TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) IN CHILDREN - AN ANESTHETIC TECHNIQUE
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S403 INTRODUCTION: The use of TEE in children has increased with the arrival of smaller TEE probes. The high quality TEE image may prevent the need for invasive cardiac catheterisation to diagnose congenital heart disease. In adults, TEEs' are usually performed with topical analgesia and light sedation, however this method is seldom tolerated by children. Deeper sedation using oral agents also often fails. The aim of this study is to review prospectively the anesthetic technique developed by our anesthesia department for pediatric TEE. METHODS: Patients are assessed pre-procedure and consent obtained. Prior to induction of anesthesia the patient gargles lidocaine mouthwash (1% - 25cc). Monitors are applied and an IV sited with nitrous oxide sedation. The patient receives O2 (2 l/min) by nasal cannula during induction of anesthesia which is with: midazolam (25mcg/kg), fentanyl (1mcg/kg), glycopyrrolate (5mcg/kg) and propofol (0.5-1 mg/kg). Topical lidocaine spray (10%, 1-4 puffs, max. 2mg/kg) is applied to the pharynx. Anesthesia is maintained with propofol by infusion (5-10 mg/kg/hr). The TEE probe is passed as the patient loses consciousness and is protected by a bite block next to which O2 (8 l/min) flows. Jaw thrust is used to maintain the airway as needed. Any patient movement is treated with further propofol (0.25mg/kg). Respiration is spontaneous. Once the TEE has finished the patient is cared for in the PARR unit until recovered. Exclusion criteria include severe respiratory disease, GERD, cardiac lesions not tolerating vasodilation. RESULTS: Ten patients are reported. The mean age was 12.5 +/- 4.8 yrs and weight 35.3 +/- 22.8 kg. Sedation and recovery times are shown in Table 1. All patients remained hemodynamically stable (Table 2). Image quality was good to excellent for all studies. Complications, which were transient and minor are shown in Table 3.Table 1: Time (min) for stages of procedure (mean +/- SD)Table 2: Cardiorespiratory changes (mean +/- SD)Table 3: Complications and dose of propofol (mean +/- SD)CONCLUSIONS: We have described an anesthetic technique which allows a child to undergo a TEE in a comfortable and safe manner with the TEE operator and the anesthesiologist sharing the airway. Propofol allows for an easily controlled level of anesthesia and along with good mucosal anesthesia the probe can be placed without patient distress. The transient desaturations on induction were related to the propofol bolus which must be carefully titrated.Keywords:
Midazolam
BACKGROUND Individual variation in the sensitivity to anesthetics induces the delayed awakening and the severe postoperative pain at an inappropriate dose. We designed the study to see the correlation of the individual sensitivity to fentanyl and that to propofol which have different mechanism. METHODS General anesthesia was induced using target controlled infusion system of fentanyl and propofol. Fentanyl effect-site concentration gradually increased towards a target plasma concentration of 3 ng x ml(-1) until the appearance of the subjective symptom such as dizziness, a sensation of warmth and other reactions. After this, propofol effect-site concentration gradually increased towards a target plasma concentration of 4 microg x ml(-1) until loss of consciousness (LOC). The effect-site concentrations of fentanyl at the symptom and propofol at loss of consciousness were measured. RESULTS The correlation between the estimated effect-site concentration of fentanyl and propofol is not significant in the whole patient. However, a positive correlation between fentanyl and propofol was found in patients from 50s to 70s years of ages (r = 0.59). CONCLUSIONS The correlation of the individual sensitivity to fentanyl and propofol was found in older age groups.
Positive correlation
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Objective To investigate the optimized anaesthesia scheme of applying the propofol and fentanyl to the painless enteroscopy.Methods 120 patients were divided into three groups at random to be performed with anaesthesia of combination of propofol and fentanyl.Patients in group A were administered with combination of propofol and 0.5 μg/kg fentanyl,patients in group B were administered with combination of propofol and 1.0 μg/kg fentanyl,and patients in group C were administered with combination of propofol and 1.5 μg/kg fentanyl.The propofol dose level for each group was recorded,as well as the necessary monitored parameters.Results Propofol's dose was gradually declined with the increase of fentanyl's dose,which indicated that there was a dose-related interaction between propofol and fentanyl.When combined with 0.5 μg/kg fentanyl,propofol's dose was 3.89 mg/kg,which did not reach expected analgesic and sedative effects,and respiratory and circulatory depression were observed.When combined with 1.0 μg/kg fentanyl,propofol's dose was 2.47 mg/kg,and expected analgesic and sedative effects were obtained without any respiratory and circulatory depression.When combined with 1.5 μg/kg fentanyl,propofol's dose was 1.53 mg/kg,and expected analgesic and sedative effects were obtained,but respiratory and circulatory triggered by propofol were observed concurrently.Conclusions Combination of 2.5 mg/kg propofol and 1.0 μg/kg fentanyl could be the optimized anaesthesia scheme to be used in painless enteroscopy.
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Objective To observe the effect of different dosage of lidocaine for prevention of injection pain caused by propofol. Methods 200 cases of abortion were divided into four groups randomly,the L0 group was given propofol without lidocaine,the L1 group was given 10 ml of 1% propofol with 1 ml of 2% lidocaine,the L2 group was given 10 ml of 1% propofol with 1.25 ml of 2% lidocaine,the L3 group was given 10 ml of 1% propofol with 1.5 ml of 2% lidocaine, each group had 50 cases.All these patients were given the intravenous fentanyl(1.0 μg/kg) before intravenous propofol with or without lidocaine(propofol 1-2 mg/kg).The situations of injection pain in each group were observed. Results The incidence of injection pain was highest in the L0 group.Patients in the L1 group still had minor injection pain.The injection pain in the L1 and L2 group was almost disappeared and had no significant difference. Conclusion The mixture of 10 ml of 1% propofol with 1.25 ml of 2% lidocaine(0.25% lidocaine in the mixture) is the best concentration for prevention of injection pain.
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This retrospective cohort study evaluated procedural efficiency and patient satisfaction in patients who had received propofol, midazolam/fentanyl/propofol (MFP), or midazolam/fentanyl, as sedation for either esophagogastroduodenoscopy or colonoscopy. Questionnaires about procedural times and patient satisfaction were administered. Use of propofol for colonoscopy resulted in shorter time (minutes) from induction to start of procedure (mean +/- standard deviation: propofol, 1.3 +/- 0.57; MFP, 3.2 +/- 2.2; midazolam/fentanyl, 3.8 +/- 2.7; P < .04) and shorter procedure time (propofol, 13 +/- 0.36; MFP, 15 +/- 0.004; midazolam/fentanyl, 75 +/- 0.005 minutes; P < .05). Recovery time was less for patients receiving propofol for their colonoscopy compared with the other groups (propofol, 9 +/- 8; MFP, 15 +/- 9; midazolam/ fentanyl, 18 +/- 117 minutes; P < .05). Patients undergoing esophagogastroduodenoscopy who received propofol had a shorter recovery time (9 +/- 7 minutes vs MFP, 14 +/- 9 minutes, and midazolam/fentanyl, 19 +/- 11 minutes; P < .05). Patients receiving propofol felt less discomfort and need for adjustment in the sedation, and remembered less of the procedure compared with the MFP group. Propofol resulted in less time in the endoscopy unit, quicker recovery and discharge, and greater patient satisfaction than did balanced or conscious sedation.
Midazolam
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Objective To observe the effects of propofol or midazolam combined with fentanyl on GABA_A receptor in acutely dissociated hippocampal pyramidal neurons of neonatal rats, so as to reveal the possible mechanism of the combined anesthesia. Methods Whole-cell patch-clamp technique was used to record the GABA_A receptor-induced currents (I_GABA) in four groups(n=5 of each), ie, propofol(groupⅠ), propofol combined with fentanyl(groupⅡ), midazolam (groupⅢ) and midazolam combined with fentanyl(groupⅣ). Results 0.3-30.0 μmol/L propofol (groupⅠ,Ⅱ) and 0.03-100.0 μmol/L midazolam (groupⅢ, Ⅳ) facilitated I_GABA with the greatest enhancement at 3.0 μmol/L of each (P0.05). Following 0.01 μmol/L fentanyl pretreatment for 10 minutes, the facilitation of I_GABA by 3.0 μmol/L propofol increased significantly [(127.2±11.2)% (groupⅠ) vs (212.5±14.9)% (groupⅡ), P0.05, n=5], whereas the effects of midazolam were not changed by fentanyl pretreatment [(158.2±34.0)% (groupⅢ) vs (116.3±46.0)% (groupⅣ), P0.05, n=5]. Conclusion Fentanyl can enhance the effects of propofol on GABA_A receptor, but not influence those of midazolam. Propofol or midazolam combined with fentanyl may prevent the neuroexcitatory effects of fentanyl, supporting their use in combination for clinical anesthesia.
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목적: 대장내시경 검사에서 의식하 진정을 위한 전 처치제로 midazolam과 propofol 병합요법이 시도되고 있으나, 병합요법의 경우 무호흡증과 같은 부작용들이 증가될 수 있어 임상적으로 많은 주의를 요한다. 이에 저자들은 midazolam과 저용량 propofol 병합요법의 효용성에 대하여 연구하고자 하였다. 대상 및 방법: 2004년 8월부터 2004년 10월까지 고려대학교 안산병원에서 의식하 진정 대장내시경 검사를 받은 56명의 환자를 대상 으로 propofol 병합유무와 midazolam 용량에 따라 A군(18명, midazolam 0.03 mg/kg+propofol 0.3 mg/kg), B군 (19명, midazolam 0.07 mg/kg+propofol 0.3 mg/kg), C군(19명, midazolam 0.07 mg/kg)으로 구분하였다. 검사 중 환자의 혈압, 맥박수, 혈중 산소포화도를 측정하였고 Aldrete score를 검사종료 후 5분, 10분, 30분에 측정하여 진정 상태에서 회복되는 정도를 평가하였다. 총 검사시간, visual analog scale (VAS) 및 검사 후 설문 조사를 통하여 환자의 만족도(검사 당일/24시간 후)를 평가하였으며 환자의 진정 상태에 대한 시술자의 만족도를 평가하였다. 결과: 평균 검사시간은 각각 14.2±7.8분, 12.2±3.8분, 11.6±3.5분으로 유의한 차이가 없었다. 안 전도 평가에서 10초 이상 산소포화도가 90% 이하로 감소된 경우는 모든 군에서 없었고, 내시경 시행 전보다 혈압이 20 mmHg 이상 감소하거나 맥박이 20% 이상 감소한 경우 역시 유의한 차이가 없었다(p＞0.05). 진정 상태에서 회복되는 정도는 각 군간 차이는 없었다(p＞0.05). VAS (0=no pain to 10=unacceptable)을 이용한 각 군간 평균 통증 정도는 1.1, 1.1, 0.9로 낮았고 각 군간 유의한 차이는 없었다(p＞0.05). 또한, 검사당일과 다음날 환자의 만족도와 시술자의 만족도 평가에서도 각 군간 유의한 차이는 없었다(p＞0.05). 결론: 의식하 진정 대장내시경 검사에서 상승적 진정 목적으로 사용한 midazolam과 저용량의 propofol 병합요법은 고용량의 midazolam 단독투여와 비교하여 합병증과 의식 회복 정도의 차이가 없어 비교적 안전하고 환자의 만족도가 높아 대장암 검진 등에 유용할 것으로 생각한다.
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Objective To analyze the correlation of auditory evoked potential index (AAI) and bispectral index (BIS) with the depth of sedation induced by fentanyl and propofol.Methods Forty-five ASAⅠorⅡadult patients undergoing elective abdominal surgery under general anesthesia were included in this study. The patients were randomly divided into 3 groups ( n = 15 each) :Ⅰpropofol group (P group) ;Ⅱpropofol + fentanyl 2μg·kg-1 group (PF2 group) andⅢpropofol + fentanyl 5μg·kg-1(PF5 group) . Baseline AAI, BIS, MAP, HR and SpO2 were measured and recorded before induction of anesthesia. Normal saline 5 ml/fentanyl 2μg·kg-1 or 5μg·kg-1 in 5 ml was injectedⅣover 30-60 seconds. 4 min later propofol was given by TCI system. The initial target plasma concentration was set at 1.0μg·ml-1 and was increased by 0.2μg·ml-1 every 3 min until OAA/S score reached 1 (5 = alert, 1 = does not respond to prodding) . The expected plasma concentration (Cp) and the effect-site concentration (Ce) of propofol, AAI and BIS values were monitored and recorded for different OAA/S scores and their correlation with the sedation induced by propofol-fentanyl was analyzed. Whether the interaction between fentanyl and propofol could be reflected by BIS or AAI was analyzed too. Results During induction of anesthesia with propofol and fentanyl, the AAI and BIS values were decreasing as the sedation was deepening and were correlated significantly with the OAA/S scores. When the patients did not respond to verbal command (OAA/S score = 2), the BIS values were significantly different among the 3 groups but there was no significant difference in AAI values among the 3 groups. Conclusion AAI can reflect the depth of sedation induced by propofol and fentanyl but BIS can not.
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Objective To study the prophylactic effect of lidocaine in different concentrations added to propofol on the propofol-induced injection pain.Methods A total of 250 ASA Ⅰ-Ⅲ patients scheduled to undergo elective surgery,were randomly assigned into five groups(n=50 each).Group A received propofol without lidocaine;group B received propofol with lidocaine 0.5 mg/ml;group C received propofol with lidocaine 1 mg/ml;group D received propofol with lidocaine 2 mg/ml;group E was pretreated with lidocaine 40 mg intravenously before propofol injection.The severity of pain when injecting propofol was assessed and recorded.Results The incidence of propofol injection pain in group A was significantly higherthan those in the other groups(P0.01).Propofol injection pain was not observed in group D.Conclusion Lidocaine added to propofol injection can effectively suppress or attenuate the propofol-induced injection pain and lidocaine 2 mg/ml can completely block the pain without affecting propofol anesthesia.
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