Combination of Propofol and Remifentanil TCI for LMA insertion in children

Dr. Alisher Agzamov MD PhD PhD

Propofol and Remifentanil TCI for LMA in children

The addition of Remifentanil (RF) to Propofol (PR) administration can improve the conditions for insertion of LMAs.

Propofol and Remifentanil TCI for LMA in children

However, the extent to which RF reduces PR requirements when both drugs are administered concomitantly via TCI in pediatric patients has not been adequately demonstrated.

Propofol and Remifentanil TCI for LMA in children

It has been determined the target concentration of PR that is required for LMA insertion at three different TCI RF target concentrations: 0; 2.5 ng/kg/min during TCI in children. 5.0 ng/kg/min during TCI in children.

Propofol and Remifentanil TCI for LMA in children

67 children; Ages: 2 to 12 years;

Propofol and Remifentanil TCI for LMA in children

Anesthesia with TCI of PR and TCI of RF using the STELPUMP program.

Propofol and Remifentanil TCI for LMA in children

The children were assigned to three groups: PR with saline (Control Group - CG); PR with 2.5 ng/mL of RF (Low-RF Group - LRFG);

PR with 5.0 ng/ ml of RF (High-RF Group - HRFG).

Propofol and Remifentanil TCI for LMA in children

The EC(50) of PR for LMA insertion at each target-concentration of RF was determined using Dixon's up-and-down method; and;

Propofol and Remifentanil TCI for LMA in children

The EC(50) of PR in each group was compared using the Kruskal-Wallis ANOVA by rank test.

Propofol and Remifentanil TCI for LMA in children

The EC(50) for PR was: 5.18 mcg/mL in the CG,

Propofol and Remifentanil TCI for LMA in children

The EC(50) for PR was: 4.81 mcg/ml in the LRFG;

Propofol and Remifentanil TCI for LMA in children

The EC(50) for PR was: 4.36 mcg/mL in the HRFG;

Propofol and Remifentanil TCI for LMA in children

Which was significantly different between the CG and the HRFG only (P<0.001).

Propofol and Remifentanil TCI for LMA in children

A higher target concentration of RF significantly reduced the PR target concentration for LMA insertion during TCI of both drugs in children;

Propofol and Remifentanil TCI for LMA in children

But low concentrations of Remifentanil failed to reduce the Propofol requirement.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol It has been determined the optimal dose of Remifentanil required for the successful insertion of Streamlined Liner of the Pharynx Airway (SLIPA) and to compare it to that required for LMA insertion in patients receiving a Propofol infusion at a standard effect-site concentration.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
58 patients scheduled to undergo GA were randomly assigned to either: The SLIPA (n = 29) group or LMA (n = 29) group.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
Premedication: Midazolam 0.05 mg x kg(-1) and Glycopyrrolate 0.004 mg x kg(-1) IM.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
GA: Lignocaine 1 mg/ kg IV;

TCI Propofol 3.5 mcg/ml with

TCI Remifentanil 4 ng/ml Without a NMBAs.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol

The Remifentanil dose: 4 ng/ml. 6 min. after induction, the airway device was inserted.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
Airway device insertion was classified as 'success' or 'failure' based on patient response.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
The EC50 of Remifentanil for SLIPA and LMA were: 0.93 ng x ml(-1) (95% confidence interval [CI] 0.81 to 1.50 ng x ml(-1) and

1.36 ng x ml(-1) (95% CI 1.19 to 2.06 ng x ml(-1)) respectively,

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
The EC95 for SLIPA and LMA insertions were: 1.90 ng x ml(-1) (95% CI 1.39 to 1.95) and

2.43 ng x ml(-1) (95% CI 1.80 to 2.46 ng x ml(1)) respectively.

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
EC50 for SLIPA was significantly less than that of LMA: 0.83 to 1.23 vs 1.26 to 2.00; (P < 0.05).

Comparison of the effect-site concentrations of Remifentanil for SLIPA vs. LMA SoftSealTM insertion during TCI of Propofol
The insertion of SLIPA needs about a 32% lower depth of anaesthesia than LMA insertion.

Effect-site concentration of Remifentanil for LMA insertion during TCI of Propofol

The effect-site concentration of Remifentanil that would provide optimal conditions for successful LMA insertion during a TCI of Propofol at 3.5 mcg/ml without the use of neuromuscular blockade has been studied.

Effect-site concentration of Remifentanil for LMA insertion during TCI of Propofol

5 min. after Propofol infusion, Remifentanil was infused at a dose determined by a modified Dixon's up-and-down method.
5 min. after Remifentanil infusion, the LMA was inserted.

Effect-site concentration of Remifentanil for LMA insertion during TCI of Propofol

The effect-site concentration of Remifentanil for successful LMA in 50% of adults (EC(50)) was:
3.04 (SD 0.49) ng.ml(-1)

During a TCI of 3.5 mcg/ml Propofol without neuromuscular blockade.

Effect-site concentration of Remifentanil for LMA insertion during TCI of Propofol

The EC(50) of Remifentanil were: 2.84 ng.ml(-1): (95% CI 2.09-3.57 ng.ml(-1));

Effect-site concentration of Remifentanil for LMA insertion during TCI of Propofol

The EC(95) of Remifentanil were: 3.79 ng.ml(-1)
(95% CI 3.26-9.25 ng.ml(-1)),

REFERENCES:
Kim HS, Park HJ, Kim CS, Lee JR. Combination of propofol and remifentanil targetcontrolled infusion for laryngeal mask airway insertion in children. Minerva Anestesiol. 2011 Jul;77(7):687-92. Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea.

REFERENCES:
Kim SH, Choi EM, Chang CH, Kim HK, Chung MH, Choi YR. Comparison of the effect-site concentrations of remifentanil for Streamlined Liner of the Pharynx Airway (SLIPA) versus laryngeal mask airway SoftSealTM insertion during target-controlled infusion of propofol. Anaesth Intensive Care. 2011 Jul;39(4):611-7. Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.

REFERENCES:
Minardi C, Astuto M, Taranto V, Gullo C, Gullo A. 936-7. Combination of propofol and remifentanil targetcontrolled infusion for laryngeal mask airway insertion in children: some remarks. Minerva Anestesiol. 2011 Sep;77(9):934-5; author reply 936-7. Comment on:Combination of propofol and remifentanil target-controlled infusion for laryngeal mask airway insertion in children. [Minerva Anestesiol. 2011] PMID: 21878876 [PubMed - indexed for MEDLINE] Free full text

REFERENCES:
Kim MK, Lee JW, Jang DJ, Shin OY, Nam SB. Effect-site concentration of remifentanil for laryngeal mask airway insertion during target-controlled infusion of propofol. Anaesthesia. 2009 Feb;64(2):136-40. Department of Anaesthesiology and Pain Medicine, College of Medicine, Kyung Hee University, Seoul, Korea.