Hostname: page-component-848d4c4894-2xdlg Total loading time: 0 Render date: 2024-06-21T19:40:17.007Z Has data issue: false hasContentIssue false
  • English
  • Français

Remifentanil-TCI and propofol-TCI for conscious sedation during fibreoptic intubation in the acromegalic patient

Published online by Cambridge University Press:  01 August 2008

T. Cafiero ,
F. Esposito ,
G. Fraioli ,
G. Gargiulo ,
A. Frangiosa ,
L. M. Cavallo ,
N. Mennella  and
P. Cappabianca
T. Cafiero*
Affiliation:
A. Cardarelli Hospital, Burn Center and Hyperbaric Center, Postoperative Intensive Care, Department of Anaesthesia, University “Federico II”, Naples, Italy
F. Esposito
Affiliation:
Department of Neurosurgery, University “Federico II”, Naples, Italy
G. Fraioli
Affiliation:
Department of Bronchoscopy, University “Federico II”, Naples, Italy
G. Gargiulo
Affiliation:
Department of Anaesthesia, University “Federico II”, Naples, Italy
A. Frangiosa
Affiliation:
A. Cardarelli Hospital, Burn Center and Hyperbaric Center, Postoperative Intensive Care, Department of Anaesthesia, University “Federico II”, Naples, Italy
L. M. Cavallo
Affiliation:
Department of Neurosurgery, University “Federico II”, Naples, Italy
N. Mennella
Affiliation:
Department of Anaesthesia, University “Federico II”, Naples, Italy
P. Cappabianca
Affiliation:
Department of Neurosurgery, University “Federico II”, Naples, Italy
*
Correspondence to: Cafiero Tullio, Department of Anaesthesia, Postoperative Intensive Care, Burn Center and Hyperbaric Center, A. Cardarelli Hospital, via A. Cardarelli, 9 Napoli 80131, Italy. E-mail: tcafiero@tiscali.it; Tel/Fax: +390815456294
Get access

Summary

Background and objective

To evaluate the use of remifentanil–propofol administered as target-controlled infusion during awake fibreoptic intubation for anticipated difficult tracheal intubation in acromegalic patients.

Method

In all, 20 consecutive acromegalic patients underwent elective endonasal endoscopic transsphenoidal pituitary surgery. After premedication with midazolam 0.03 mg kg−1, initially a target-controlled infusion of remifentanil 1.0 ng mL−1 and propofol 1.5 μg mL−1 was started. The fibreoptic intubation was performed by the same physician experienced with the fibreoptic technique. During the fibreoptic procedure the target concentrations of remifentanil and propofol ranged between 1.0 and 5.0 ng mL−1, and between 1.5 and 3.5 μg mL−1, respectively. Changes in heart rate and mean arterial pressure were recorded during airway manipulation, during tracheal intubation, and at 1 and 3 min after. On the first postoperative day, patient recall and level of discomfort during fibreoptic intubation were evaluated.

Results

Endotracheal intubation was efficaciously and quickly secured in all patients. A significant increase in mean arterial pressure and heart rate was recorded only during tracheal intubation (P < 0.05). Oxygenation was sufficient and no bradypnea or apnoea was recorded. All patients later described their anaesthetic experience as satisfactory. During fibreoptic intubation, remifentanil (ng mL−1) and propofol (μg mL−1) mean effect-site concentrations were 3.2 ± 0.3 and 2.0 ± 1.0, respectively.

Conclusion

Remifentanil and propofol target-controlled infusion provided satisfactory conscious sedation allowing for successful oral fibreoptic intubation in acromegalic patients with no recall.

Keywords

REMIFENTANILPROPOFOL, target-controlled infusionACROMEGALYINTUBATION INTRATRACHEAL, fibreoptic
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 8 , August 2008 , pp. 670 - 674
Copyright
Copyright © European Society of Anaesthesiology 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Messick, JM Jr, Cucchiara, RF, Faust, RJ. Airway management in patients with acromegaly. Anesthesiology 1982; 56 (2): 157.Google Scholar
2.Southwick, JP, Katz, J. Unusual airway difficulty in the acromegalic patient--indications for tracheostomy. Anesthesiology 1979; 51 (1): 72–73.CrossRefGoogle ScholarPubMed
3.Cafiero, T, Gargiulo, G, Spaziante, R et al. Anesthesiologic problems in transsphenoidal surgery of GH-secreting and ACTH-secreting adenomas. Minerva Anestesiol 1986; 52 (12): 455–461.Google ScholarPubMed
4.Hakala, P, Randell, T, Valli, H. Laryngoscopy and fibreoptic intubation in acromegalic patients. Br J Anaesth 1998; 80 (3): 345–347.CrossRefGoogle ScholarPubMed
5.Dougherty, TB, Cronau, LH Jr. Anesthetic implications for surgical patients with endocrine tumors. Int Anesthesiol Clin 1998; 36 (3): 31–44.CrossRefGoogle ScholarPubMed
6.Ovassapian, A, Doka, JC, Romsa, DE. Acromegaly – use of fiberoptic laryngoscopy to avoid tracheostomy. Anesthesiology 1981; 54 (5): 429–430.Google Scholar
7.Ovassapian, A, Krejcie, TC, Yelich, SJ, Dykes, MH. Awake fibreoptic intubation in the patient at high risk of aspiration. Br J Anaesth 1989; 62: 13–16.CrossRefGoogle ScholarPubMed
8.Passot, S, Servin, F, Allary, R et al. Target-controlled versus manually controlled infusion of propofol for direct laryngoscopy and bronchoscopy. Anesth Analg 2002; 94 (5): 1212–1216.CrossRefGoogle ScholarPubMed
9.De Castro, V, Godet, G, Mencia, G, Raux, M, Coriat, P. Target controlled infusion for remifentanil in vascular patients improves hemodynamics and decreases remifentanil requirement. Anesth Analg 2003; 96: 33–38.CrossRefGoogle ScholarPubMed
10.Marsh, B, White, M, Morton, N, Kenny, GNC. Pharmacokinetic model driven infusion of propofol in children. Br J Anaesth 1991; 67: 41–48.Google Scholar
11.Minto, CF, Schnider, TW, Egan, TD et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology 1997; 86 (1): 10–23.Google Scholar
12.Hakala, P, Randell, T, Valli, H. Laryngoscopy and fibreoptic intubation in acromegalic patients. Br J Anaesth 1998; 80: 345–347.CrossRefGoogle ScholarPubMed
13.Nandi, PR, Charlesworth, CH, Taylor, SJ, Nunn, JF, Dore, CJ. Effect of general anaesthesia on the pharynx. Br J Anaesth 1991; 66 (2): 157–162.Google Scholar
14.Asai, T, Shingu, K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions. Br J Anaesth 2004; 92 (6): 870–881.CrossRefGoogle Scholar
15.Beers, R, Camporesi, E. Remifentanil update: clinical science and utility. CNS Drugs 2004; 18 (15): 1085–1104.CrossRefGoogle ScholarPubMed
16.Puchner, W, Egger, P, Puhringer, F, Lockinger, A, Obwegeser, J, Gombotz, H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand 2002; 46 (4): 350–354.Google Scholar
17.Machata, AM, Gonano, C, Holzer, A et al. Awake nasotracheal fiberoptic intubation: patient comfort, intubating conditions, and hemodynamic stability during conscious sedation with remifentanil. Anesth Analg 2003; 97 (3): 904–908.CrossRefGoogle ScholarPubMed
18.Neidhart, G, Kovacs, AF, Bremerich, DH, Kessler, P. Remifentanil-propofol for bronchoscopic fiber optic intubation under capnographic control. Anaesthesist 2000; 49 (6): 523–526.CrossRefGoogle ScholarPubMed
19.Reusche, MD, Egan, TD. Remifentanil for conscious sedation and analgesia during awake fiberoptic tracheal intubation: a case report with pharmacokinetic simulations. J Clin Anesth 1999; 11 (1): 64–68.CrossRefGoogle ScholarPubMed
20.Hall, AP, Thompson, JP, Leslie, NAP, Fox, AJ, Kumar, N, Rowbotham, DJ. Comparison of different doses of remifentanil on cardiovascular response to laryngoscopy and tracheal intubation. Br J Anaesth 2000; 84: 100–102.Google Scholar
21.Donaldson, AB, Meyer-Witting, M, Roux, A. Awake fibreoptic intubation under remifentanil and propofol target-controlled infusion. Anaesth Intensive Care 2002; 30 (1): 93–95.Google Scholar
22.Mertens, MJ, Olofsen, E, Engbers, FH, Burm, AG, Bovill, JG, Vuyk, J. Propofol reduces perioperative remifentanil requirements in a synergistic manner: response surface modeling of perioperative remifentanil-propofol interactions. Anesthesiology 2003; 99 (2): 347–359.CrossRefGoogle Scholar
23.Jones, HE, Pearce, AC, Moore, P. Fibreoptic intubation. Influence of tracheal tube tip design. Anaesthesia 1993; 48: 672–674.CrossRefGoogle ScholarPubMed
24.Schwartz, D, Johnson, C, Roberts, J. A maneuver to facilitate flexible fiberoptic intubation. Anesthesiology 1989; 71: 470–471.Google Scholar