double-blind controlled trial, 100 patients undergoing outpatient surgery were randomized to 2 groups. Intubation in one group was performed under remifentanil, propofol and sevoflurane. In the other, intubation was performed under remifentanil, propofol, and the nondepolarizing neuromuscular blocker rocuronium. We recorded dysphonia at 24 hours, Cormack-Lehane classification at laryngoscopy, mandibular relaxation, vocal cord position and mobility, and cough or movement during laryngoscopy, on intubation and on cuff inflation. Blood pressure and heart rate before and after tracheal intubation were also recorded. RESULTS No significant between-group differences were observed in dysphonia 24 hours after surgery, Cormack-Lehane classification at laryngoscopy, mandibular relaxation, the position or mobility of vocal cords, or cough or movement during laryngoscopy, intubation or cuff inflation. After intubation the mean (SD) systolic blood pressure was 119.7 (75.4) mm Hg in the rocuronium group and 97.5 (54.5) mm Hg in the sevoflurane group. Mean heart rate was 80.7 beats/min in the rocuronium group and 66.7 beats/min in the sevoflurane group. The differences were significant (P < .05). CONCLUSIONS Adequate doses of remifentanil, propofol, and sevoflurane provide intubation conditions that are similar to those achieved by using a nondepolarizing neuromuscular blocker, without exposing patients to additional risk. Avoiding use of a neuromuscular blocker would circumvent the development of complications associated with use of these agents or their antagonists and costs would be lower.
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MESH Headings
- Adult
- Androstanols/administration & dosage
- Androstanols/adverse effects
- Androstanols/pharmacology
- Anesthesia, Inhalation
- Anesthesia, Intravenous
- Anesthetics, Combined/administration & dosage
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Inhalation/adverse effects
- Anesthetics, Inhalation/pharmacology
- Anesthetics, Intravenous/administration & dosage
- Anesthetics, Intravenous/adverse effects
- Anesthetics, Intravenous/pharmacology
- Cough/etiology
- Double-Blind Method
- Dysphonia/etiology
- Female
- Hemodynamics/drug effects
- Humans
- Intubation, Intratracheal/adverse effects
- Male
- Methyl Ethers/administration & dosage
- Methyl Ethers/adverse effects
- Methyl Ethers/pharmacology
- Middle Aged
- Neuromuscular Nondepolarizing Agents/administration & dosage
- Piperidines/administration & dosage
- Piperidines/adverse effects
- Piperidines/pharmacology
- Propofol/administration & dosage
- Propofol/adverse effects
- Propofol/pharmacology
- Remifentanil
- Rocuronium
- Sevoflurane
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Oh HJ, Kim YH, Lee JU. The optimal effect site concentration of remifentanil for tracheal intubation without muscle relaxant during inhalation anesthetic induction using sevoflurane in adult. Korean J Anesthesiol 2009; 56:639-645. [PMID: 30625803 DOI: 10.4097/kjae.2009.56.6.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sevoflurane has been shown to be suitable for inhalation induction of anesthesia in adults. The addition of remifentanil during sevoflurane induction allows for rapid and smooth tracheal intubation without muscle relaxant. The high concentration of remifentanil can result in improved conditions for tracheal intubation but also caused a cardiovascular instability. We tried to estimate optimal effect site concentration of remifentanil for tracheal intubation without muscle relaxants during inhalation anesthetic induction with 8 vol% sevoflurane and 50% N2O. METHODS One hundred five ASA I and II patients were randomly allocated to receive an effect site concentration of remifentanil 2, 4, or 6 ng/ml. Trachea was intubated without muscle relaxant after 3 minutes of inhalation induction with 8 vol% sevoflurane and 50% N2O. The intubating conditions for tracheal intubation were assessed and blood pressure and heart rate were recorded at the baseline, before intubation, just after intubation, 1, and 3 minute after intubation. RESULTS Tracheal intubation was successful in all patients. Clinically acceptable intubation conditions were 60%, 94%, and 100% in 2 ng/ml, 4 ng/ml, and 6 ng/ml group respectively. However, the number of patient who requested rescue medication for bradycardia in 6 ng/ml group was significantly higher than that in the other group (P < 0.05). CONCLUSIONS We concluded that 4 ng/ml effect site concentration of remifentanil is adequate concentration for tracheal intubation without muscle relaxants during inhalation induction using sevoflurane.
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Affiliation(s)
- Hyun Jin Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea.
| | - Yoon Hee Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea.
| | - Jung Un Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea.
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Kim JY, Kwak YL, Lee KC, Chang YJ, Kwak HJ. The optimal bolus dose of alfentanil for tracheal intubation during sevoflurane induction without neuromuscular blockade in day-case anaesthesia. Acta Anaesthesiol Scand 2008; 52:106-10. [PMID: 17976223 DOI: 10.1111/j.1399-6576.2007.01477.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to determine the optimal bolus dose of alfentanil required to provide successful intubating conditions following inhalation induction of anaesthesia using 5% sevoflurane and 60% nitrous oxide without neuromuscular blockade in adult day-case anaesthesia. METHODS Twenty-four adults, aged 18-60 years, undergoing general anaesthesia for short ambulatory surgery were enroled into the study. After vital capacity induction, with sevoflurane 5% and 60% nitrous oxide in oxygen, pre-determined dose of alfentanil was injected over 30 s. The dose of alfentanil was determined by modified Dixon's up-and-down method (2 microg/kg as a step size). Ninety seconds after the end of bolus administration of alfentanil, the trachea was intubated. Systolic blood pressure, heart rate and SpO2 were recorded at anaesthetic induction, before, 1 min and 3 min after intubation. RESULTS The bolus dose of alfentanil for successful tracheal intubation was 10.7+/-2.1 microg/kg in 50% of patients during inhalation induction. From probit analysis, 50% effective dose (ED(50)) and ED(95) values (95% confidence limits) of alfentanil were 10.7 microg/kg (8.0-12.9 microg/kg) and 14.9 microg/kg (12.9-31.1 microg/kg), respectively. CONCLUSIONS Using the modified Dixon's up-and-down method, the bolus dose of alfentanil for successful tracheal intubation was 10.7+/-2.1 microg/kg in 50% of adult patients during inhalation induction using 5% sevoflurane and 60% nitrous oxide in oxygen without neuromuscular blocking agent in day-case anaesthesia.
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Affiliation(s)
- J Y Kim
- Department of Anaesthesiology and Pain Medicine, Gachon University of Medicine and Science, Gil Medical Center, Incheon, Korea
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9
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Sztark F, Chopin F, Bonnet A, Cros AM. Concentration of remifentanil needed for tracheal intubation with sevoflurane at 1 MAC in adult patients. Eur J Anaesthesiol 2005; 22:919-24. [PMID: 16318662 DOI: 10.1017/s0265021505001560] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2005] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Inhalation induction with sevoflurane provides acceptable conditions for tracheal intubation. Opioids significantly decrease the alveolar concentration needed to achieve tracheal intubation. The purpose of this study was to determine the target concentration of remifentanil providing excellent conditions for tracheal intubation with sevoflurane at 1 minimum alveolar concentration without muscle relaxant. METHODS Twenty-four consecutive patients, aged 18-50 yr, ASA I or II, were studied. Induction of anaesthesia was performed with sevoflurane at age-adjusted minimum alveolar concentration. Remifentanil was simultaneously administered using target-controlled infusion with the Minto model. Target plasma concentration of remifentanil was selected for each patient according to an up-and-down method. RESULTS The mean target concentration of remifentanil for successful tracheal intubation was 3.3 ng mL(-1) (95% confidence interval: 2.6-3.9 ng mL(-1)). Arterial pressure, heart rate and bispectral index did not increase after tracheal intubation in the group of patients with successful intubation. CONCLUSIONS Remifentanil at 3.3 ng mL(-1) together with sevoflurane at 1 minimum alveolar concentration provides excellent conditions for tracheal intubation in 50% of patients.
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Affiliation(s)
- F Sztark
- Centre Hospitalier Universitaire Pellegrin, Département d'Anesthésie-Réanimation I, Bordeaux, France.
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Alpiger S, Helbo-Hansen HS, Vach W, Ording H. Efficacy of A-line AEP Monitor as a tool for predicting acceptable tracheal intubation conditions during sevoflurane anaesthesia. Br J Anaesth 2005; 94:601-6. [PMID: 15749734 DOI: 10.1093/bja/aei111] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND It is essential for the clinical anaesthetist to know whether patients are sufficiently anaesthetized to tolerate direct laryngoscopy and endotracheal intubation. Because of the lack of an accurate objective method to determine the level of general anaesthesia, under- or overdosing of anaesthetics may occur. Auditory evoked potential (AEP) is one of several physiological parameters under investigation. We aimed to determine the clinically required depth of anaesthesia, measured by the A-line AEP Monitor and expressed as A-Line ARX Index (AAI) for 90% probability of acceptable conditions for endotracheal intubation. METHODS We studied 108 patients anaesthetized by mask with increasing concentration of sevoflurane in 30% oxygen and 70% nitrous oxide. Fentanyl 1.5 microg kg(-1) and glycopyrrolate 0.2 mg were administered intravenously immediately before starting induction of anaesthesia. The monitor was programmed to give an alarm at AAI 10, 15, 20, 25 or 30 according to randomization. When the alarm sounded, the end-expiratory sevoflurane concentration was registered and endotracheal intubation was attempted. Intubation conditions were assessed by an observer blinded to the AAI. RESULTS At AAI 10 we found acceptable conditions in 91% (confidence interval [CI 72-99%]) of patients. The prediction probability value P(K) of AAI was 0.69 (CI 0.59-0.79) and the P(K) of end-expiratory sevoflurane concentration was 0.93 (CI 0.87-0.99). ED(90) (the AAI with a 90% probability of acceptable intubation conditions) was calculated as 8.5 (CI 0-17.5). CONCLUSIONS AAI indicates the depth of anaesthesia necessary for acceptable endotracheal intubation conditions. Under the conditions of the present study, end-expiratory sevoflurane concentration was a better predictor and may turn out to be more useful in the clinical setting.
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Affiliation(s)
- S Alpiger
- Department of Anaesthesiology, Vejle Hospital, Vejle, Denmark.
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Sufentanil supplementation of sevoflurane during induction of anaesthesia: a randomized study. Eur J Anaesthesiol 2004. [DOI: 10.1097/00003643-200410000-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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