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Kuo YW, Chen YT, Lieu AS, Lee MS, Su YF, Lai HC, Wu ZF. Predicting the optimal concentration of remifentanil for skull pin fixation with hemodynamic and analgesia nociception index monitoring. Sci Rep 2024; 14:6441. [PMID: 38499567 PMCID: PMC10948835 DOI: 10.1038/s41598-024-56283-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024] Open
Abstract
Inadequate antinociception during skull pin fixation may cause hemodynamic instability in intracranial surgery. The optimal concentration of remifentanil to provide adequate antinociception and stable hemodynamics during skull pin fixation under analgesia nociception index monitoring is unknown. This study is to assess the 90% effective concentration of remifentanil for skull pin fixation under hemodynamic and analgesia nociception index monitoring. Twenty-six patients were enrolled for intracranial surgery, anesthesia was induced and maintained under total intravenous anesthesia using target-controlled infusion for remifentanil and propofol under analgesia nociception index and bispectral index monitoring. Skull pin fixation was performed at different effect-site concentrations of remifentanil required for Dixon's up-and-down method with a step size of 0.5 ng/ml under bispectral index 40-60. Inadequate antinociception is defined when either ANI < 30 or > 20% in hemodynamic changes from baseline (e.g. heart rate > 100 beats/min, or blood pressure > 180/100 mmHg) and the effect-site concentration of remifentanil is considered as failure. It is considered success as ANI > 30 and < 20% hemodynamic changes from baseline simultaneously. Seven pairs of failure/success were used for probit analysis. The 90% effective concentration of remifentanil for skull pin fixation with adequate antinociception and hemodynamic stability was 4.7 ng/ml.
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Affiliation(s)
- Yi-Wei Kuo
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Ying-Tzu Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Ann-Shung Lieu
- Department of Surgery, Division of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yu-Feng Su
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, ROC.
| | - Zhi-Fu Wu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC.
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, ROC.
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC.
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.
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Lee JM, Bahk JH, Lim YJ, Lee J, Lim L. The EC 90 of remifentanil for blunting cardiovascular responses to head fixation for neurosurgery under total intravenous anesthesia with propofol and remifentanil based on bispectral index monitoring: estimation with the biased coin up-and-down sequential method. BMC Anesthesiol 2017; 17:136. [PMID: 29017455 PMCID: PMC5635491 DOI: 10.1186/s12871-017-0426-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background Head fixation can induce hemodynamic instability. Remifentanil is commonly used with propofol for total intravenous anesthesia (TIVA) during neurosurgery. This study investigated the 90% effective concentration (EC90) of remifentanil for blunting of cardiovascular responses to head fixation during neurosurgery via bispectral index (BIS) monitoring. Methods Fifty patients undergoing neurosurgery requiring head fixation were enrolled. This study was performed using the biased coin up-and-down design sequential method (BCD). After tracheal intubation, the effect-site target concentration (Ce) of remifentanil was adjusted to achieve hemodynamic stability and reset to the level preoperatively assigned to each patient, according to the BCD method, approximately 10 min before head fixation. Baseline hemodynamic values were recorded before head fixation. An ineffective response was defined as a case with a > 20% increase in hemodynamic values from baseline. Otherwise, the response was determined to be effective. The EC90 of remifentanil was calculated as a modified isotonic estimator. Results Forty-three patients completed this study. The EC90 of remifentanil for blunting cardiovascular responses to head fixation was estimated to be 6.48 ng/mL (95% CI, 5.94–6.83 ng/mL). Conclusions Adjustment of the Ce of remifentanil to approximately 6.5 ng/mL before head fixation could prevent noxious cardiovascular responses in 90% of neurosurgical ASA I-II patients aged 20 to 65 years old during propofol target-controlled infusion titrated to maintain BIS between 40 and 50. Trial registration ClinicalTrials.gov Identifier NCT01489137, retrospectively registered 5 December 2011.
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Affiliation(s)
- Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Young-Jin Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, 56, Dalseong-ro, Daegu, 41931, Republic of Korea
| | - Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Abstract
Abstract
Background
The nociception level (NoL) index is an index of nociception based on nonlinear combination of heart rate, heart rate variability, photoplethysmograph wave amplitude, skin conductance, skin conductance fluctuations, and their time derivatives. The authors evaluated the abilities of the NoL index and other measures of nociception to discriminate between noxious and nonnoxious stimuli, to progressively respond to graded stimuli, and to respond to opioid administration.
Methods
Intraoperative NoL was compared to heart rate, pulse plethysmograph amplitude, noninvasive blood pressure, and the surgical pleth index around five specific stimuli: tetanic stimulation with and without fentanyl analgesia, intubation, first incision/trocar insertion, and a nonnoxious period. The response around first incision was analyzed at two target plasma concentrations of remifentanil.
Results
In 58 patients, the NoL index responded progressively to increased stimulus intensity and remained unchanged in response to nonnoxious stimuli. Compared to other accepted measures of nociception, the NoL index better discriminated noxious from nonnoxious stimuli with an area under the curve of 0.93 (95% CI, 0.89 to 0.97) and a sensitivity of 87% at a specificity of 84%. The NoL index was the only measure that reliably reflected two different analgesic concentrations of remifentanil during initial skin incision or trocar insertion.
Conclusions
The NoL index changes proportionately with patients’ response to various clinical and experimental noxious stimuli and discriminates noxious from nonnoxious stimuli with high sensitivity and specificity. The NoL index also responds progressively to increasing stimuli intensity and is appropriately blunted by analgesic administration. The NoL index was superior to other compared measures and appears to accurately characterize nociception during general anesthesia.
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