Bispectral index monitoring (BIS) as a guide for intubation without neuromuscular blockade in office-based pediatric general anesthesia: a retrospective evaluation

Office-based General Anesthesia for a Patient With a History of Neuroleptic Malignant Syndrome

First described in 1956 subsequent to a reaction reported to the newly introduced antipsychotic drug chlorpromazine, neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening reaction to antipsychotic drugs characterized by high fever, muscle rigidity, altered mental status, and autonomic instability. All neuroleptics, including newer antipsychotics, have been linked to this condition. Due to similar symptoms, it is debatable if individuals with NMS can be susceptible to malignant hyperthermia (MH). This case report presents the anesthetic care of a 30-year-old male undergoing general anesthesia in the office-based dental environment. The rationale behind the selected total intravenous anesthesia technique without NMS or MH triggering agents is outlined as well as other agents that may still be questionable regarding their trigger effect for NMS.

Effect of bispectral index-guided total intravenous anesthesia in younger children: A prospective, randomized, controlled trial

BACKGROUND

BIS-guided total intravenous anesthesia (TIVA) is widely used in children, but few studies have attempted to evaluation of the effect of BIS-guided TIVA in younger children. This study aimed to evaluate the effect of bispectral index (BIS) guidance during TIVA in younger children during anesthesia.

METHODS

This study is a prospective, randomized, single-blind and controlled clinical trial. This study enrolled pediatric patients (aged 1-3 years) who were scheduled for surgery under TIVA with propofol and remifentanil. The children were randomly assigned to the BIS group (group B) and standard clinical practice group (group S). The BIS values in group B were maintained at 45-60. The anesthesiologist controlled the depth of anesthesia in group S according to the variation in the clinical signs of the children. The time of extubation, duration of stay in post-anesthesia care unit (PACU), as well as BIS values, heart rate (HR), mean arterial pressure (MAP), pulse oxygen saturation at eight time points 1 min before induction (T1), 1 min after induction (1 min after the induction drugs were administrated) (T2), immediately after intubation (T3), immediately after skin incision (T4), 30 min after the start of the operation (T5), 60 min after the start of operation (T6), immediately after drug withdrawal (T7), and immediately after extubation (T8), propofol consumption, and postoperative adverse reactions were recorded.

RESULTS

There was no significant difference in time to extubation 15(10,21) vs 14 (11,20) and duration of stay in PACU 27 (20,37) vs. 29 (22,39) between the group B and group S. At the time points 30 min after the start of the operation, 60 min after the start of operation and immediately after drug withdrawal, the BIS values in group S were significantly higher than those in group B (57 ± 9, 57 ± 9, 60 ± 8 vs 52 ± 7, 54 ± 7, 57 ± 6).

CONCLUSIONS

The use of BIS-guided total intravenous anesthesia in younger children does not shorten the time of extubation and the duration of stay in the PACU.

TRIAL REGISTRATION

Chictr.org.cn identifier: 24/11/2017, ChiCTR-IOR-17013530.

Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway

Background:

Both nasal and oral routes can be used for fiberoptic intubation. Often it leads to hemodynamic disturbances, which may have a significant effect in patients with limited cardiopulmonary reserve as well as with cerebrovascular diseases.

Aims:

The aim of the study was to evaluate whether there is a clinically relevant difference between the circulatory responses to oral and nasal fiberoptic intubation.

Settings and Design:

This was a prospective, randomized, and comparative study.

Materials and Methods:

In this study, a total of 90 patients with the American Society of Anesthesiologist physical status I and II of either sex in the age group of 18–60 years and having anticipated difficult airway (DA) posted for elective surgery under general anesthesia were randomly allocated into two groups. Patients underwent fiberoptic intubation via either oral or nasal route under sevoflurane anesthesia with bispectral index guidance. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), time taken to intubation, and need of maneuver were measured.

Statistical Analysis Used:

All the analyses were carried out on SPSS 16.0 version (Inc., Chicago, USA). Mean and standard deviation were calculated. The test of analysis between two groups was done by unpaired t-test.

Results:

Demographic and DA characteristics were similar in both the groups. Significantly (P < 0.01) lesser alteration in HR, SBP, DBP, and MAP was seen in oral fiberoptic intubation when compared to nasal fiberoptic intubation in the early phase of postintubation. Time taken to intubation was also significantly (P < 0.01) lesser in the oral route compared to the nasal route.

Conclusions:

Oral fiberoptic intubation causes less hemodynamic alteration and takes less time in comparison to nasal fiberoptic intubation.

Effect of rocuronium on the bispectral index under anesthesia and tracheal intubation

The aim of the present study was to investigate the effect of various doses of rocuronium on bispectral index (BIS) responses to propofol induction and tracheal intubation, as well as the role of the non-depolarization muscle relaxant rocuronium on the depth of sedation. A total of 72 patients (American Society of Anesthesiologists physical status I-II) were anaesthetized with propofol using a target-controlled infusion, and randomly divided into two sedation level groups (n=36). The patients were divided into 2 groups according to the BIS value: A normal sedation group (group 1), with a stable BIS value at 40-60, and a deep sedation group (group 2), with a BIS value <20 or with burst suppression. Each group was randomly divided into 4 subgroups A-D (n=9) according to the various doses of rocuronium (0.3, 0.6, 0.9 and 1.2 mg/kg). Tracheal intubation was performed after 2 min of rocuronium administration. BIS, electromyography (EMG), heart rate (HR) and mean arterial pressure (MAP) were recorded continuously and averaged over 1 min during baseline (T1), steady state (T2), 2 min after rocuronium infusion (T3), and 0, 2 and 5 min after tracheal intubation. The results demonstrated that HR and MAP decreased significantly at T2 and T3 compared with T1. Following tracheal intubation (L0), HR and MAP significantly increased compared with T2 and T3, and returned to levels similar to those prior to intubation after 5 min. In group 1C and 1D, BIS was significantly decreased at T3 compared with T2; BIS was significantly increased at L0 compared with T3 in group 1A and 1B. EMG at earlier stages of anesthesia was significantly higher compared with other points, and was significantly increased at L0 compared with T3 in group 1A and 1B. These results demonstrated that BIS response may be associated with the dosage of rocuronium in the normal sedation group, although no association was observed with the deep sedation group. Tracheal intubation resulted in marked hemodynamic changes under both normal and deep sedation.