Effects of different doses of sufentanil and remifentanil combined with propofol in target-controlled infusion on stress reaction in elderly patients

Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study

BACKGROUND

Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients.

MATERIALS AND METHODS

The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction.

RESULTS

The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%).

CONCLUSIONS

Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.

Effect of additional equipotent fentanyl or sufentanil administration on recovery profiles during propofol-remifentanil-based anaesthesia in patients undergoing gynaecologic laparoscopic surgery: a randomized clinical trial

Background

In clinical practice, sufentanil has a stronger sedative effect on patients than fentanyl at equivalent doses. This study hypothesized that, at equivalent doses, patients undergoing gynaecologic laparoscopic surgery (GLS) receiving fentanyl would have an earlier emergence from anaesthesia (EA), a shorter time to extubation (TE), and a better degree of wakefulness. Therefore, this study evaluated the effects of equipotent doses of fentanyl and sufentanil on the quality of emergence in patients undergoing GLS.

Methods

One hundred seven patients scheduled for GLS under general anaesthesia were randomly divided into two groups and were induced with 0.35 µg/kg sufentanil (Group S; n = 55) or 3.5 µg/kg fentanyl (Group F; n = 52). When the GLS was almost over, the patient's abdominal cavity was flushed with warm saline, and 5 µg of sufentanil or 50 µg of fentanyl in a double-blind manner was intravenously injected into the patients. The primary outcomes of the study included EA, TE, the rate of leaving the surgical bed voluntarily and the incidence of endotracheal tube tolerance. The Ramsay Sedation Scale (RSS), and Verbal Rating Scale (VRS) scores at 15 and 30 min in the postanaesthesia care unit (PACU), as well as other adverse events, including nausea and vomiting, itching, delirium, dizziness, chills, and respiratory depression (SpO₂ < 95%) in the PACU, were evaluated as secondary outcomes.

Results

There were no statistically significant dissimilarities between the two groups with respect to baseline characteristics. For recovery, the EA (9.0 ± 4.8 min vs. 8.9 ± 3.0 min; P = 0. 146), TE (9.5 ± 4.7 min vs. 9.0 ± 3.0 min; P = 0.135), rate of leaving the surgical bed voluntarily (31.18% vs. 38.46%; P = 0.976), and incidence of endotracheal tube tolerance (94.55% vs. 96.15%; P = 0.694) were not significantly different between the two groups. In the PACU, the 15-min RSS score (2.07 ± 0.38 vs. 2.15 ± 0.36; P = 0.125), the 30-min RSS score (2.02 ± 0.13 vs. 2.04 ± 0.19; P = 0.207), the 15-min VRS score (0.50 ± 0.57 vs. 0.67 ± 0.55; P = 0.295), and the 30-min VRS score (0.45 ± 0.50 vs. 0.75 ± 0.52; P = 0.102) were not significantly different between Groups S and F. No adverse events, such as nausea, vomiting, pruritus, delirium, and tremors, occurred in either group. The rates of respiratory depression (1.82% vs. 1.92%; P = 0.968) and dizziness (0.00% vs. 4.85%; P = 0.142) were not different between Groups S and F in the PACU.

Conclusions

The majority of patients scheduled for GLS were able to rapidly and smoothly emerge from anaesthesia. After surgery, similar outcomes, including EA, TE, the incidence of endotracheal tube tolerance, the rate of leaving the surgical bed voluntarily, RSS scores, VRS scores, and adverse events in the PACU, were achieved for the patients between the two anaesthetic protocols.

Protective Effect of Sufentanil on Myocardial Ischemia-Reperfusion Injury in Rats by Inhibiting Endoplasmic Reticulum Stress

Objective

Sufentanil is the most common drug in clinical practice for the treatment of ischemic heart disease. This study is to investigate the protective mechanism of sufentanil on rat myocardial ischemia-reperfusion (I/R) injury.

Methods

A rat I/R model was established by ligating the left anterior descending coronary artery. A total of 24 SD male rats were enrolled and divided randomly into the control group, I/R group, sufentanil group (SUF; 3 μg/kg), and diltiazem group (DLZ; 20 mg/kg; positive control). The rat hearts were subjected to 30 min of ischemia followed by 120 min of reperfusion. Subsequently, hemodynamics, pathological changes of myocardial tissue, serum biochemical parameters, oxidative stress factors, the level of serum inducible nitric oxide synthases (iNOS), interleukin-6 (IL-6), and other bioactive factors were analyzed in the rats.

Result

Compared with the I/R group, sufentanil significantly improved cardiac action, myocardial fiber, and cardiomyocyte morphology and reduced inflammatory cell infiltration in rats in the SUF group. And the level of creatine kinase isoenzyme (CK-MB), troponin (cTn), lactate dehydrogenase (LDH), malondialdehyde (MDA), iNOS, and IL-6 was significantly declined in the serum of SUF group, while the activities of glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD) were significantly activated in the myocardial tissues. In addition, sufentanil also significantly decreased the protein expression of GRP78, CHOP, Caspase 12, and ATF6 in the myocardial tissue of the SUF group.

Conclusion

Sufentanil has a significant protective activity on myocardial I/R injury in rats, the mechanism of which may be associated with the inhibition of endoplasmic reticulum stress and oxidative stress.

Effects of Additional Intraoperative Administration of Sufentanil on Postoperative Pain, Stress and Inflammatory Responses in Patients Undergoing Laparoscopic Myomectomy: A Double-Blind, Randomized, Placebo-Controlled Trial

Purpose

Although pain after laparoscopic surgery is assumed to be minor, many women still suffer from unexpected postoperative pain. Thus, we aimed to assess whether additional intraoperative administration of sufentanil could help to improve postoperative pain and related agitation, stress, and inflammation response in patients undergoing laparoscopic myomectomy.

Patients and Methods

Forty female patients with uterine myoma scheduled for laparoscopic myomectomy under general anesthesia were randomized to receive sufentanil (group T, n=20) or normal saline (group C, n=20) 1h before the end of the surgery. The postoperative pain, agitation, stress, inflammation, and adverse effects were measured.

Results

As the primary outcome, the visual analog scale (VAS) pain score was significantly reduced in group T as compared with group C at each measured time point in a post-anesthesia care unit (PACU), VAS 5 min (31.5 ± 2.7 vs 40.6 ± 5.6) (P<0.001), VAS 30 min (36.5 ± 4.5 vs 46.0 ± 2.9) (P<0.001), VAS 1h (37.8 ± 4.0 vs 48.6 ± 5.5) (P<0.001). The secondary outcomes, including the sedation agitation scale (SAS) scores, plasma concentrations of epinephrine and norepinephrine, and the levels of plasma interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-α) in group T were remarkably lower than those in group C (P < 0.001). The cough cases in group T also showed a significant reduction in comparison with group C (P < 0.05). In addition, the anesthetic recovery time, including the spontaneous breathing recovery time and extubation time, were not significantly different between the two groups, as were the cases of respiratory depression and postoperative delirium (P > 0.05).

Conclusion

For patients undergoing laparoscopic myomectomy, administration of sufentanil 1 h before the end of surgery shows excellent analgesic and sedative effects, alleviated postoperative stress and inflammatory responses, reduced incidence of cough, without prolonging anesthetic recovery time and increasing adverse reactions.

Comparing remifentanil and sufentanil in stress reduction during neurosurgery: a randomised controlled trial

Background In most scenarios, anaesthesiologists titrate opioids to control nociceptive surgical stress based on intraoperative haemodynamic changes. Remifentanil was reported to cause more profound cardiovascular depression than sufentanil. A concern is that this direct cardiovascular depression might counteract the hypertension and tachycardia caused by surgical manipulation and mask inadequate analgesia. Objective To compare remifentanil and sufentanil, titrated to maintain a comparable haemodynamic range (within 20% of baseline) and combined with the same propofol regimen, in stress reduction measured as plasma levels of putative mediators of surgical stress. Setting Huashan Hospital of Fudan University, Shanghai, China. Method Forty-five patients undergoing supratentorial glioma resection were randomised to the remifentanil group or the sufentanil group. Main outcome measures Plasma concentrations of cortisol, epinephrine, norepinephrine, interleukin-6, interleukin-10 and lymphocyte counts were analysed before anaesthesia, 1 h after incision, at the end of surgery and 24 h after incision using enzyme-linked immunosorbent assay and an automatic haematology analyser. Recovery profiles during emergence from anaesthesia were also compared. Results Except for a lower epinephrine concentration in the remifentanil group 24 h after incision (median [interquartile range], 4.2 [3.4-6.1] vs. 8.4 [4.8-12.5] ng/ml; P = 0.003), stress biomarkers were not significantly different between the two groups. Patients in the sufentanil group had lower grades in coughing, restlessness (P = 0.001 and < 0.001, respectively) and a lower incidence of postoperative shivering (P = 0.007). Conclusion Compared to that of sufentanil, the direct cardiovascular depression of remifentanil does not mask the clinical manifestation of inadequate analgesia when both drugs are titrated according to haemodynamic variables in neurosurgery.

Comparative effects of target-controlled infusion of anesthetic sufentanil and remifentanil on inflammatory factors and oxidative stress indicators in patients of colorectal cancer

This study was designed to compare the recovery of target-controlled infusion of sufentanil and remifentanil in patients of colorectal cancer. In total, 104 patients were randomly divided into sufentanil and remifentanil groups. One group was given target-controlled infusion of sufentanil, while the other group received remifentanil. Inflammatory factors and oxidative stress indicators were measured at 10 min before induction of anesthesia (T1), 1 h (T2), 24 h (T3), and 72 h (T4) after surgery. Adverse reactions were also compared. The extubation and recovery time of sufentanil group were longer than remifentanil group. The levels of CRP, IL-8, and IL-4 in sufentanil group and remifentanil group increased continuously. CRP contents at T3, T4, and IL-8 and IL-4 contents at T2, T3, and T4 of remifentanil group were lower ( P < 0.05). The incidence of adverse reactions in sufentanil group was 15.4%, which was significantly ( P < 0.05) lower than remifentanil group (28.8%). The recovery and extubation time of sufentanil were longer than remifentanil, while the remifentanil can effectively reduce the levels of inflammatory factors and oxidative stress.

Effect of anesthetic methods on postoperative CD3+, CD4+ and CD4+CD25+ in patients with lung cancer undergoing radical operation

Effects of anesthesia methods on immune function in patients with lung cancer undergoing radical operation were investigated. A total of 122 patients undergoing radical resection of lung cancer who were treated in Zhejiang Cancer Hospital from September 2013 to April 2016 were randomly divided into the combined anesthesia group and the intravenous anesthesia group, with 61 cases in each group. The patients in the combined anesthesia group were given intravenous combined epidural anesthesia. Patients in the intravenous anesthesia group were given intravenous anesthesia. The change of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at time-point T0 (before anesthesia), T1 (the time of anesthesia), T2 (after operation), T3 (24 h after operation), T4 (72 h after operation) were compared between the two groups. The levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T1, T2, T3 and T4 in the combined anesthesia group were higher than that in the intravenous anesthesia group (P<0.05). Αfter starting anesthesia, the levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ began to decrease in both groups. The levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T2 and T1 were lower than those at T0 (P<0.05). The levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T2 were lower than T1 (P<0.05). After T3, the levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ began to increase in both groups. Τhe levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T3 and T4 were higher in both groups than those at T2 and T1 (P<0.05), and the levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T4 were higher in both groups than those at T3, but the levels of CD3⁺, CD4⁺ and CD4⁺CD25⁺ at T3 and T4 were lower than those at T0 (P<0.05). Intravenous combined epidural anesthesia can maintain a relatively stable immune function compared with simple intravenous anesthesia patients.

Nalbuphine analgesic and anti-inflammatory effects on patients undergoing thoracoscopic lobectomy during the perioperative period

This study sought to investigate the analgesic effects of nalbuphine on patients undergoing thoracoscopic lobectomy during the perioperative period, as well as its effects on inflammatory cytokines. We selected 92 patients with early lung cancer who were admitted to Xiangyang No. 1 People's Hospital between January 2016 and December 2016. The patients were randomly divided into control and observation groups (n=46 each). All patients underwent thoracoscopic lobectomy, with those in the observation group receiving intravenous nalbuphine hydrochloride prior to induction (the control group received saline). Intraoperative blood loss, operation time and anesthetic dosages were compared between groups. The analgesic effects during the perioperative period were compared using a visual analogue scale. The adverse effects of anesthetics (nausea, vomiting, dizziness and drowsiness) were compared between the two groups. Finally, serum inflammatory cytokine [tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and IL-10] levels were measured using ELISA at 1, 3, 5 and 7 days after operation. There were no significant differences in intraoperative blood loss and operation time between the two groups (p>0.05). However, dosages of propofol and remifentanil used were lower in the observation group than in the control group (p<0.05), and the effective rate of postoperative analgesia in the observation group was significantly higher than that in the control group (p<0.05). The degree of postoperative pain in both groups were lower than preoperative rates (p<0.05), while the incidence of adverse reactions in the observation group was significantly lower than in the control group (p<0.05). Finally, TNF-α, IL-6 and IL-10 levels were significantly lower in the observation group relative to the control group at 1, 3, 5 and 7 days after operation (p<0.05). Therefore, nalbuphine has a significant analgesic effect during thoracoscopic lobectomy. The application of nalbuphine can reduce the incidence of adverse reactions, reduce postoperative inflammatory responses, and promote rapid patient recovery, thus demonstrating the clinical value of nalbuphine.

Sufentanil protects the rat myocardium against ischemia-reperfusion injury via activation of the ERK1/2 pathway

Sufentanil, a lipophilic opioid, is the most frequently used clinical drug for ischemic heart disease. The effects of sufentanil on MAPK signaling in ischemic heart disease were explored. The effects of sufentanil on ischemia-reperfusion (IR)-induced myocardial injury in a rat model were examined. The serum levels of CK, LDH, MDA and SOD, and the activities of Na⁺-K⁺-ATPase and Ca²⁺-Mg²⁺-ATPase were measured. The levels of total and phosphorylated ERK1/2, JNK, and p38 were measured by western blotting in the heart, and the myocardial H9C2 cell line was studied. Using the Cell Counting Kit-8, the growth rate of H9C2 cells affected by sufentanil was studied. The serum levels of CK, LDH and MDA were higher in the IR group than in the SO and SUF groups. The SOD level, as well as the activities of Na⁺-K⁺-ATPase and Ca²⁺-Mg²⁺-ATPase, were lower in the SO and SUF groups than in the IR group. The phosphorylated ERK1/2 level was lower in the IR group than in the SO and SUF groups. The growth rate of H9C2 cells increased with the concentration of sufentanil and the exposure time. The phosphorylated ERK level was upregulated by 4-12 h of sufentanil exposure, indicating that the effects were time-dependent. Furthermore, an inhibition of ERK signaling by chemical inhibition suppressed the sufentanil-mediated increase in the growth rate of H9C2 cells. Sufentanil appears to be beneficial for cases of worsening ischemic heart disease. Further studies are necessary before a clinical application is considered.

Pharmacodynamic analysis of target-controlled infusion of propofol in patients with hepatic insufficiency

The effect of liver dysfunction on target-controlled infusion (TCI) of propofol remains poorly documented. The pharmacodynamic performance of propofol TCI was evaluated in a cohort of Chinese patients with hepatic insufficiency. Fifty-three patients with hepatic insufficiency were enrolled in the current prospective, observational study. Anesthesia was induced with propofol via TCI to a plasma concentration of 3 µg/ml. Following loss of consciousness (LOC), fentanyl and cisatracurium were administered. Pharmacodynamic parameters were recorded during TCI, including time to LOC, bispectral index (BIS), heart rate (HR) and blood pressure. Patients were divided into two groups based on model of end stage liver disease (MELD) score: Those with a MELD score of ≤9 and those with a MELD score of ≥10. BIS, mean arterial pressure and HR were demonstrated to vary according to time, but were not affected by liver dysfunction. Hypotension was prominent in patients with a MELD score of ≥10 30 min after induction. The proportion of bradycardia and hypotension at the other time points was not significantly different between MELD scores of ≤9 and ≥10. Notably, no bradycardia was observed in MELD of ≥10. Thus, bradycardia and hypotension was observed in patients with hepatic insufficiency over time, although patients with different severities of hepatic insufficiency did not present with different depths of anesthesia. TCI of propofol to 3 µg/ml may be not suitable for patients with hepatic insufficiency, particularly those with severe liver dysfunction. Predictive concentrations (Cp) of TCI propofol requires further investigation and adjustment in patients with hepatic insufficiency (trial registration no. ChiCTR-OCH-12002255).

Effective Target Concentration of Sufentanil Combined With Sevoflurane Anesthesia for Abdominal Surgery: A Dose-Response Study

This study was designed to investigate the effects of target-controlled infusion (TCI) of sufentanil with sevoflurane anesthesia on hemodynamics and postoperative recovery of abdominal surgery. Target-controlled infusion of opioid analgesics provides efficient drug use, allowing an accurate achievement of the desired analgesia level and fewer overdose-induced adverse effects. A total of 80 patients receiving abdominal surgery (surgery for gastric cancer or colorectal cancer) were divided into 4 groups to receive anesthesia with sevoflurane accompanied with different doses of sufentanil (0.4, 0.6, 0.8, or 1.0 ng/mL). Systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, times to recovery of spontaneous respiration, eye opening, extubation, and orientation were recorded. Hemodynamic measurements were compared among groups. Comparison between the 2 groups of subjects was made with one-way analysis of variance (ANOVA), LSD-t test, or χ2 test. Although sufentanil at 0.8 and 1.0 ng/mL maintained stable perioperative hemodynamics, the higher dose was associated with increased incidence of bradycardia following intubation (10/19 cases, 52.6%; P &lt; 0.05). Additionally, no differences were observed in the incidence of hypotension, hypertension, or tachycardia between groups (P &gt; 0.05). Increased dose of sufentanil was associated with delayed postoperative recovery. These results demonstrate that TCI at 0.8 ng/mL sufentanil accompanied with sevoflurane anesthesia is a suitable anesthetic regimen for abdominal surgery.

Comparison of recovery effect for sufentanil and remifentanil anesthesia with TCI in laparoscopic radical resection during colorectal cancer

The aim of the present study was to compare the recovery of sufentanil and remifentanil anesthesia by target-controlled infusion (TCI) in elderly patients with laparoscopic-assisted radical resection of colorectal cancer. The effect of anesthesia on patient stress response and cellular immune function was also observed. Elderly patients (n=192) who underwent laparoscopic radical resection of colorectal cancer between July 2014 and October 2015 were randomly divided into the sufentanil and remifentanil groups (n=96 per group). The two groups used sufentanil- and remifentanil-based anesthesia by TCI. The wake-up time, extubation time, orientation recovery time, vital signs, stress response, distribution of T-cell subsets and incidence of adverse reactions were recorded and compared. The wake-up and extubation times of the remifentanil group were significantly shorter than those of the sufentanil group. The difference of orientation recovery time was not statistically significant. The differences in heart rate, mean arterial pressure, and arterial oxygen saturation following anesthesia and during surgery and those prior to anesthesia of the sufentanil group were not statistically significant. However, those of the remifentanil group significantly improved following anesthesia. The concentrations of glucose, cortisol (COR), and interleukin-6 and C-reactive protein were stable in the sufentanil group, whereas the indices in the remifentanil group had a tendency of increasing during the anesthesia and surgery, and had a longer postoperative recovery time. The decreasing degree of T-cell subsets in the sufentanil group was significantly lower than that in the remifentanil group, and had a short recovery of cellular immunity following surgery. The adverse reactions rate during anesthesia of the remifentanil group was significantly higher than that of the sufentanil group. In conclusion, sufentanil- and remifentanil-based anesthesia with TCI has certain advantages, including improved recovery effect, less stress response, less inhibition of cellular immunity and fewer adverse reactions. It has the potential to become the first choice of anesthetic in the clinic for elderly patients who undergo laparoscopic radical resection for colorectal cancer.

Total Intravenous Anesthesia-Target Controlled Infusion for colorectal surgery. Remifentanil TCI vs sufentanil TCI

The aim of the study was to compare the effect of remifentanil and sufentanil administered for total intravenous anaesthesia (TIVA) using target-controlled infusion (TCI) on intraoperative hemodynamic response, tracheal intubation and extubation times in patients undergoing colorectal surgery.

METHODS

Sixty patients undergoing open colorectal surgery for colorectal tumors or inflammatory diseases were randomized prospectively into one of two groups: remifentanil group R (n = 30) received TIVA-TCI with propofol and remifentanil and sufentanil group S (n = 30) received TIVA-TCI with propofol and sufentanil. Changes of mean arterial pressure (MAP) and heart rate (HR) were compared during induction and maintenance of anaesthesia. Response to tracheal intubation was assessed as episodes of hypertension, increased HR and bispectral index values, sweating, lacrimation, and coughing. The numbers of target plasma concentration (Cp) adjustments of opioids and propofol due to painful stimulation were recorded during surgery. Recovery time expressed as extubation time was also evaluated.

RESULTS

MAP and HR, expressed as area under the curve (AUC), were not significantly different between groups during anesthesia and surgery. During induction of anesthesia, MAP values decrease from baseline, in both groups (p < 0.001). Intergroup comparison revealed that MAP decreased more in the remifentanil than sufentanil group (p = 0.027). HR decreased from baseline values only in the remifentanil group (p = 0.05). The number of target concentration adjustments for propofol and opioid was higher in the remifentanil group as compared with sufentanil group (p = 0.02 and p = 0.04). Hemodynamic responses to tracheal intubation and extubation times were not significantly different between the groups.

CONCLUSION

Both remifentanil and sufentanil TCI produced stable hemodynamic conditions during open colorectal surgery but sufentanil TCI was associated with less decrease in blood pressure and heart rate, and required fewer dose adjustments during anesthesia induction.