OBJECTIVE: To determine the maximum dose of continuously infused mivacurium for intraoperative neuromonitoring and observe its adverse effects in thyroid surgery. METHODS: Twenty-eight patients undergoing thyroid surgery with intraoperative neuromonitoring received continuous infusion of mivacurium at the initial rate of 5.43 μg?kg?min, and the infusion rate for the next patient was adjusted based on the response of the previous patient according to the results of neurological monitoring. The depth of anesthesia was maintained with sevoflurane and remifentanil during the surgery. The LD50 and 95% of mivacurium were calculated using Brownlee's up-and-down sequential method. RESULTS: The LD50 of continuously infused mivacurium was 8.94 μg?kg?min (95% : 8.89- 8.99 μg?kg?min) during thyroid surgery, which did not affect neurological function monitoring. Transient chest skin redness occurred after induction in 9 patients (32.1%). None of the patients experienced intubation difficulties or showed intraoperative body motions during the surgery. CONCLUSIONS In patients undergoing thyroid surgery under anesthesia maintained by inhalation and intravenous infusion, the LD50 of mivacurium was 8.94 μg?kg?min (95% : 8.89-8.99 μg?kg?min) for continuous infusion, which does not cause serious adverse effects during the operation.
Anesthesia ; Anesthetics, Inhalation ; Anesthetics, Intravenous ; Humans ; Intraoperative Neurophysiological Monitoring ; methods ; Lethal Dose 50 ; Mivacurium ; administration & dosage ; adverse effects ; Neuromuscular Nondepolarizing Agents ; administration & dosage ; adverse effects ; Remifentanil ; Sevoflurane ; Thyroid Gland ; surgery

BACKGROUND/AIMS: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation. METHODS: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale. RESULTS: The mean BIS value throughout the procedure was 74.3 +/- 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists' experience level (36.9 +/- 29.6 and 11.3 +/- 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively). CONCLUSIONS: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.
Adult ; Aged ; Anesthetics, Intravenous/*administration & dosage/adverse effects ; *Clinical Competence ; *Colonoscopy ; Conscious Sedation/adverse effects/*nursing ; Consciousness/*drug effects ; *Consciousness Monitors ; Electroencephalography/*instrumentation/*nursing ; Female ; Humans ; Male ; Middle Aged ; *Nurse Anesthetists ; Predictive Value of Tests ; Propofol/*administration & dosage/adverse effects ; Prospective Studies ; Republic of Korea

Several factors can affect the perioperative immune function. We evaluated the effect of propofol and desflurane anesthesia on the surgery-induced immune perturbation in patients undergoing breast cancer surgery. The patients were randomly assigned to receive propofol (n = 20) or desflurane (n = 20) anesthesia. The total and differential white blood cell counts were determined with lymphocyte subpopulations before and 1 hr after anesthesia induction and at 24 hr postoperatively. Plasma concentrations of interleukin (IL)-2 and IL-4 were also measured. Both propofol and desflurane anesthesia preserved the IL-2/IL-4 and CD4+/CD8+ T cell ratio. Leukocytes were lower in the propofol group than in the desflurane group at 1 hr after induction (median [quartiles], 4.98 [3.87-6.31] vs. 5.84 [5.18-7.94] 10(3)/microL) and 24 hr postoperatively (6.92 [5.54-6.86] vs. 7.62 [6.22-9.21] 10(3)/microL). NK cells significantly decreased 1 hr after induction in the propofol group (0.41 [0.34-0.53] to 0.25 [0.21-0.33] 10(3)/microL), but not in the desflurane group (0.33 [0.29-0.48] to 0.38 [0.30-0.56] 10(3)/microL). Our findings indicate that both propofol and desflurane anesthesia for breast cancer surgery induce a favorable immune response in terms of preservation of IL-2/IL-4 and CD4+/CD8+ T cell ratio in the perioperative period. With respect to leukocytes and NK cells, desflurane anesthesia is associated with less adverse immune responses than propofol anesthesia during surgery for breast cancer. (Clinical trial registration at https://cris.nih.go.kr/cris number: KCT0000939)
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Anesthesia/adverse effects ; Anesthetics, Inhalation/*therapeutic use ; Anesthetics, Intravenous/*therapeutic use ; Breast Neoplasms/immunology/*surgery ; *CD4-CD8 Ratio ; Female ; Humans ; Interleukin-2/blood ; Interleukin-4/blood ; Isoflurane/*analogs & derivatives/therapeutic use ; Middle Aged ; Postoperative Period ; Propofol/*therapeutic use ; Young Adult

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.
Adult ; Airway Management/*methods ; Anesthesia Recovery Period ; Anesthetics, Intravenous/*administration & dosage ; Cough/prevention & control ; Device Removal ; Dose-Response Relationship, Drug ; Double-Blind Method ; Female ; Humans ; Infusions, Intravenous ; Laryngeal Masks/*adverse effects ; Male ; Middle Aged ; Piperidines/*administration & dosage ; Postoperative Complications/prevention & control ; Psychomotor Agitation ; Vomiting/prevention & control

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.
Adult ; Airway Management/*methods ; Anesthesia Recovery Period ; Anesthetics, Intravenous/*administration & dosage ; Cough/prevention & control ; Device Removal ; Dose-Response Relationship, Drug ; Double-Blind Method ; Female ; Humans ; Infusions, Intravenous ; Laryngeal Masks/*adverse effects ; Male ; Middle Aged ; Piperidines/*administration & dosage ; Postoperative Complications/prevention & control ; Psychomotor Agitation ; Vomiting/prevention & control

OBJECTIVETo explore the impacts on EC50 in the remifentanil inhibition of tracheal intubation response by the transcutaneous electrical acupoint stimulation (TEAS) at Hegu (LI 4) and Neiguan (PC 6).

METHODSForty patients with selective surgery undergoing endotracheal intubation with intravenous general anesthesia were divided into I to II degree by the American Society of Anesthesiologists (ASA) and were randomized into an observation group and a control group, 20 cases in each one. Before general anesthesia induction, in the observation group, the transcutaneous electric stimulation was applied to bilateral Hegu (LI 4) and Neiguan (PC 6) for 30 min, with dense-disperse wave, 2 Hz/100 Hz in frequency; in the control group, the sham-stimulation was applied to the acupoints, with the lamp on, but without electric current output. Afterwards, the general anesthesia induction started. When the target concentration of propofol and remifentanil was stabilized at the preset value, the endotracheal intubation was conducted. Dixon sequential method was applied for the determination of ECs in remifentanil inhibition of tracheal intubation response.

RESULTSThe level of EC50 in remifentanil inhibition of tracheal intubation response was 3. 46 ng/mL, 95% confidence interval was 2. 80 ng/ml to 4. 27ng/mL in the observation group; those were 4. 18 ng/mL and 3. 30 ng/mL to 5. 29 ng/mL in the control group separately. The differences were significant in comparison of the two groups (P<0. 01).

CONCLUSIONTEAS apparently reduces EChe in the remifentanil inhibition of tracheal intubation response by around 17%as.

Acupuncture Points ; Adult ; Aged ; Anesthetics, Intravenous ; administration & dosage ; Female ; Humans ; Intubation, Intratracheal ; adverse effects ; Male ; Middle Aged ; Pain ; etiology ; Pain Management ; Piperidines ; administration & dosage ; Transcutaneous Electric Nerve Stimulation

PURPOSE: Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS: A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS: The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION: BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.
Aged ; Anesthetics, Intravenous/*administration & dosage/therapeutic use ; *Consciousness Monitors ; Endoscopy/methods ; Female ; Humans ; Intraoperative Complications/*prevention & control ; Male ; Middle Aged ; Monitoring, Physiologic/methods ; Piperidines/*administration & dosage/adverse effects/therapeutic use ; Propofol/*administration & dosage/adverse effects/therapeutic use

OBJECTIVETo compare the effects on anesthesia recovery between assisted-electroacupuncture fast tracking anesthesia and simple fast tracking anesthesia in patients with minim ally invasive percutaneous nephrolithotomy (mPCNL).

METHODSEighty cases of mPCNL were selected and randomly divided into a treatment group and a control group. Fentanyl (1-2 microg/kg), sevoflurane (8%) and rocuronium (0.5 mg/kg) were applied to perform anesthesia induction in both groups, and endotracheal inhalation of sevoflurane and intravenous pump injection of remifentanil were adopted to main anesthesia status during the operation. 20 min before anesthesia induction, bilateral Neiguan (PC 6), Neimadian, Hegu (LI 4), Yangxi (LI 5), Zhongji (CV 3), Qichong (ST 30), Zuwuli (LR 10) were selected and punctured in the treatment group, and elecctroacupuncture was given after arrival of qi until 30 min after the wake-up from anesthesia and withdrawal of endotracheal tube. The dosage for anesthesia maintenance, recovery time of awareness, extubation time, incidences of nausea, vomiting and chill and irritation of urethral catheters were observed and recorded.

RESULTS(1) The dosages of remifentanil and sevoflurane in the treatment group during the operation were obviously less than those in the control group [remifentanil: (5. 27 +/-1.23) micro g/kg h vs (7.35+/-1.70) micro g/kg . h; sevoflurane: (1.12+/-0.43) vol% vs (2.35+/-0.87) vol% , both P<0. 001]. (2) The recovery time of awareness and extubation time in the treatment group were significantly earlier than those in the control group [recovery time of awareness: (5.65 +/- 2.34) min vs (8. 87 +/- 6. 84) min, P<0. 01; extubation time : (7. 23+/-4. 35) min vs (10. 62+/-8. 16) min, P<0. 05]. (3) The incidences of nausea, vomiting and chill in the treatment group were significantly less than those in the control group (all P<0. 05). (4) The irritation of urethral catheters on urethra in the treatment group was significantly less than that in the control group (P<0. 001).

CONCLUSIONThe assisted-electroacupuncture anesthesia could reduce the dosage of remifentanil and sevoflurane in mPCNL fast tracking anesthesia in urinary surgery, reduce the incidences of nausea, vomiting, chill and irritation of urethral catheters during recovery stage, and prompt recovery of mPCNL patients.

Adolescent ; Adult ; Anesthesia Recovery Period ; Anesthetics, Intravenous ; administration & dosage ; adverse effects ; Electroacupuncture ; Female ; Fentanyl ; administration & dosage ; adverse effects ; Humans ; Male ; Methyl Ethers ; administration & dosage ; adverse effects ; Middle Aged ; Nephrostomy, Percutaneous ; Piperidines ; administration & dosage ; adverse effects ; Postoperative Nausea and Vomiting ; therapy ; Young Adult

Although intravenous lipid emulsion (LE) is used mainly for parenteral nutrition, recently it has been used to treat patients with cardiopulmonary resuscitation (CPR)-resistant cardiovascular collapse induced by a toxic dose of local anesthetics or other drugs. Intravenous LE resolves symptoms of local anesthetic systemic toxicity, including convulsion, myoclonus, loss of consciousness, cardiac arrest, supraventricular tachycardia, and ventricular fibrillation. The main underlying mechanisms suggested to be responsible for LE-induced reversal of cardiac arrest due to drug toxicity are the lipid sink effect and the metabolic effect. The lipid sink theory posits that LE extracts a lipid-soluble toxic drug from the tissue. When a patient with cardiovascular collapse induced by a local anesthetic or another lipid-soluble drug is unresponsive to supportive treatments, including CPR and vasopressor therapy, LE administration can be considered. The suggested dosing regimen is as follows: 1) an initial intravenous bolus administration of 20% LE (1.5 mL/kg) is followed by a continuous infusion of 20% LE (0.25 mL/kg/min); and 2) when hemodynamic functions are unstable after the initial LE infusion, an intravenous administration of 20% LE (1.5 mL/kg) is repeated and followed by an increased continuous infusion of 20% LE (0.5 mL/kg/min). Further research is warranted regarding other possible mechanisms of LE's effect, the timing of LE administration, and the effect of various fatty acids on the LE-mediated reversal of cardiac arrest. This article reviews case reports and experimental evidence concerning the LE-mediated reversal of intractable cardiac arrest induced by drug toxicity, the underlying mechanism, and the dosing regimen.
Administration, Intravenous ; Anesthetics, Local* ; Cardiopulmonary Resuscitation ; Drug-Related Side Effects and Adverse Reactions ; Fatty Acids ; Heart Arrest ; Hemodynamics ; Humans ; Myoclonus ; Parenteral Nutrition ; Seizures ; Tachycardia, Supraventricular ; Unconsciousness ; Ventricular Fibrillation

OBJECTIVETo explore the preventive effect of etomidate-induced myoclonus by different concentrations of target-controlled infusion of remifentanil.

METHODSA total of 120 cases undergoing general anesthesia were randomly divided into 4 groups according to different concentrations of target controlled infusion of remifentanil using plasma target controlled infusion ( Minto model) , in which the target concentration was set as 1 f.Lg/L ( group A) , 2 f.Lg/L ( group B) , 3 f.Lg/L ( group C) , and 4 f.Lg/L ( group D) . Five minutes after the balance of effect compartment, induction with etomidate 0. 3 mglkg was conducted intravenously. The intensity and duration of myoclonus was recorded.

RESULTSThe incidence of etomidate-induced myoclonus was 70.9%, 33.3%, 26.7%, and 0 in groups A, B, C, and D, respectively. Along with the increase of the remifentanil concentration, the incidence of severe myoclonus gradually reduced, which was significantly lower in group B and C than in group A ( P < 0. 05). When the concentration reached 4 f.Lg/L, bradycardia and apnea appeared.

CONCLUSIONMyoclonus induced by etomidate under general anesthesia can be prevented by target controlled infusion of remifentanil, with 2-3 f.Lg/L being the optimal concentration.

Adult ; Anesthetics, Intravenous ; administration & dosage ; adverse effects ; Etomidate ; adverse effects ; Female ; Humans ; Male ; Middle Aged ; Myoclonus ; chemically induced ; prevention & control ; Piperidines ; administration & dosage